Just Another Crazy TAVI Case

Horst Sievert, Sameer Gafoor,

Laura Vaskelyte, Ilona Hofmann, Stefan Bertog,

Predrag Matić, Markus Reinartz, Kolja Sievert

CardioVascular Center Frankfurt - CVC,

Frankfurt, Germany

Just Another Crazy TAVI Case...

ICI 2015 Tel Aviv, Israel, Dec 13-15, 2015

.

.............min

Physician name Company Relationship

Horst Sievert Abbott, Access Closure, AGA, Angiomed, Aptus,

Atrium, Avinger, Bard, Biosense Webster, Boston

Scientific, Bridgepoint, Carag, Cardiac

Dimensions, CardioKinetix, CardioMEMS,

Cardiox, Celonova, CGuard, Coherex, Contego,

Covidien, CSI, CVRx, EndoCross, ev3,

FlowCardia, Gardia, Gore, GTIMD Medical,

Guided Delivery Systems, Hemoteq, InSeal

Medical, InspireMD, Lumen Biomedical, HLT,

Lifetech, Lutonix, Maya Medical, Medtronic, NDC,

Occlutech, Osprey, Ostial, PendraCare, pfm

Medical, Recor, ResMed, Rox Medical,

SentreHeart, Spectranetics, SquareOne, Svelte

Medical Systems, Tendyne, Trireme, Trivascular,

Valtech, Vascular Dynamics, Venus Medical,

Veryan, Vessix

Consulting fees,

Travel expenses,

Study honoraria

Cardiokinetix, Access Closure, Velocimed, Lumen

Biomedical,

Coherex, SMT

Cook, St. Jude Medical

Stock options,

Stocks

Grant Research Support

Disclosures

CardioVascular Center Frankfurt CVC

TAVI

• Has become a routine procedure

• Access problems < 5%

• Surgeons don't wont to give direct stand-

by anymore

- "you will do it right"

• And nevertheless - always good for a

complication session

On 02.11.2015 17:51, Arik Finkelstein wrote:

Dear friends.

We are all going to share an outstanding and exciting "My

crazy TAVI case" session during the ICI meeting in Tel Aviv.

Each presentation will be 7 minutes followed by a 5 minutes

discussion.

Please, send my your case title, so we can put it into the

program.

Looking forward to see you all in Tel Aviv,

Best,

Arik

How this presentation evolved

Something

is wrong!


Dear friends.

We are all going to share an outstanding and exciting "My

crazy TAVI case" session during the ICI meeting in Tel Aviv.

Each presentation will be 7 minutes followed by a 5 minutes

discussion.

Please, send my your case title, so we can put it into the

program.

Looking forward to see you all in Tel Aviv,

Best,

Arik

How this presentation evolved

From: Horst Sievert [mailto:[email protected]] Sent: Sunday, November 15, 2015 1:57 AM To: Arik Finkelstein Subject: Re:

7 min only?

mailto:[email protected]

On 15/11/15 06:10, Arik Finkelstein wrote:

Dear Horst.

This is formal, but like last year, you are not

going to be limited…

Do you have a title to your case?

Best,

Arik

From: Horst Sievert [mailto:[email protected]] Sent: Sunday, November 15, 2015 12:00 PM To: Arik Finkelstein Subject: Re:

So I am not absolutely limited to 7 min?

Regarding the title, I will have to work on

it. The problem is that I do not have crazy

cases - I have only complications :-(

Horst

mailto:[email protected]


Dear Horst.

•You are not absolutely limited and absolutely

not limited…

•Complications and crazy are synonyms…

•The main issue is that it will be something that

the audience can learn from

Best,

Arik

Subject: Re:

Date: Sun, 15 Nov 2015 22:58:45 +0100

From: Horst Sievert <[email protected]>

To: Arik Finkelstein <[email protected]>

perfect - so I have 15 min

- Thank you very much


Warning

• This is not one of these "funny"

complications

• Not one of those where the operator

ends up to be a hero

• One of the most severe complications I

ever had

• Patient expired

• But may be it helps to avoid this kind of

complications in the future

Self expanding Edwards Sapien Balloon

expandable

CoreValve Sapien

Self expanding

CoreValve • Disadvantages

- Higher pacemaker rate

- Access to coronary

arteries may be limited

occasionally

• Advantages

- Exact measurements

are not as important as

with Edwards Sapien

- Lower profile

• If used without sheath

Self expanding

CoreValve

- Can be pulled back into

the ascending aorta

even after release

- Slow deployment

instead of "one shot"

- No need for rapid pacing

- Can be partially

repositioned before

release

- Can be completely

removed before release

• Advantages

Self expanding

CoreValve

- Some typical Edwards

Sapien complications

almost never occur:

• Annulus rupture

• Valve embolisation into

the LV

• Obstruction of the

coronaries

• Dissection of the

ascending aorta

• Advantages

Now you know that the CoreValve

is much more safe and reliable

than the Edwards Sapien ...

... and some of you may feel bad

that they do not have the

CoreValve available


Patient History

• 85 yrs, female

• High-grade aortic valve stenosis

• Progressive dyspnea (NYHA IV),

pulmonary hypertension

• COPD

• Hyperthyreosis

• Immunocytoma (diagnosed 1995)

• EuroSCORE 30

Clinically a clear

TAVI indication!

Let's move on!


ECG

• Sinus rhythm

• Incomplete right bundle branch

block

• Heart rate: 80/min


TTE • LV

- EF 56%

- Hypertrophy (septum 17mm)

• Aortic valve

- AV peak/mean gradient: 92/62 mmHg

- AVA 0.6 cm2

- Mild AR

• Mitral valve: moderate MR

• Tricuspid valve: PAPsyst 50mmHg

Looks good!

Can we move on?


TEE

• LVOT 21 mm

• annulus 22 mm

• sinotubular junction

24 mm

• ascending aorta

33mm

• Hight of sinus

valsalva 15.5mm


LCA (LAO)


LCA (RAO)


RCA (LAO)


RCA (RAO)


Aortogram (LAO)

33.5 mm

24.4 mm

28.4 mm


Aortogram (ap)

10.9 mm


Aortogram, iliac

8.7 mm 8.6 mm

"A little bit of kinking on the left side"

Looks good!

Can we move on?


Suitable for

Edwards Sapien ...


... but also a good

CoreValve case

• 22mm annulus 26mm valve

- Annulus > 23 or 24 mm would

require a 29mm Valve

• Access right femoral because

there is less kinking

Now ....

... can we move on?


No, we can not!

We havn't done

the checklists!






And now?

Can we

move on now?


5 F Sheath in the right CFA


10 F Prostar left CFA

What is unexpected?


• More kinking

on the left!

• So why did I

introduce the

Prostar from

the left?

• Can we move

on?


22 mm Balloon


Position correct?

26mm CoreValve


26mm CoreValve

Too high?


Can we move on?

26mm CoreValve

• Aorta 90/50 mmHg

26mm CoreValve

Can we move on?



26mm CoreValve

What's wrong?


22 mm Balloon


Gab es hier nicht schon

Angios mit KM? Nein,

leider nicht

After post-dilatation

"Excellent!!"


But it was not!

• Nausea

• Cold sweat

• BP 90/45mmHg

• Puncture site ok

• Echo: no pericardial effusion

• ECG unchanged


2nd run after post-dilatation Haben Sie alle Szenen chronologisch eingefügt?

Oder fehlen welche?

Bis auf eine Szene zu Beginn der Procedur,

welche identisch mit der Szene auf PPP-Folie 31 war,

wurden alle Szenen der CD eingefügt. Die Reihenfolge

war streng chronologisch.


A minute later ...

• BP < 40mmHg systolic

• Patient unconscious

• No tamponade

• ECG normal

Intubation, CPR started


What had happened and

how to move on?


Puncture site ok


Let's look at the last run Haben Sie alle Szenen chronologisch eingefügt?

Oder fehlen welche?

Bis auf eine Szene zu Beginn der Procedur,

welche identisch mit der Szene auf PPP-Folie 31 war,

wurden alle Szenen der CD eingefügt. Die Reihenfolge

war streng chronologisch.

Left main looks obstructed?


"Let's move on

and open it up"


6F EBU 3.5


And now?

• Intermittent CPR

• Catecholamines, ...

• IABP inserted

• IABP ineffective exchanged for

percutaneous pump


Some flow in the LCA ...


... but I could not get in!

How about the RCA?

Let's have a look at the

prior cine runs



The first cine run after valve implantation

What's wrong?


Both coronaries

are occluded!


Options

• Continue with PCI attempt

- hopeless

• Snare the valve and pull it

- Difficult to snare the eylets in narrow aortic

rout

- Difficult to pull the valve if post-dilatation

has been performed


Difficult Decision

• Horst Sievert: "Nalan: would you like to

move on to CABG?"

• Nalan Schnelle (cardiac surgeon): "I don't

know"

• Horst Sievert: "I don't know either"

• Nalan Schnelle: "If you tell me you can

not open it then I will move on"

"Schnelle"

means "fast" in

German


Set-up in the Sankt Josefs Hospital

• TAVIs are performed in the cath lab

• Patient is prept for surgery

• Pump is filled and ready to go

• 2 OR nurses in the room

• Surgical sets are open and ready to go

• Anesthesia is in the room

• 2 cardiac surgeons are scrubbed in for

each procedure


Difficult Decision

• Horst Sievert: "Nalan: would you like to

move on to CABG?"

• Nalan Schnelle (cardiac surgeon): "I don't

know"

• Horst Sievert: "I don't know either"

• Nalan Schnelle: "If you tell me you can

not open it then I will move on"

"Schnelle"

means "fast" in

German


Difficult Decision

• Horst Sievert: "Move on!"


Outcome

• 2 grafts implanted within a

very short time period

• But could not get off pump

• IABP ineffective

• Patient passed away on the

table


Looking back:


What was the initial mistake?

• Patient selection

- Aortic root rather small

• although within the limits

- Sinus valsalva short

• although within the limits on echo

(not measured on angio)

- Too much calcium?


Other major mistakes

• I overlooked the RCA occlusion

• I failed to re-open the LCA

• Maybe conversion to surgery was a

mistake

- Pump + further recanalization

attempts?


What was the point of no return?

• Post dilatation!


What could I have done

before the point of no return?

• Snare the valve and pull it into the

ascending aorta

- Difficult decision because the RCA was

very small and the position of the valve

otherwise perfect

• Wire the LCA before post-dilatation of

the valve to keep access?

- Difficult technically and because there was

also severe AR and hemodynamics not

stable


How to avoid this in the future?

• To be more restrictive in

borderline cases?

• Additional imaging (CT, ...)?

• Other advanced technology?

- Computer simulation of device

implantation?

- Rapid prototyping?


Thank you!



Corevalve Beurteilung

-------- Original Message --------

Subject: Re: Patienten CSI

Date: Mon, 2 Jul 2012 12:40:52 +0200

From: Kuester, Frank <[email protected]>

To: Horst Sievert <[email protected]>

Hallo Herr Prof. Sievert,

Leider kann ich Sie telefonisch nicht erreichen.

Kurz zusammengefasst die Antworten auf Ihre Fragen:

Bei Habermann ist die Anatomie recht klein sie würde für eine 26mm Corevalve

in Frage kommen. Sie hat einen kleinen Sinus und viel Kalk, deshalb sollte

man auf die Koronarien achten, d.h., eventuell die Klappe etwas tiefer bzw.

Nicht zu hoch implantieren.

vielen Dank und Schöne Grüße,

Frank Kuester

TDM

Transcathetervalves

Medtronic GmbH

Mobil:0175/9354814

Am 02.07.2012 um 09:22 schrieb "Horst Sievert" <[email protected]>:

> PS: Frage zu Habermann: Hatten Sie sie auch in Holland beurteilen lassen?

>

>

>>

>>

>> On 18.06.2012 09:32, Kuester, Frank wrote:

>>> Hallo Herr Prof. Sievert,

>>> Im folgenden die Beurteilung Ihrer Patienten.

>>>

>>> Patientin Habermann, Johanna

>>> Leistengefäße OK.

>>> Annulus 19-21mm ( Echo, CT), relativ stark verkalkt.

>>> 26 mm Corevalve Implantation möglich.

>>> Vielen Dank und Schöne Grüße,

>>>

>>>

>>>

>>>

>>>

>>>

>>>

>>> Frank Kuester

>>> TDM

>>> Transcathetervalves

>>> Medtronic GmbH

>>> Mobil:0175/9354814

>>>

>>>>



Thank you!

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Just Another Crazy TAVI Case