1. 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

2. Alec Vahanian, MD Honoraria: Valtech Edwards Lifesciences Medtronic
Abbott

3. (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: ,
Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4: ) 4

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: ,
Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4: )

5. 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: ,
Eur J Cardiothorac Surg 34 (2008) 1-8

6. 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

7. 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)

8. 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

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)….

10. 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

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

12. 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

13. 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

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

15. 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

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

17. 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: ,
Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4: )

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

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

20. Echocardiography is Helpful in Monitoring the Procedure

21. New Systems for Navigation and Positioning during TAVI

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

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

24. « 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: )

25. Traumatic Iliac Dissection
Post-procedure
angio
Dissection Stenting
Final Result

26. Rescue Surgery
« Be prepared »

27. 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

28. 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

29. 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

30. 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

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

32. 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: ,
Eur J Cardiothorac Surg 34 (2008) 1-8, Eurointerv. 2008; 4: )

33. 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

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