Dr. León Valdivieso Staff. Dpto de Cardiología Intervencionista. Fundación Favaloro

Transcripción

1 TAVI Complicaciones periprocedimiento. Impacto en la evolución Dr. León Valdivieso Staff. Dpto de Cardiología Intervencionista

2 Conflictos de Intereses: Ninguno relacionado a esta presentación.

3 LBBB Stroke Vascular Complications Mitral Regurgitation SRIS Aortic Regurgitation Myocardial Injury

4 Left bundle-branch block induced by transcatheter aortic valve implantation increases risk of death. Multicenter Registry n = 679 CoreValve n = 387 (57%) Edwards SAPIEN n = 292 (43%) New LBBB 51.1% n = 233 (34.3%) 12.0% Follow-up 15 months Houthuizen et al. Circulation 2012;126:720-8

5 Left bundle-branch block induced by transcatheter aortic valve implantation increases risk of death. Mortality According to the Development of New LBBB ,8 24 All-cause Mortality p=0.002 New LBBB No New LBBB Houthuizen et al. Circulation 2012;126:720-8

6 Left bundle-branch block induced by transcatheter aortic valve implantation increases risk of death. Independent predictors of all-cause mortality New LBBB (HR: 1.54; CI: ) COPD (HR: 1.56; CI: ) Female (HR: 1.39; CI: ) LVEF 50% (HR: 1.38; CI: ) Baseline Creat. (HR, 1.32; CI, ) Houthuizen et al. Circulation 2012;126:720-8

7 30 Days - CoreValve The Bern Experience N=150 Eltchaninoff EHJ in press N=78 Zahn EHJ in press N=588 Avanzas RevEspCard 2010 N=108 Petronio Circ Interv 2010 N=514 Piazza EuroInterv 2008 N=646 Bleiziffer EurJCVSurg 2009 N=103 Grube Circ Interv 2008 N=136 Büllesfeld submitted N=126 S Wendecker. %

8 Risk of Stroke After Ttanscatheter Aortic Valve Implantation (TAVI): A Meta-Analysis of 10,037 Published Patients. Meta-analysis of 53 studies ( ) withn 10,037 TAVI patients ,2 3,3 1,5 Procedural 30 days 1 year Eggebrecht H et al. EuroIntervention 2012;8:129-38

9 Risk of Stroke After Ttanscatheter Aortic Valve Implantation (TAVI): A Meta-Analysis of 10,037 Published Patients ,5 Stroke No Stroke d Mortality 6,9 Eggebrecht H et al. EuroIntervention 2012;8:129-38

10 25 Peri-procedural Complications - CoreValve Vascular Complications 20 19,5 16,0 % ,9 1,8 5,6 13,0 9,5 7,5 0 Mu Piazza Eur Petronio It Sp Ger Net Tch Fr Bleiziffer EurJCVSurg 2009 N=103 EuroInterv 2008 N=646 Circ Interv 2010 N=514 Avanzas RevEspCard 2010 N=108 Zahn EHJ in press N=588 v. Mieghem EuroInt 2010 N=99 Tchetche EuroInt 2010 N=21 Eltchaninoff EHJ in press N=78 S Wendecker.

11 Vascular Complications After Transcatheter Aortic Valve Replacement TF-TAVI n = 419 PARTNER B (inoperable) n = 177 PARTNER A (high-risk) n = 242 Vascular Complications (VC) n = 114 (27.2%) Major VC* n = 64 (15.3%) * female gender was the only independent predictor of major VC Généreux el al. JACC 2012;60: Minor VC n = 50 (11.9%)

12 Vascular Complications After Transcatheter Aortic Valve Replacement 30-d MAJOR VASCULAR COMPLICATIONS 0,7 9,5 3,4 1,6 0,5 Vascular dissection Vascular perforation 22,9 62,8 Access site hematoma Retroperitoneal bleeding 31,3 False aneurysm Gastro-intestinal ischemia Aortic dissection LV perforation Généreux el al. JACC 2012;60:

13 Vascular Complications After Transcatheter Aortic Valve Replacement 30-d Events According to the Occurrence of Major VC p< ,9 p< ,7 Major VC p< p= No Major VC ,1 12,6 3,1 2,8 6,8 5,4 Death CV Death Major bleed Transfusion Généreux el al. JACC 2012;60:

14 Vascular Complications After Transcatheter Aortic Valve Replacement 1-y Events According to the Occurrence of Major VC ,4 p=0.001 p< ,8 27,4 Major VC No Major VC ,7 0 Death CV Death Généreux el al. JACC 2012;60:

15 Transcatheter Aortic Valve Replacement: Outcomes of Patients With Moderate or Severe Mitral Regurgitation. 451 TAVI patients stratified by MR status (71% mild, 29% mod/sev) Mejor* Sin Cambio Peor Inicial 1 año Inicial 1 año Inicial 1 año Moderada n=89 62% 58% 27% 17% 5% 1% Severa n=43 60% 49% 33% 16% - - * - Gradiente aórtico medio 40 mmhg - Funcional MR - Ausencia de HTTP - Ausencia de FA Toggwiler S, et al. JACC 2012;59:

16 Transcatheter Aortic Valve Replacement: Outcomes of Patients With Moderate or Severe Mitral Regurgitation. Toggwiler S, et al. JACC 2012;59:

17 Mortalidad (%) Systemic Inflammatory Response Syndrome Predicts Increased Mortality in Patients After TAVR Single-center study of 152 high-risk pts with symptomatic severe aortic stenosis January 2008 to June SIRS in 40.1% 2 de los siguientes: - Fiebre > 38 C o Hipotermia ,5 p< Taquipnea (< 20 x ) o PaCO2 < Taquicardia > 90 lpm - Leucocitos > o < 4000 o neutrófilos inmaduros > 10% p< ,9 SIRS No SIRS - TAS < 90 o TAD < 60 mmhg 0 1,1 30 días 1 año Sinning J-M, et al. Eur Heart J. 2012;Epub ahead of print.

18 Aortic 2 Year Gerckens, Ulrich, MD. Safety, Durability and Effectiveness at Two Years with the 18 Fr CoreValve Transcatheter Aortic Valve. EuroPCR 2010

19 Impact of Paravalvular Leakage on Outcome in Patients After Transcatheter Aortic Valve Implantation 122 TAVI ptes (CoreValve 79.5%, Edwards SAPIEN 20.5%) Severity of periar was evaluated by: Echocardiography Angiography Periprocedural measurement of the dimensionless AR index: diastolic blood pressure - left ventricular end-diastolic pressure x 100 systolic blood pressure A cutoff value of 25 was used to identify patients at risk. Vasa-Nicotera et ak. JACC Intv 2012;5:858-65

20 Impact of Paravalvular Leakage on Outcome in Patients After Transcatheter Aortic Valve Implantation 100% 80% 1,6 14,8 4,3 16,8 60% 40% 62,3 25,1 Severe Moderate Mild None 20% 21,3 29,4 0% Echo AR Index Vasa-Nicotera et ak. JACC Intv 2012;5:858-65

21 Impact of Paravalvular Leakage on Outcome in Patients After Transcatheter Aortic Valve Implantation 1-y Mortality p % Echo No/Mild 19.6 <0.001 Echo Mod/Sev 60.0 AR Index <0.001 AR Index < Echo No/Mild AR Index Echo No/Mild AR Index < Vasa-Nicotera et ak. JACC Intv 2012;5:858-65

22 Incidence, Predictive Factors, and Prognostic Value of Myocardial Injury Following Uncomplicated Transcatheter Aortic Valve Implantation 101 TAVI ptes (TF 38, TA 63). TnT and CKmb at 6, 12, 24, 48 and 72 hs. MORTALIDAD 30 días: 6 muertes TnT 0.98 ( ) 95 vivos TnT 0.48 ( ) 9 meses: HR 1.14 ( ) por cada 0.1 ug/l p=0.19 p=0.028 Cutoff > 0.6 ug/l S 67%, E 62% Rodés-Cabau et al. JACC 2011;57:

23 Incidence, Predictive Factors, and Prognostic Value of Myocardial Injury Following Uncomplicated Transcatheter Aortic Valve Implantation LVEF decrease according changes in cardiac biomarkers Cutoff: > 26 ug/l > 0.48 ug/l S 72% S 64% E 64% E 79% Rodés-Cabau et al. JACC 2011;57:

24 Conclusiones: Las complicaciones de TAVI, que impactan en forma adversa en la evolución son frecuentes, ocurren independientemente de las otras y por ende, puede esperarse que un porcentaje significativo de estos pacientes presenten al menos una de ellas. Todo esfuerzo farmacológico, endovascular y quirúrgico encaminado a prevenir, atenuar y/o corregir estas complicaciones deberá probar su eficacia en disminuir el impacto negativo de las mismas. Disminuyendo los factores adversos haremos de TAVI un procedimiento cada vez más seguro y efectivo.

25 Thank you for your attention