Alec Vahanian, FESC, FRCP Bichat Hospital, Paris Assembling the “Heart team” : Dynamics , Decision making and Collaboration During Procedures Alec Vahanian, FESC, FRCP Bichat Hospital, Paris Put the title of french society of cardiology ,see with stephanie

Alec Vahanian, MD Honoraria: Valtech Edwards Lifesciences Medtronic Abbott

(EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29: 1463-1470, Euro intervention a rajouter chaque fois (EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29: 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4:193-199) 4

The “Heart Team” A group of valve specialists who collaborate to: Select the most appropriate procedure Perform the procedures Evaluate the results (EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29: 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4:193-199)

Transcatheter Aortic Valve Implantation The « Heart Team » CARDIOLOGISTS SURGEONS Anesthesiologists Transcatheter Aortic Valve Implantation Other specialists: Geriatricians …… Imaging specialists (Echo, CT, MRI) With expertise in the treatment of valve disease EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29: 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8

Risk-Benefit Assessment Decision-making for intervention is multifactorial: Prognosis according to severity and consequences of valvular disease Risks and late consequences of intervention Patient life expectancy and quality of life Patient wishes after information Local resources, in particular results of surgery

Predicted mortality (STS ) :11.7% Observed operative mortality : 6.4% Risk Scores Good discrimination (low vs. high risk) But poor calibration (predicted vs. observed risk) (Iung Heart 2008;94:519-24) PARTNER A Predicted mortality (STS ) :11.7% Observed operative mortality : 6.4% (Dewey et al. JTCS 2008;135:180-7) (Brown et al. JTCS 2008;136:566-71)

Assessment of Frailty Surgeon’s eye-ball test and beyond !!!! In the past, surgeons have determined whether patients are frail or not frail based on gross physical examination and clinical covariates commonly associated with frailty (age, gender, BMI, comorbid conditions) • The patient just “looks too frail” • However, there are potential issues with subjective assessment: • Even greater challenge in the AS/heart failure population • Surgeon dependent: wide variation among evaluating physicians because it’s purely subjective. • May be based on chronologic age alone which is not always appropriate. 9

Assessment of Extra-Cardiac Factors Frailty (Katz score + Ambulation Aid + Dementia) Neurological dysfunction (with functional impairment) Pulmonary disease (GOLD stage II) Peripheral vascular disease (including porcelain aorta) Renal disease (KDOQI Stage 3, GFR < 60 mL/min) Poor Metabolic state (high bilirubin, low albumin, Diabetes, hyponatraemia, PT …), BMI < 20, Liver failure (Child-Pugh)….

Conventional AVR Medical Rx (59%) Screening in Bichat among 603 High-risk Patients Referred for TAVI EuroSCORE ≥ 20% - STS PROM ≥ 10% / CI to AVR Conventional AVR 54 (9%) Medical Rx 195 (32%) TAVI 354 (59%) « Cohort C » 11

Needs Who Skills Cardiologists/ Clinical/ echocardiography Surgeons Surgeons/ Anesthesiologists/ Geriatricians Skills Clinical/ echocardiography Clinical

Risk-Benefit Assessment Decision-making for intervention is multifactorial: Prognosis according to the severity and consequences of valvular disease Risks and late consequences of intervention Patient life expectancy and quality of life Patient wishes after information Local resources, in particular results of surgery Feasibility of transcatheter intervention

Transcatheter Aortic Valve Implantation Multi-Modality Screening before Transcatheter Aortic Valve Implantation Measurement of aortic annulus When looking at the decision for implantation and the choice of prosthesis size based on TEE the decision would have changed in 40% of patients if MSCT was used (Messika-Zeitoun. J Am Coll Cardiol, 2010;55:186-94) Distance coronary – aortic valve Evaluation of calcium distribution

Other Contraindication LV apical thrombus Contrast echo, MSCT Dynamic subaortic obstruction Echo Severe organic MR is a contraindication but functional MR is not

Vascular Access Judgement based on the combination of : Conventional angio + MSCT Sagittal + transversal views Judgement based on the combination of : Minimal diameters 18 Fr: 6mm 22 Fr: 7mm 24 Fr: 8mm Calcification (grading) Tortuosity Choice of the approach

Needs Skills Who Clinical/ Cardiologists/ Surgeons echocardiography Echocardiography / CT/ MRI Who Cardiologists/ Surgeons Cadiologists/ Surgeons/ Geriatricians Cardiologists/ Radiologists/Surgeons

The “Heart Team” A group of valve specialists who collaborate to: Select the most appropriate procedure Perform the procedures Evaluate the results (EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29: 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4:193-199)

Where Should we Perform? In cardiology and cardiac surgery centers Make in specialised centres appear first then as it is 19

FRANCE 2 Procedural characteristics (84%) 74.7% 15.3% 9.9% (21%) (12%) (84%) General anesthesia, % 59 % Per-procedure TEE, % 60.7 % 74.7% (67%) Operative room Cath-lab Hybrid room

Echocardiography is Helpful in Monitoring the Procedure

New Systems for Navigation and Positioning during TAVI

Transfemoral Approach Percutaneous access + surgical closure Surgical access and closure Percutaneous access and closure (closure device)

Alternatives to the TF approach Transapical (Edwards Sapien) Subclavian (Medtronic CoreValve) Transaortic (Both)

« Complementary Techniques » Severe symptomatic AS Agreed high surgical risk Annular sizing Echo/CT/both Coronary sinus/LVOT suitable Re-evaluate surgical options 18-20 mm 20-25 mm 25-27 mm Proximal ascending aorta ≤40 mm (20-23 mm annuli) ≤ 43 mm (23-27 mm annuli) no Femoral sizing angio/CT/both Femoral>6mm yes no Femoral sizing angio/CT/both Fem ≥ 6 mm no yes no yes Axillary ≥ 6 mm Edwards Transapical Edwards Transfemoral CoreValve Transfemoral no yes or Direct Aortic Access CoreValve Transaxillary (Jilaihawi. JACC: Cardiovasc Int 2010;3:859-66.)

Traumatic Iliac Dissection Post-procedure angio Dissection Stenting Final Result

Rescue Surgery « Be prepared »

Needs Who Skills Cardiologists/surgeons Clinical /echocardiography Cardiologists/surgeons/ Geriatricians Cardiologists/surgeons/ radiologists Interventionists/ echocardiographists/ anesthesiologists/ surgeons/paramedical staff of cath lab Skills Clinical /echocardiography Clinical Echocardiography/CT Working in a sterile environment/valvular catheterization/balloon valvuloplasty/vascular access/peripheral intervention /valve surgery/cardiac assistance

Needs Who Skills Interventionists/ anesthesiologists/ surgeons/ paramedical staff of cath lab and/or Cardiologists/surgeons/ anesthesists/intensive care/EP specialists Skills Working in a sterile environment/Valvular catheterization/balloon valvuloplasty/vascular access/peripheral intervention/monitoring/valve surgery/Cardiac assistance Post operative care

Training Steps basic training Advanced skills Device specific skills Device training Advanced skills Disease or procedure-specific skills basic training Basic endovascular skills Basic surgical and valve disease skills 31

Accredited Programs vs Alternative Training Current pathway Cross training Bench training and Simulators Animal lab PCR / TCT / CRT /JIM / ICI ........... Industry sponsored postgraduate courses Scientific Societies sponsored postgraduate courses Accredited postgraduate residency or fellowship training program 32

The “Heart Team” A group of valve specialists who collaborate to: Select most appropriate procedure Perform it Evaluate the results

Evaluation of TAVI As well as enrolment in randomized clinical trials, data should be accumulated in registries with F.U. In centres performing TAVI, multidisciplinary meetings should be held to discuss indications, procedural techniques, and case outcomes. Hospitals should keep proof of close medico-surgical collaboration and maintain a log of all patients referred to TAVI for continuous evaluation of the programme (EACTS/ESC/EAPCI Position Statement, Eur Heart J, 2008; 29: 1463-1470, Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4:193-199)

Conclusions Team members must learn to collaborate, select the best candidates, perform the procedure and evaluate the results Institutional and individual training is necessary The appropriate environment must be available in terms of sterility, imaging, access to surgery and cardiac support

“We may have all come in different ships, but we’re in the same boat now” Martin Luther King, Jr.