What would you suggest? AVR or not?

60-something y/o male patient who isn’t physically active but does ADLs.  Scheduled for CABG but has AI, PVD, EF 40%, HTN, HLD.  Would you suggest an AVR or not…. along with the CABG?

IMG_20180131_095240.jpgIMG_20180131_095301.jpg

IMG_20180131_095407.jpg

What would you suggest?

 

Advertisements

Transcatheter Mitral Valve Replacement

Our hospital will be partaking in the Medtronic APOLLO study.

The data so far from other hospitals in an easy to read format.

f14-large

PPT from Duke 2017

Peri-procedural imaging for transcatheter mitral valve replacement. Cardiovasc Diagn Ther. 2016 Apr; 6(2): 144–159.

Role of echocardiography for catheter-based management of valvular heart disease. Journal of Cardiology 69 (2017) 66–73.

EAE/ASE Recommendations for the Use of Echocardiography in New Transcatheter Interventions for Valvular Heart Disease.  J ASE Sept 2011.

Multimodality Imaging in the Context of Transcatheter Mitral Valve Replacement. JACC: CARDIOVASCULAR IMAGING, VOL. 8, NO. 10, 2015.

Echo in mitral valve intervention. ESC 2012.

Mitral Valve Morphology Assessment: Three-Dimensional Transesophageal Echocardiography Versus Computed Tomography. Ann Thorac Surg 2010;90:1922–9.

Transcatheter Mitral Valve Replacement for Patients With Symptomatic Mitral Regurgitation. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY VOL. 69, NO. 4, 2017. 

This slideshow requires JavaScript.

Transcatheter Mitral Valve Intervention, An Issue of Interventional Cardiology Clinics, E-Book.

Quantification of Mitral Valve Morphology With Three-Dimensional Echocardiography.  Can Measurement Lead to Better Management? Circulation Journal Official Journal of the Japanese Circulation Society http://www.j-circ.or.jp. 2014.

Transcatheter valve replacement and valve repair: Review of procedures and intraprocedural echocardiographic imaging. Circ Res. 2016;119:341-356.

Philips: TMVR

Guidelines for Performing a Comprehensive Transesophageal Echocardiographic Examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64.

Transcatheter Mitral Valve Repair. Summer 2014Volume 19, Issue 2, Pages 219–237.

g8237128

Mitraclip and TEE for MR

 

Transthoracic Echocardiography (TTE)

Transthoracic echo: a beginner’s guide #tte #cardiac #echo #meded

Knowing how to do a quick focused echo exam can be instrumental in diagnosis as well as treatment.  This has helped me determine how severe cardiac tamponade has been in an emergent case prior to induction when there was no prior echo.  There are so many more useful answers that a bedside echo can provide.  Time to get acquainted.

Helpful links:

acoustic_windows
From Visible Heart Lab

Helpful articles:

b9780323089296000081_f008-001ad-9780323089296
From ClinicalGate.com

Mitraclip and TEE for MR

IMG_0056

 

European Heart Journal – Cardiovascular Imaging (2013) 14, 935–949.  Peri-interventional echo assessment for the MitraClip procedure. 

Everest Clinical Trial results PPT

Open Heart 2014;1:e000056. Two-year outcomes after percutaneous mitral valve repair with the MitraClip system: durability of the procedure and predictors of outcome.

ASE Echo 2016: Percutaneous approaches to MR. UofMichigan PPT.

2015: The role of 3D TEE in the MitraClip procedure – UofColorado PPT

Abbott TTE checklist for MitraClip

EuroValve Congress 2015: MR in the MitraClip Era

2012: Echo in mitral valve intervention. 

IMG_0057

Abbott MitraClip device and delivery system package insert

Neth Heart J (2017) 25:125–130. MitraClip step by step; how to simplify the procedure.

IMG_0059

IMG_0060

Transseptal Puncture technique with TEE

JACC Cardiovascular Imaging: July 2012. Role of echo in percutaneous mitral valve interventions. 

MitraClip Cases with TEE: Mayo Clinic.

 

General anaesthesia vs. conscious sedation for transfemoral aortic valve implantation: a single UK centre before-and-after study – Miles – 2016 – Anaesthesia – Wiley Online Library

http://onlinelibrary.wiley.com/doi/10.1111/anae.13522/full?platform=hootsuite
Updated: Feb 24, 2017: http://apsf.org/newsletters/html/2017/Feb/10_TAVRsafety.htm

HeartWare vs. HeartMate LVAD

A couple of weeks ago, I took care of a patient who desperately needed to get better from acute CHF.  At that time, we placed the patient on an impella… but the next day, it was deemed that he needed ECMO to reperfuse his organs.  After a week on ECMO with continued impella support, ECMO was titrated down and off while maintaining 3.9L/min flow from the impella.  During the wean off ECMO, the patient had been extubated and was mentating clearly and interacting appropriately.

Fast forward a couple days after getting extubated, the patient was ripe for an LVAD.  But which one? (We ended up placing the patient on HeartWare LVAD).

YouTube: LVAD 101 – Anatomy & Physiology

YouTube: LVAD Pathophysiology


HeartWare

heartware-hvad-7x4

HeartWare brochure

YouTube vid of HeartWare (no sound) ; Vid of HeartWare with detailed explanation

 

gr2_lrg


HeartMate II

heartmate-index_1

HeartMate II website

YouTube vid of HeartMate II


Summary

  • Cost-effectiveness: HeartWare > HeartMate II (UK NHS study, April 2014)
  • LV Geometry: HeartWare = HeartMate II (J CT Surg, 2013)
  • Stroke & GI bleed risk: HeartWare > HeartMate II (J Card Surg 2013)
  • Risk of device failure: HeartWare < HeartMate II
  • ENDURANCE trial: Randomized patients eligible for DT 2:1 to the HeartWare centrifugal flow LVAD versus the HeartMate II axial flow LVAD. The trial did reach its primary noninferiority endpoint of stroke free survival at 2 years (55.0% in the HeartWare patients versus 57.4% in the HeartMate II patients). Of note, a change in the design of the HeartWare device during the trial (sintering of the inflow cannula) appeared to decrease the incidence of pump thrombosis. Overall, the stroke rate was higher in the HeartWare arm whereas device malfunctions requiring exchange or urgent transplantation were more common in the HeartMate II arm. Data analysis suggested that better blood pressure control in the HeartWare arm may decrease the stroke rate and a second cohort of patients is being enrolled with more attention being paid to blood pressures management.

38ff1