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...
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