The IX t h Makassed Medical Congress - American University of Beirut

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T h e I X t h M a k a s e d M e d i c a l C o n g r e s s Transcatheter Aortic Valve Implantation Kapadia and Tuzcu 469 Figure 1. Different approaches for implanting a transcatheter aortic valve. A, Transfemoral approach. B, Transapical approach. C, Transseptal approach. Implantation approaches • The prosthetic valves can be delivered in retrograde or antegrade fashion (Fig. 1). Currently, the CoreValve can be deployed only retrogradely, whereas the Sapien valve can be deployed antegradely or retrogradely. The retrograde delivery is commonly performed from the femoral artery, but subclavian access has been used in some patients with signifi cant iliofemoral disease receiving the CoreValve device. In the initial experience with the fi rst-generation Cribier-Edwards valve (an equine valve; Edwards Lifesciences), transseptal access allowing an antegrade approach was used. An antegrade approach from the apex of the heart (transapical) has been used in some patients with severe iliofemoral disease receiving the Edwards Sapien valve. • The transfemoral approach (Fig. 1A) is the simplest and quickest way to access the aortic valve. Access is obtained by percutaneous puncture or by surgical cutdown of the femoral artery. Perclose devices (Perclose, Menlo Park, CA) typically are used to close the arteriotomy if the percutaneous approach is used. The aortic valve is then crossed in the usual manner, commonly using an AL1 catheter and a straight wire. A stiff wire is placed in the left ventricle with a big loop. A temporary pacing wire is placed in the right ventricle for rapid pacing. Rapid pacing is critical for the balloon-expandible valve to avoid unintentional motion of the valve during deployment. Initially, the aortic valve is dilated using a 20- to 23-mm balloon with rapid pacing. Following this procedure, the prosthetic valve is advanced into position and the native aortic valve is crossed. Positioning of the valve at the correct height is a crucial step during transcatheter valve replacement because currently available valves are not repositionable. Transesophageal echocardiographic and fl uoroscopic guidance is necessary for accurate positioning. The valve is deployed under rapid pacing once the satisfactory position is achieved for the Edward Sapien valve. The CoreValve is deployed without pacing by unsheathing the valve. Proper valve deployment is confi rmed by online imaging. • With the transapical approach (Fig. 1B), access is obtained by mini-thoracotomy. The apex of the heart is punctured using a needle after two layers of pursestring sutures are placed around the intended site. The aortic valve 84
470 Valvular, Myocardial, Pericardial, and Cardiopulmonary Disease Outcomes is crossed antegradely, dilated, and then stented under rapid pacing as in the transfemoral route, except that the Edwards Sapien valve is mounted appropriately with its sleeve on the ventricular side of the valve. • The transseptal approach (Fig. 1C) is somewhat more challenging for an interventionalist who may not be accustomed to working in the left atrium. There is some danger of damaging the mitral valve with the stiff wire if adequate slack is not maintained during the procedure. Femoral venous access is obtained and a balloon-tipped catheter advanced into the left ventricle after transeptal puncture. The aortic valve is then crossed with a wire or the catheter itself. The wire is then snared via femoral arterial access, and a catheter is passed to the aortic valve for adequate control of the wire. Valvuloplasty and valve replacement steps are similar to those of other approaches. • Percutaneous AVR was fi rst performed via transseptal access by Dr. Allan Cribier in Rouen, France in April 2002. The initial experience from compassionate use of the balloon-expandable 23-mm valve from the antegrade approach was reported in the I-REVIVE (Initial Registry of Endovascular Implantation of Valves in Europe) and RECAST (Registry of Endovascular Critical Aortic Stenosis Treatment). The procedural success rate was 75%, with a 30-day mortality rate of 23%. Moderate to severe aortic regurgitation was reported in 63% of patients, partly as a result of the valve size. Concerns also were raised about the procedural challenges posed by the transseptal puncture and the potential for damage to the mitral valve apparatus by the stiff wire and aortic prosthesis. • Signifi cant advances were made by Dr. John Webb in Vancouver in implanting this valve retrogradely via the transfemoral route. His team successfully implanted the Cribier-Edwards valve in 14 of 18 patients who had previously been deemed unsuitable for SAVR [16]. The measured aortic valve area increased from 0.6 ± 0.2 to 1.6 ± 0.4 cm 2 and remained stable at 1-month follow-up [16]. The early mortality rate was 11% (2 of 18), and short-term survival was 89% (16 of 18) at a mean follow-up of 75 days [16]. The same group reported both short- and long-term outcomes in an extended cohort of 50 patients [24••]. Procedural success increased from 76% in the fi rst 25 patients to 96% in the second [25], and 30-day mortality fell from 16% to 8%. Further, this series demonstrated that paravalvular leak is not a major issue if the valve size is larger than the annulus (ie, a 23-mm valve for a 17- to 21-mm annulus and a 26-mm valve for a 21- to 24-mm annulus). It also was apparent that the success rate was very dependent on proper patient selection, with the main focus on vascular access to prevent procedural vascular complications. • Lichtenstein et al. [25] successfully implanted the Cribier-Edwards valve using the apical approach and fl uoroscopic guidance in all seven patients in whom they attempted the procedure. All patients were deemed by an experienced operator to be unsuitable for SAVR and also for percutaneous transfemoral percutaneous heart valve implantation because of severe aortoiliac disease [25]. Four of the seven patients were alive at 6 months [26]. Subsequently, Walther et al. [27] published their data describing implantation of the Cribier-Edwards valve in 30 elderly patients. At a mean follow-up of 108 days, 86% of the patients reportedly were doing well [27]. 85
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The IX th Makassed Medical Congress
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CONGRESS PRESIDENT Said Sayegh, MD,
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GENERAL INFORMATION
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• Target Audience: Physicians, Pr
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Durriya Sinno, MD Pediatrics Americ
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Moderators
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PEDIATRICS Bassem Abou Merhi, MD Pe
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Maroun Sokhn, MD Pediatrics Saint G
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Scientific Program
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Session 3: Intensive Care Neonatolo
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Session 1: Pediatric Intensive Care
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8:00 - 8:05 08:05 - 08:10 Welcome r
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Cardiology Session III: Interventio
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Cardiology Session VI: Intervention
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Cardiology Symposia (NON-CME) Frida
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T h e I X t h M a k a s e d M e d i
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The IX t h Makassed Medical Congress - American University of Beirut

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