Gates Vascular Institute

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Presentation transcript:

Gates Vascular Institute Emergent TAVR in a Failed Surgical Aortic Bioprosthesis Presenting in Cardiogenic Shock Vijay Iyer MD PhD Rose Hansen DNP Gates Vascular Institute Buffalo New York

Rose Hansen DNP I have no relevant financial relationships I have no relevant financial relationships Vijay Iyer MD PhD

Learning objectives Diagnosis of AR in C-Shock TAVR VIV App Urgent Application Feasibility of Emergent VIV TAVR for Cardiogenic shock

Clinical Presentation : 7/11/16 @1600 Outlying Facility Initial Trop 0 Clinical Presentation : 7/11/16 @1600 Outlying Facility Initial Trop 0.1 CP resolved Age: 52 year old Male STS:41.8%/80% NYHA Class IV CAD, PCI to LAD2005 Combined : CABG 2 valves 2014 ~ LIMA to Diag/SVG to RCA ~MV Repair Edwards Physio Annuloplasty ring with Alfieri Suture ~ AVR Medtronic Freestyle 25mm Labs Creatinine= 1.35 GFR= WBC= 8.7 PLT= Hgb= 12.3 HCT= BNP= 109 INR=1.1 Albumin=3.5 Bili=0.8 troponin 3.2 Rheumatoid arthritis, previously treated with methotrexate NIDDM LBBB Former smoker 35-pack-year history Ht: 180cm Wt: 88kg BSA: 2.1 BMI:27.8 7/11 @ 1600Pt presented with acute onset chest pain and shortness of breath while working. Allergies: NKDA Stable awaiting AM transfer for R&L Summary:

Presenting EKG 7/11

Summary: 7/12/16 transferred to GVI for R&L Heart Cath 7/12 @1500 SOB, Decompensated Flash Pulmonary Edema requiring intubation while awaiting catheterization. R&L revealed patent grafts, patent LAD. EF 50%. TEE revealed torn/flail aortic valve leaflet, severe aortic regurgitation. TAVR TEAM was finishing a TAVR case when urgent call came for Surgeon. Edwards Rep Onsite Team prepped for TF TAVR with available information Summary:

Native Left Coronary

Cath: LIMA/LAD

RCA

SVG to PDA

AortaGram

Pre TEE

Illiofemoral Runoff

VIV APP: 26mm Sapien3

Post TAVR deployment

Summary: 52-year-old with cardiogenic shock and aortic regurgitation in a bioprosthetic valve Successful implantation of 26 mm Edwards Sapien 3 into a 25 mm Freestyle Implantation of lmpella 2.5L for hemodynamic support × 24 hours LBBB development Transfer to CVICU Perioperative CVA Per MRI with right foot drop Discharged to home postop day 7 Right peroneal nerve compression improved Return to light duty work in 2 weeks 30 day follow-up. No complaints chest pain or CHF. Drives. Echo EF 45%, mean gr 15mmhg Creat 0.8 LBBB resolved

30 Day Post TAVR

Take Home Messages Emergent TAVR can be done successfully in select cases Valve in valve application proved invaluable A well trained heart team can save lives and promote good outcomes.