Trans-aortic TAVR · 2018. 1. 22. · Vinnie (Vinayak) Bapat Consultant Cardiothoracic Surgeon Guys...
Transcript of Trans-aortic TAVR · 2018. 1. 22. · Vinnie (Vinayak) Bapat Consultant Cardiothoracic Surgeon Guys...
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Trans-aortic TAVR
Vinnie (Vinayak) Bapat
Consultant Cardiothoracic Surgeon
Guys and St. Thomas’ Hospital, London
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Disclosure
• Consultant
Edwards Lifesciences
Medtronic Inc
St. Jude Medical
Symetis
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• What is TAo
• Technique
• Practical tips
• Patient screening
• Access options
• Lab set up
• Key points
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• TAo
Edwards Sapien
Medtronic CoreValve
Future
Any device which can
be implanted
through TF
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Sapien Valve
Ascendra 1 & 2
Ascendra plus*
Retroflex 3*
CoreValve *
Nosecone is important
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TAo: Mini-Sternotomy
TAo: Mini-Sternotomy
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TAo: Right thoracotomy
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Q4. Advantage of TAo over TA is:
a. Purse string on the aorta and familiarity
b. Less effect on respiratory function
c. LV is untouched
d. All of the above
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Practical tips
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Retractor position
Don’t cover your landmarks
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Watch the wire
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Suture Collar
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TAo on CPB
Same incision Unhurried procedure No pacing Short CPB Excellent recovery
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Patient screening
• Suitable for TAVR
• Suitability for TAo
• Access options when suitable
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‘TAo zone’
As straight as possible
Free of calcium
Minimum distance
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23 to 29 - 5 to 6 cms
Purse-string distance from aortic Annulus
Sapien CoreValve
All sizes - >6cms
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Porcelain aorta and TAo?
CT scan can identify calcium free TAo zone
Case example
TAo + CABGx2
Case example
TAo
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Relationship between aorta, sternum and rib cage
Two approaches
Mini sternotomy
Right thoracotomy
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At the level of 2nd rib
• Measure distance from rib to aorta
• % of aorta to the right of the sternum
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Right thoracotomy
If it is <6cms and >50% aorta is to the right
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Mini sternotomy
Aorta 5cm from sternum
But is on left side
Aorta on right side
But > 7 cms deep
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Confirm under fluoroscopy During procedure
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Is TAo possible if it’s a redo?
Yes
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Mini sternotomy in Redo cases
Safe when vein and aorta are not close to sternum
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Also lie of the LIMA
LIMA lies lateral RIMA not crossing anteriorly
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Right thoracotomy- useful in redo
Aorta or vein stuck to sternum
Aorta >50% to right
< 6cms deep
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Redo - examples
Mini-sternotomy Right thoracotomy
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Room set up
• Check the C-arm orientation
• Speak to the Anaesthetist
– Position of their equipment
– Treat it like head-neck surgery
– Longer lines
– Double lumen tube
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X R
ay
IC
C
S
Monitor
1
Power
Injector
Echo
Rapid
Pacer
Anesth
esia
Monitor
2
E
C
A
C
S
Bypass Circuit
Cri
mp
ing
Ta
ble
(>
13
0
cm
)
R
Surgical
Equipment
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X R
ay
IC
C
S
Monitor
1
Power
Injector
Echo
Rapid
Pacer
Anesthesia
Monitor
2
E
C
A
C
S
Bypass Circuit
Cri
mp
ing
Ta
ble
(>
13
0
cm
)
R
Surgical
Equipment
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Key Points
• CT scan assessment
TAo zone
Access option
• Room Set up
• Choose correct site for Purse-string
Check the access site distance
Alignment to annulus
• Catheters – watch the wire
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Better Control
Familiarity
Avoids ventricle
CPB
Preferred for Patients with Poor
lung reserve
Easy Conversion to
open
Use of embolic
Protection
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Thank You
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Trans-aortic TAVR
Vinnie (Vinayak) Bapat
Consultant Cardiothoracic Surgeon
Guys and St. Thomas’ Hospital, London