Trans-aortic TAVR

Vinnie (Vinayak) Bapat

Consultant Cardiothoracic Surgeon

Guys and St. Thomas’ Hospital, London

Disclosure

• Consultant

Edwards Lifesciences

Medtronic Inc

St. Jude Medical

Symetis

• What is TAo

• Technique

• Practical tips

• Patient screening

• Access options

• Lab set up

• Key points

• TAo

Edwards Sapien

Medtronic CoreValve

Future

Any device which can

be implanted

through TF

Sapien Valve

Ascendra 1 & 2

Ascendra plus*

Retroflex 3*

CoreValve *

Nosecone is important

TAo: Mini-Sternotomy

TAo: Mini-Sternotomy

TAo: Right thoracotomy

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

Practical tips

Retractor position

Don’t cover your landmarks

Watch the wire

Suture Collar

TAo on CPB

Same incision Unhurried procedure No pacing Short CPB Excellent recovery

Patient screening

• Suitable for TAVR

• Suitability for TAo

• Access options when suitable

‘TAo zone’

As straight as possible

Free of calcium

Minimum distance

23 to 29 - 5 to 6 cms

Purse-string distance from aortic Annulus

Sapien CoreValve

All sizes - >6cms

Porcelain aorta and TAo?

CT scan can identify calcium free TAo zone

Case example

TAo + CABGx2

Case example

TAo

Relationship between aorta, sternum and rib cage

Two approaches

Mini sternotomy

Right thoracotomy

At the level of 2nd rib

• Measure distance from rib to aorta

• % of aorta to the right of the sternum

Right thoracotomy

If it is <6cms and >50% aorta is to the right

Mini sternotomy

Aorta 5cm from sternum

But is on left side

Aorta on right side

But > 7 cms deep

Confirm under fluoroscopy During procedure

Is TAo possible if it’s a redo?

Yes

Mini sternotomy in Redo cases

Safe when vein and aorta are not close to sternum

Also lie of the LIMA

LIMA lies lateral RIMA not crossing anteriorly

Right thoracotomy- useful in redo

Aorta or vein stuck to sternum

Aorta >50% to right

< 6cms deep

Redo - examples

Mini-sternotomy Right thoracotomy

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

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

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

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

Better Control

Familiarity

Avoids ventricle

CPB

Preferred for Patients with Poor

lung reserve

Easy Conversion to

open

Use of embolic

Protection

Thank You

Trans-aortic TAVR

Vinnie (Vinayak) Bapat

Consultant Cardiothoracic Surgeon

Guys and St. Thomas’ Hospital, London