IGNOU MSCCFT and PGDCFT Exam Question Pattern: MCFT003 Counselling and Family...
What's New in Cardiac
1. What’s new inWhat’s new in
Cardiac?Cardiac?
WatchmanWatchman
Chris Saraceno, DNAP, CRNAChris Saraceno, DNAP, CRNA
NCANA District 3 & 4 MeetingNCANA District 3 & 4 Meeting
February 4February 4thth
, 2017, 2017
3. WatchmanWatchman boston Scientificboston Scientific
• Atrial fibrillationAtrial fibrillation
• Most common cardiac arrythmiaMost common cardiac arrythmia
• Morbidity & mortality of AFibMorbidity & mortality of AFib
• StrokesStrokes
• 15-20% of CVAs from Afib15-20% of CVAs from Afib
• ~30% CVAs in persons > 80 y.o.~30% CVAs in persons > 80 y.o.
• Particularly devastatingParticularly devastating
• Large emboliLarge emboli
4. Major culpritMajor culprit
• Purpose of the LAAPurpose of the LAA
• Contribute to atrial kickContribute to atrial kick
• Loss of this function in AfibLoss of this function in Afib
• Atrial natriuretic peptide (ANP)Atrial natriuretic peptide (ANP)
• Reason for clot formation in the LAAReason for clot formation in the LAA
• Shape of LAAShape of LAA
6. LAA MorphologyLAA Morphology
• A. Chicken wingA. Chicken wing
• B. WindsockB. Windsock
• Most suitable forMost suitable for
WatchmanWatchman
• C. Broccoli/cauliflowerC. Broccoli/cauliflower
• D. CactusD. Cactus
7. Prevention ofPrevention of
strokes from AFibstrokes from AFib
• Stop the arrythmia:Stop the arrythmia:
• Medical regimenMedical regimen
• antiarrythmicsantiarrythmics
• Radiofrequency Ablation (RFA)Radiofrequency Ablation (RFA)
• Problem:Problem:
• Typically, Afib is not eradicated with either treatmentTypically, Afib is not eradicated with either treatment
• ACC Guidelines do not recommend d/c of oralACC Guidelines do not recommend d/c of oral
anticoagulants (OAC)anticoagulants (OAC)
** decreased risk of CVA in patients with RFA than without** decreased risk of CVA in patients with RFA than without
8. Prevention of strokesPrevention of strokes
from AFibfrom AFib
• AnticoagulantsAnticoagulants
• Warfarin-standard of careWarfarin-standard of care
• Drug interactionsDrug interactions
• Risk of bleedingRisk of bleeding
• Narrow therapeutic rangeNarrow therapeutic range
• Frequent blood testingFrequent blood testing
• Poor compliancePoor compliance
• Diet restrictions due to food interactionsDiet restrictions due to food interactions
• Pradaxa®, Xarelto®, Eliquis®Pradaxa®, Xarelto®, Eliquis®
• Risk of bleedingRisk of bleeding
• No antidoteNo antidote
26. Aortic stenosisAortic stenosis
• Mortality with onsetMortality with onset
of symptoms:of symptoms:
• Angina: first symptom inAngina: first symptom in
2/3 pts2/3 pts
• < 5 yrs< 5 yrs
• Syncope: first symptomSyncope: first symptom
in 15-30% of ptsin 15-30% of pts
• 3-4 yr life expenctancy3-4 yr life expenctancy
• CHFCHF
• 1-2 yr life expenctancy1-2 yr life expenctancy
• Risk of sudden cardiacRisk of sudden cardiac
deathdeath
27. Aortic valveAortic valve
Repair/replacementRepair/replacement
• Current treatmentCurrent treatment
• Gold standard: AVRGold standard: AVR
• Morbidity and mortalityMorbidity and mortality
• Non-surgical candidates?Non-surgical candidates?
• PARTNER TRIALPARTNER TRIAL
• Placement of Aortic Transcatheter ValvesPlacement of Aortic Transcatheter Valves
• Superior to standard therapySuperior to standard therapy
• Equivalent to surgery in high-risk patientsEquivalent to surgery in high-risk patients
28. Sapien/sapien xtSapien/sapien xt
• Edwards LifesciencesEdwards Lifesciences
• First human implant 2002First human implant 2002
• FDA approved 2011FDA approved 2011
31. Sapien/sapien xtSapien/sapien xt
Valve Sheath Minimal arteral diameter
Sapien 23 mm 22 F 7 mm
26 mm 24 F 8 mm
Sapien XT 23 mm 18 F 6 mm
26 mm 19 F 6.5 mm
Edwards Lifesciences
32. Tavr procedure:Tavr procedure:
femoral approachfemoral approach
• PrepPrep
• TimeoutTimeout
• EquipmentEquipment
• AntibioticAntibiotic
• AccessAccess
• Femoral arterial accessFemoral arterial access
• Aortic angiographyAortic angiography
• Femoral venous accessFemoral venous access
• Pacer wire in right ventriclePacer wire in right ventricle
• Rapid ventricular pace @ 180-Rapid ventricular pace @ 180-
200 bpm200 bpm
• Heparinize prior to traversingHeparinize prior to traversing
aortic valveaortic valve
• Valvuloplasty with rapid pacingValvuloplasty with rapid pacing
• DeliveryDelivery
• Balloon deflated & withdrawnBalloon deflated & withdrawn
38. Tavr complicationsTavr complications
• Acute coronary obstructionAcute coronary obstruction
• Displaced native valveDisplaced native valve
• DeviceDevice
• Coronary ostia not far from aortic valveCoronary ostia not far from aortic valve
• even smaller in AS ptseven smaller in AS pts
** Left main: CPB, device explantation, AVR** Left main: CPB, device explantation, AVR
40. Tavr complicationsTavr complications
• Annular and aortic root rupture/dissectionAnnular and aortic root rupture/dissection
• Device too largeDevice too large
• Risk increases with manipulation of deviceRisk increases with manipulation of device
• Perivalvular regurgitationPerivalvular regurgitation
• Inappropriate sizing- too smallInappropriate sizing- too small
• * embolize device* embolize device
• Malposition (valve in valve)Malposition (valve in valve)
• Under expansion of deviceUnder expansion of device
41. Tavr complicationsTavr complications
• AV blockAV block
• 1.8-8.5%1.8-8.5%
• AnnuloplastyAnnuloplasty
• RBBB- increases riskRBBB- increases risk
of AV blockof AV block
• PacemakerPacemaker
47. PARTNER IIA TRIALPARTNER IIA TRIAL
• December 2011-NovemberDecember 2011-November
20132013
• Severe ASSevere AS
• Intermediate riskIntermediate risk
• 1011 patients1011 patients
• RandomizedRandomized
• 57 centers in U.S. and57 centers in U.S. and
CanadaCanada
• Results:Results:
• Pacemaker requirementsPacemaker requirements
• No change fromNo change from
PARTNER TrialPARTNER Trial
• Aortic regurgitationAortic regurgitation
• 3.7%3.7%
• Not related to adverseNot related to adverse
outcomesoutcomes
2016 FDA approves Sapien XT & Sapien 3 for intermediate risk
48. Sapien 3Sapien 3
• Base on data fromBase on data from
PARTNER II TrialPARTNER II Trial
• Paravalvular leakParavalvular leak
• Skirt of fabric at base ofSkirt of fabric at base of
devicedevice
49. VARCVARC
• VALVE ACADEMIC RESEARCH CONSORTIUMVALVE ACADEMIC RESEARCH CONSORTIUM
• ComplicationsComplications
• Stroke & TIAsStroke & TIAs
• ARAR
• Vascular access complicationsVascular access complications
• Conduction system disturbancesConduction system disturbances
• Coronary artery occlusionCoronary artery occlusion
• ARFARF
65. FutureFuture
• EVEREST II TrialEVEREST II Trial
• 20152015
• 5 year follow up:5 year follow up:
• If intervention required (surgery): first 6 monthsIf intervention required (surgery): first 6 months
• After 1 year- cardiac remodelingAfter 1 year- cardiac remodeling
• Clinical outcomes similar to surgical approachClinical outcomes similar to surgical approach
• ** greater level of safety** greater level of safety
Editor's Notes
De Backer O, Arnous S, Ihlemann N, et al Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update Open Heart 2014;1:e000020. doi: 10.1136/openhrt-2013-000020
De Backer O, Arnous S, Ihlemann N, et al Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update Open Heart 2014;1:e000020. doi: 10.1136/openhrt-2013-000020
De Backer O, Arnous S, Ihlemann N, et al Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update Open Heart 2014;1:e000020. doi: 10.1136/openhrt-2013-000020
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