Tratamiento de la insuficiencia mitral cuando quirurgico y cuando percutaneo

NOVEDADESQUIRÚRGICAS EN TERAPIA VALVULAR. 2011

José L. Pomar, MD, PhDDirector AdjuntoInstituto Clínico del TóraxHospital ClinicUniversidad de Barcelona

CONGRESO ANNUAL DE LA SEC Maspalomas, Octubre 2011


PRIMERAS PRÓTESIS HETEROTÓPICAS


PRIMERAS PRÓTESIS ORTOTÓPICAS


ULTIMOS DISEÑOS DE BIOPROTESIS


LO MAS NOVEDOSO, ES NOVEDOSO ?


VALVULA AÓRTICAHomoinjertos: Presente y futuro de unos pocos privilegiadosBioprótesis: Crecimiento exponencial. Nuevos diseños. Nuevos accesos

Procedimientos percutaneos.Prótesis mecánicas: la anticoagulación, será imprescindible?

VALVULA MITRALReparar siempre mejor que cambiar?Algo nuevo en la reparación?Procedimientos percutaneos

VALVULA TRICUSPIDEReparaciones en VD muy dilatadosPrótesis: Está ya todo dicho?

LA IMAGEN Y LA CIRUGIA VALVULAR


VÁLVULA AÓRTICA


HOMOINJERTOS E INGENIERIA TISULAR


HOMOINJERTOS Y SOLUCIONES


REPARACION VALVULAR AÓRTICA

Form follows function


BIOPROTÉSIS


BIOPROTÉSISDel implante tradicional al simplificado


BIOPROTÉSISDel implante tradicional al simplificado

Perceval de SorinIntuitive de Edwards

Hospital ClinicUniversity of Barcelona

CURSO PRACTICO DE ACTUALIZACIÓN CARDIOVASCULAR. Barcelona 2008

90%

69%P=0.01

179 patients with symptomatic severe aortic stenosis

Porcelain ascending aorta


2 parts composite graft


INDICATIONS for TAVI

•Quantitative assessment

•LOGISTIC EUROSCORE >20%

•STS >10%

•Clinical judgment

•Chest radiation

•Previous CABG

•Porcelain aorta

•Liver cirrhosis

•Etc…..


≤ 30-Day Adverse Events (N = 948)

30‐Day All Mortality Rate 68 (7.2%)Cardiac Deaths** 42 (4.4%)Myocardial Infarction 6 (0.6%)Major Arrhythmias 30 (3.2%)Pacemaker 84 (8.9%)Renal Failure 10 (1.1%)Stroke 14 (1.5%)TIA 5 (0.5%)Structural Valve Dysfunction 0 (0.0%)Valve Migration 0 (0.0%)


Interferencia con los orificios coronarios


Pseudoaneurisma post apical



Symetis reports on its trans-apical ACURATE TATM first-in- man clinical study

Paniagua Enable PHV AorTx

SadraDirect Flow

Heart Leaflet Technologies Perceval JenaValvexchange


Unknowns by 2011

• Unknown durability in humans after 6 years

• Unknown effects on heart failure progression

• Unknown effects of remaining AoI on ventricular remodeling

• Unknown effect on the ability to do subsequent valve repair or replacement



MCRI's On-X Prosthetic Heart Valve in Aspirin Study; Clinical Study May Provide Evidence to Support Eliminating the Use of Warfarin As an Anticoagulant for On-X Mechanical Valve Recipients

PROACT: Early results show high-risk patients do well with low warfarin and carbon valve


Enrollment Objective Achieved for Aspirin and Clopidogrel Patient Group of the On-X Heart Valve Anticoagulation Clinical Study

Two Antiplatelets No Better Than Aspirin Alone After TAVI


VÁLVULA MITRAL

The echocardiographic assessment

Perforation of the leaflet observed under normal, colour doppler and at surgery

The Master of Valve therapy Bad Neustadt, October 2011

Large defect on the Anterior Leaflet


Flail leaflet after chordal rupture in BE

Perforation on a previously rheumatic mitral


Repairing with a pericardial patch a Type I lesion of an acute endocarditis

RD.Leiden MCRD.Leiden MC


Reconstruction of anterior leaflet and posterior commissure


SURGICAL FINDINGS SURGICAL REPAIR

The use of a prosthetic ring was unnecessary in this case


Posterior annulus managementradical excisiondirect reconstruction ?autologous pericardial patch with GApartial homograft

Anterior annulus managementmitro-aortic continuity mitro-aortic managementradical excisionmulti-patch reconstruction

Commissuresradical excisionplication and annuloplastypartial homograft

Mitral abscesses and tissue destruction management


Mitral homograft implant in an IVDA patient and histopathology after 12 years

Mitral homograft

Partial Homograft Mitral Valve Implantation


Indirect MITRAL VALVE AnnuloplastyCS - Reshaping

Distal AnchorProximal Anchor

Bridge

Distal AnchorProximal Anchor

Bridge

Carillon XE

PTMA ImplantHub and Cap (Ti)

PTMA Implant DeviceProximal Stops (Ti)

PTMA Implant DeviceShaft ( NiTi )

PTFE UnusedLumen Filler

PTMA ImplantHub and Cap (Ti)

PTMA Implant DeviceProximal Stops (Ti)

PTMA Implant DeviceShaft ( NiTi )

PTFE UnusedLumen Filler


MONARCH ELS

CARRILLON CARDIAC DIMENSIONS

PTMA VIACOR

Indirect MITRAL VALVE AnnuloplastyCS – Reshaping

NIH CERCLAGE of Lederman


• Circumferential tension around mitral annulus• CS – proximal septal branch of GCV –

image guided (MRI roadmapping coupled with fluoroscopy) traversal of myocardium to reenter right heart chambers

• Circle is closed by snare retrieval than applying and fixing graded tension to reduce MR

• Successful MR reduction in 14/16 swine with suitable anatomy

Direct Annuloplasty

• Retrograde access to post MV annulus - Direct annular reduction: Suture-anchor plication

• Guiding catheter in CS with radio-opaque markers placed at P1, P2 and P3

• Trident catheter delivers wires in P1, P2 and P3• FIM: Jan-2008 – Dr. Adrian Ebner – Paraguay• CE Pilot study PI: Prof. E. Grube

MITRALIGN


49

Direct Annuloplasty

Cinching implant below the posterior mitral annulus -Trigone-to-Trigone

AnchorsAnchors Therapeutic Area

Therapeutic Area

Anterior LeafletAnterior Leaflet

Posterior Leaflet

Posterior Leaflet

P1P1

P2P2

P3P3

Aortic ValveAortic Valve

AnchorsAnchors

ACCUCINCH GDS


• Ring implanted surgically during conventional surgical repair

• Direct mechanical adjustability• in OR or Cath Lab• 2 sizes• 24 to 30• 30 to 38

Direct Adjustable Annuloplasty(Hybrid Techniques)

Pre-implant Post-implant Post-adjustment


MICARDIA


• RF energy mediated reshaping• In OR by suture-electrodes• In Cath Lab with a catheter-

basket and electrode mounted on the splines - docking confirmed by impedance

• Completed FIM trials 2012


• RF energy mediated reshaping• In OR by suture-electrodes• In Cath Lab with a catheter-

basket and electrode mounted on the splines - docking confirmed by impedance

• Completed FIM trials 2012

Direct Adjustable Annuloplasty(Hybrid Techniques)

DYNAPLASTY MICARDIA


52

Leaflet Plication

• Over 300 cases - Everest I and Everest II (randomized+registry) in 36 sites• Freedom from death at 36 Mo: 97%• Freedom from Sx at 36 Mo: 85%• Freedom from death, surgery or MR>2+ at 36 Mo: 67%

• Guide catheter 17-19 Fr

• Stitch Catheter 11-12 Fr

• Housing with a vacuum port, needles and suture

• Fastener catheter 7 Fr.

• After FIM, device is being redesigned

• Guide catheter 17-19 Fr

• Stitch Catheter 11-12 Fr

• Housing with a vacuum port, needles and suture

• Fastener catheter 7 Fr.

• After FIM, device is being redesigned

Stitch + Nitinol AnchorStitch + Nitinol Anchor


MITRACLIP ABBOT

Leaflet PlicationMitraFlex – TransCardiac Therapeutics

TransCardiac Port™• Allow access into the chambers of a beating

heart

TransCardiac Navigator™• Enables maneuverability within a beating heart

Clip advanced to hold the leaflets at midpoint


Leaflet Plication

Leaflet Stabilizer ™ deployed to hold leaflets in place

Reach the Mitral ValvePercutaneously

Clip or Stitch to hold the leaflets at midpoint

MitraFlex – TransCardiac Therapeutics


Percutaneous Artificial Chordae Implantation

Fiber optics


NEO CHORDS

Percutaneous Artificial Chordae Implantation

Artificial Cordae ImplantedArtificial Cordae Implanted


BABIC DEVICE


MitraClip

Space Occupier

• Femoral Access• I.C.E visualization• Trans-septal approach• Anchor in apex• Mitra-Spacer™ positioned mid-valve• Self-centering• Currently finishing chronic animal

studies – Pre Clinical• Acute animal n=40• Chronic animal n=10 (30,90 and 180 days)

Mitra-Spacer and Percu-Pro by Cardiosolutions


• Active anchoring• Rigidity and structure is

not stent based• Re-deployable• Fully valve-sparing• In-vivo ovine testing is

ongoing

Endovalve-Herrmann Prosthesis

Percutaneous Mitral Valve Implantation


Percutaneous Mitral Valve ImplantationGeorg Lutter Mitral Valve Prosthesis

Figure 1. Transesophageal echocardiographic views of the mitral valved stent. Figure 1A shows the valved stent along LV long axis view at 0 degree angle. Note the visible valve leaflets inside the body of the stent. Figure 1B represents the color frame showing the unobstructed LVOT and its relationship with the new mitral valved stent.

Figure 2. TEE Doppler examination of the mitral valved stent and LVOT flows. Figure 2A illustrates the amount of regurgitation (trace) on Continuous Wave Doppler exam to assess the forward flow through the mitral valved stent. Figure 2B shows the Pulse Doppler exam through the LVOT showing unobstructed flow by the neighboring mitral valved stent.

(Lozonschi L and Lutter G: University of Kiel and University of Wisconsin)



Minithoracotomy


VÁLVULA TRICUSPIDE


Callahan et al.Am Heart J.1982;50:762

Is it to repair, replace by a bioprosthesis or a mechanical device?


LA IMAGEN REVOLUCIONA EL DIAGNOSTICO Y EL TRATAMIENTO

Allied Health Care Professionals The Roland Hetzer Society, Lisbon 2011

But training and caring of all our allied personnel is also crucial


Christakis NA, Fowler JH. NEJM 357 (4):370‐379, 2007

The obesity network


Hubs in biological interaction networksExperimental asthma in a mouse model


SystemsCollection of linked individual elements with emerging properties that can not be attributed to each element considered separately.

Tratamiento de la insuficiencia mitral cuando quirurgico y cuando percutaneo

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