Tratamiento de la insuficiencia mitral cuando quirurgico y cuando percutaneo

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Maspalomas, Octubre 2011

NOVEDADES QUIRÚRGICAS EN TERAPIA VALVULAR. 2011 José L. Pomar, MD, PhD Director Adjunto Instituto Clínico del Tórax Hospital Clinic Universidad de Barcelona

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PRIMERAS PRÓTESIS HETEROTÓPICAS

Maspalomas, Octubre 2011

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PRIMERAS PRÓTESIS ORTOTÓPICAS

Maspalomas, Octubre 2011

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ULTIMOS DISEﾃ前S DE BIOPROTESIS

Maspalomas, Octubre 2011

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LO MAS NOVEDOSO, ES NOVEDOSO ?

Maspalomas, Octubre 2011

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Maspalomas, Octubre 2011

VALVULA AÓRTICA Homoinjertos: Presente y futuro de unos pocos privilegiados Bioprótesis: Crecimiento exponencial. Nuevos diseños. Nuevos accesos Procedimientos percutaneos.

Prótesis mecánicas: la anticoagulación, será imprescindible?

VALVULA MITRAL Reparar siempre mejor que cambiar?

Algo nuevo en la reparación?

Procedimientos percutaneos VALVULA TRICUSPIDE Reparaciones en VD muy dilatados Prótesis: Está ya todo dicho?

LA IMAGEN Y LA CIRUGIA VALVULAR

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VÁLVULA AÓRTICA

Maspalomas, Octubre 2011

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HOMOINJERTOS E INGENIERIA TISULAR

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HOMOINJERTOS Y SOLUCIONES

Maspalomas, Octubre 2011

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REPARACION VALVULAR AÓRTICA

Maspalomas, Octubre 2011

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BIOPROTÉSIS

Form follows function

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BIOPROTÉSIS Del implante tradicional al simplificado

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BIOPROTÉSIS Del implante tradicional al simplificado

Perceval de Sorin Intuitive de Edwards

179 patients with symptomatic severe aortic stenosis

90% 69% P=0.01

Hospital Clinic University of Barcelona

CURSO PRACTICO DE ACTUALIZACIÓN CARDIOVASCULAR. Barcelona 2008

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Porcelain ascending aorta

Maspalomas, Octubre 2011

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2 parts composite graft

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INDICATIONS for TAVI

•Quantitative assessment

•Clinical judgment

•LOGISTIC EUROSCORE >20%

•Chest radiation

•STS >10%

•Previous CABG •Porcelain aorta •Liver cirrhosis •Etc…..

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Maspalomas, Octubre 2011

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≤ 30-Day Adverse Events (N = 948)

30‐Day All Mortality Rate

68 (7.2%)

Cardiac Deaths** Myocardial Infarction Major Arrhythmias Pacemaker

42 (4.4%) 6 (0.6%) 30 (3.2%) 84 (8.9%)

Renal Failure Stroke TIA Structural Valve Dysfunction Valve Migration

10 (1.1%) 14 (1.5%) 5 (0.5%) 0 (0.0%) 0 (0.0%)

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Maspalomas, Octubre 2011

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Interferencia con los orificios coronarios

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Pseudoaneurisma post apical

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Symetis reports on its trans-apical ACURATE TATM first-in- man clinical study

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Paniagua

Enable PHV

Maspalomas, Octubre 2011

AorTx

Direct Flow

Heart Leaflet Technologies

Valvexchange

Sadra

Perceval

Jena

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Unknowns by 2011 • Unknown durability in humans after 6 years

• Unknown effects on heart failure progression

• Unknown effects of remaining AoI on ventricular remodeling

• Unknown effect on the ability to do subsequent valve repair or replacement

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Maspalomas, Octubre 2011

PROACT: Early results show high-risk patients do well with low warfarin and carbon valve

MCRI's On-X Prosthetic Heart Valve in Aspirin Study; Clinical Study May Provide Evidence to Support Eliminating the Use of Warfarin As an Anticoagulant for On-X Mechanical Valve Recipients

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Maspalomas, Octubre 2011

Enrollment Objective Achieved for Aspirin and Clopidogrel Patient Group of the On-X Heart Valve Anticoagulation Clinical Study

Two Antiplatelets No Better Than Aspirin Alone After TAVI

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VÁLVULA MITRAL

Maspalomas, Octubre 2011

The Master of Valve therapy

Bad Neustadt, October 2011

The echocardiographic assessment

Perforation of the leaflet observed under normal, colour doppler and at surgery

The Master of Valve therapy

Bad Neustadt, October 2011

Large defect on the Anterior Leaflet

The Master of Valve therapy

Bad Neustadt, October 2011

Flail leaflet after chordal rupture in BE Perforation on a previously rheumatic mitral

The Master of Valve therapy

Bad Neustadt, October 2011

The Master of Valve therapy

RD.Leiden MC

Bad Neustadt, October 2011

RD.Leiden MC

Repairing with a pericardial patch a Type I lesion of an acute endocarditis

The Master of Valve therapy

Bad Neustadt, October 2011

Reconstruction of anterior leaflet and posterior commissure

The Master of Valve therapy

Bad Neustadt, October 2011

The Master of Valve therapy

SURGICAL FINDINGS

Bad Neustadt, October 2011

SURGICAL REPAIR

The use of a prosthetic ring was unnecessary in this case

The Master of Valve therapy

Bad Neustadt, October 2011

Mitral abscesses and tissue destruction management Posterior annulus management radical excision direct reconstruction ? autologous pericardial patch with GA partial homograft Anterior annulus management mitro-aortic continuity radical excision multi-patch reconstruction Commissures radical excision plication and annuloplasty partial homograft

mitro-aortic management

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Partial Homograft Mitral Valve Implantation

Mitral homograft

Mitral homograft implant in an IVDA patient and histopathology after 12 years

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Indirect MITRAL VALVE Annuloplasty CS - Reshaping

Bridge

MONARCH ELS Distal Anchor

Proximal Anchor

CARRILLON

CARDIAC DIMENSIONS

Carillon XE

PTMA Implant Device Shaft ( NiTi ) PTFE Unused Lumen Filler

PTMA

VIACOR

PTMA Implant Device Proximal Stops (Ti)

PTMA Implant Hub and Cap (Ti)

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Indirect MITRAL VALVE Annuloplasty CS – Reshaping NIH CERCLAGE of Lederman • Circumferential tension around mitral

annulus • CS – proximal septal branch of GCV –

image guided (MRI roadmapping coupled with fluoroscopy) traversal of myocardium to reenter right heart chambers • Circle is closed by snare retrieval than applying and fixing graded tension to reduce MR • Successful MR reduction in 14/16

swine with suitable anatomy

Maspalomas, Octubre 2011

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Direct Annuloplasty

MITRALIGN

• Retrograde access to post MV annulus - Direct annular reduction: • • • •

Suture-anchor plication Guiding catheter in CS with radio-opaque markers placed at P1, P2 and P3 Trident catheter delivers wires in P1, P2 and P3 FIM: Jan-2008 – Dr. Adrian Ebner – Paraguay CE Pilot study PI: Prof. E. Grube

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Maspalomas, Octubre 2011

Direct Annuloplasty Aortic Valve

ACCUCINCH GDS

Anterior Leaflet

Cinching implant below the posterior mitral annulus Trigone-to-Trigone

P3

P 1

Posterior Leaflet

P 2

Anchors

Anchors Therapeutic Area

49

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Direct Adjustable Annuloplasty (Hybrid Techniques) MICARDIA • Ring implanted surgically during

conventional surgical repair • Direct mechanical adjustability • in OR or Cath Lab • 2 sizes • 24 to 30 • 30 to 38

Pre-implant

Post-implant

Post-adjustment

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Direct Adjustable Annuloplasty (Hybrid Techniques)

DYNAPLASTY MICARDIA

• Ring implanted surgically during conventional surgical repair • RF energy mediated reshaping • In OR by suture-electrodes • In Cath Lab with a catheterbasket and electrode mounted on the splines - docking confirmed by impedance • Completed FIM trials 2012

Maspalomas, Octubre 2011

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Maspalomas, Octubre 2011

Leaflet Plication MITRACLIP ABBOT • Over 300 cases - Everest I and Everest II (randomized+registry) in 36 sites • Freedom from death at 36 Mo: 97% • Freedom from Sx at 36 Mo: 85% • Freedom from death, surgery or MR>2+ at 36 Mo: 67%

•

Guide catheter 17-19 Fr

•

Stitch Catheter 11-12 Fr

•

Housing with a vacuum port, needles and suture

•

Fastener catheter 7 Fr.

•

After FIM, device is being redesigned

Stitch + Nitinol Anchor

5 2

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Leaflet Plication MitraFlex – TransCardiac Therapeutics TransCardiac Port™ •

Allow access into the chambers of a beating heart

TransCardiac Navigator™ •

Enables maneuverability within a beating heart

Clip advanced to hold the leaflets at midpoint

Maspalomas, Octubre 2011

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Leaflet Plication MitraFlex – TransCardiac Therapeutics

Reach the Mitral Valve Percutaneously

Leaflet Stabilizer ™ deployed to hold leaflets in place Clip or Stitch to hold the leaflets at midpoint

Maspalomas, Octubre 2011

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Percutaneous Artificial Chordae Implantation NEO CHORDS

Fiber optics

Maspalomas, Octubre 2011

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Percutaneous Artificial Chordae Implantation BABIC DEVICE

Artificial

Cordae Implanted

Maspalomas, Octubre 2011

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MitraClip

Maspalomas, Octubre 2011

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Space Occupier Mitra-Spacer and Percu-Pro by Cardiosolutions

• • • • • • •

Femoral Access I.C.E visualization Trans-septal approach Anchor in apex Mitra-Spacer™ positioned mid-valve Self-centering Currently finishing chronic animal studies – Pre Clinical • Acute animal n=40 • Chronic animal n=10 (30,90 and 180 days)

Maspalomas, Octubre 2011

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Percutaneous Mitral Valve Implantation Endovalve-Herrmann Prosthesis

• Active anchoring • Rigidity and structure is

not stent based • Re-deployable • Fully valve-sparing • In-vivo ovine testing is ongoing

Maspalomas, Octubre 2011

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Maspalomas, Octubre 2011

Percutaneous Mitral Valve Implantation Georg Lutter Mitral Valve Prosthesis Figure 1. Transesophageal echocardiographic views of the mitral valved stent. Figure 1A shows the valved stent along LV long axis view at 0 degree angle. Note the visible valve leaflets inside the body of the stent. Figure 1B represents the color frame showing the unobstructed LVOT and its relationship with the new mitral valved stent.

Figure 2. TEE Doppler examination of the mitral valved stent and LVOT flows. Figure 2A illustrates the amount of regurgitation (trace) on Continuous Wave Doppler exam to assess the forward flow through the mitral valved stent. Figure 2B shows the Pulse Doppler exam through the LVOT showing unobstructed flow by the neighboring mitral valved stent.

(Lozonschi L and Lutter G: University of Kiel and University of Wisconsin)

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Minithoracotomy

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VÁLVULA TRICUSPIDE

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VÁLVULA TRICUSPIDE

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Is it to repair, replace by a bioprosthesis or a mechanical device?

Callahan et al.Am Heart J.1982;50:762

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LA IMAGEN REVOLUCIONA EL DIAGNOSTICO Y EL TRATAMIENTO

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LA IMAGEN REVOLUCIONA EL DIAGNOSTICO Y EL TRATAMIENTO

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LA IMAGEN REVOLUCIONA EL DIAGNOSTICO Y EL TRATAMIENTO

Allied Health Care Professionals

The Roland Hetzer Society, Lisbon 2011

But training and caring of all our allied personnel is also crucial

Allied Health Care Professionals

The Roland Hetzer Society, Lisbon 2011

The obesity network

Christakis NA, Fowler JH. NEJM 357 (4):370‐379, 2007

Allied Health Care Professionals

The Roland Hetzer Society, Lisbon 2011

Hubs in biological interaction networks Experimental asthma in a mouse model

Allied Health Care Professionals

The Roland Hetzer Society, Lisbon 2011

Systems Collection of linked individual elements with emerging properties that can not be attributed to each element considered separately.