3/18/2013
Egyptian TAVI Experience …
How to Initiate a TAVI
Program in Egypt
Ahmed Khashaba
Assistant Professor, Cardiology Department
Ain Shams University
Cath Lab Director, Al Dorrah Heart Care Hospital
Expansion Through Safe Growth
> 34,000 patients
> 60 Countries
Safe Growth Achieved Through Careful Site Selection
and Consistent Training Processes
BIBA Medical Quarterly TAVI Report, Q2 2012. 2012 data annualized.
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3/18/2013
For a successful TAVI program …
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The “Program” concept
“Heart Team” Is Essential
The Setup
Site Activation
Adjunctive Imaging
TAVI Interventionalist … Specialized Skill
Vascular Access and Closure
The “Program” concept …
• TAVI needs to be a
PROGRAM
• No single physician
can do it
• It is the
interdisciplinary
team approach
that leads to a
successful program
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3/18/2013
For a successful TAVI program …
•
•
•
•
•
•
•
The “Program” concept
“Heart Team” Is Essential
The Setup
Site Activation
Adjunctive Imaging
TAVI Interventionalist … Specialized Skill
Vascular Access and Closure
“Heart Team” Is Essential…
Cardiac Team for patient
selection
• It requires a lot of “wisdom”
• Exclude the ideal surgical
candidate.
• Exclude the patient with multiple
comorbidities that will not feel
better without aortic stenosis.
• Analysis of frailty: quantitative
(scales) and subjective (eye test).
• Value of Valvuloplasty
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3/18/2013
“Heart Team” Is Essential…
Cardiac Team for patient
selection
Cath Lab/OR expert
team
• Surgical program with extensive
experience in valvular heart
disease: heart surgeons,
anesthesiologists, ICU care team,
nursing team.
• Cath Lab with extensive
experience in structural and
PVD: high quality imaging,
vascular dedicated tools (i.e.
stent grafts), and the ability to
handle serious complications
“Heart Team” Is Essential…
Cardiac Team for patient
selection
Cath Lab/OR expert
team
ICU expert team
Clinical Cardiologists for
post TAVI care
• Cardiac Anesthesiology
• Conscious Sedation vs General
Anesthesia
• management of the complex
hemodynamics of critical AS
undergoing TAVI
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3/18/2013
“Heart Team” Is Essential…
Cardiac Team for patient
selection
Cath Lab/OR expert
team
ICU expert team
Clinical Cardiologists for
post TAVI care
• Nurses
• Fellows
• Techs
• Coordinators
…. etc
Clinical team
“Heart Team” Is Essential…
Cardiac Team for patient
selection
Cath Lab/OR expert
team
ICU expert team
Clinical Cardiologists for
post TAVI care
Clinical team
Network of
Internists/Cardiologists
• Updates on the diagnosis and
management of Severe AS
through lectures, dinner
meetings, flyers, phone calls, etc.
• Timing for AVR
• Value of Exercise Testing in AS
• Diagnostic, bridge and palliative
value of Valvuloplasty
• The TAVI procedure
• Results of TAVI (Partner)
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3/18/2013
First Egyptian TAVI Team
Heart Team
Ahmed Khashaba
Alaa Roshdi
Ahmed Gafar
Walaa Adel
Sherif Essam
M El Gendy
M Imam
Nursing
M Ali
Wafaa Ali
Technicians
Hussein, Salah
Coordination
Sanaa Hassan
Recruitments
M Imam
Sanaa Hassan
Support
Suzan Fawaz
Hala Ahmed
Shaymaa M
Tamer El Deeb
Amal Mohsen
Industry
Mahmud Bassyouni
For a successful TAVI program …
•
•
•
•
•
•
•
The “Program” concept
“Heart Team” Is Essential
The Setup
Site Activation
Adjunctive Imaging
TAVI Interventionalist … Specialized Skill
Vascular Access and Closure
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3/18/2013
THE ROOM
Sterile surgical technique essential to
minimize the risk of infection
LIMIT THE NUMBER OF PEOPLE IN THE ROOM !
Room Setup
Additional Equipment
• Pacemaker capable of rapid atrial pacing above
200 bpm
Bailout Material
• Bypass equipment primed and ready
• Surgical Instruments
• Coronary stenting
• Peripheral interventions
– Including occlusions balloons and vascular stents
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3/18/2013
The Room
General Anesthesia
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Anesthetic consult
Inhalational +/- intravenous anesthetic
Non-depolarizing muscle relaxant
Endotracheal intubation
Central venous access
Radial arterial pressure, oximetry, capnography
Extubate in cath lab
Defibrillation pads placed on all patients (bi-axillary position)
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3/18/2013
For a successful TAVI program …
•
•
•
•
•
•
•
The “Program” concept
“Heart Team” Is Essential
The Setup
Site Activation
Adjunctive Imaging
TAVI Interventionalist … Specialized Skill
Vascular Access and Closure
Edwards THV Program
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3/18/2013
Edwards THV Program
April 2002
December 11, 2011
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3/18/2013
For a successful TAVI program …
•
•
•
•
•
•
•
The “Program” concept
“Heart Team” Is Essential
The Setup
Site Activation
Adjunctive Imaging
TAVI Interventionalist … Specialized Skill
Vascular Access and Closure
Echocardiography
AVA: 0.8 cm2
Peak PG: 98 mmHg
RVSP: 50 mmHg
AV annulus: 21 mm
Mean PG: 61 mmHg
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3/18/2013
Cardiac CT
Access Evaluation
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3/18/2013
For a successful TAVI program …
•
•
•
•
•
•
•
The “Program” concept
“Heart Team” Is Essential
The Setup
Site Activation
Adjunctive Imaging
TAVI Interventionalist … Specialized Skill
Vascular Access and Closure
TAVI Interventionalist …
• See as many cases as possible (live
demonstrations, visits to TAVI Centers, training
sessions, etc.).
• Be familiar with the published literature:
indications, procedural aspects, complications.
• Have extensive Valvuloplasty experience.
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3/18/2013
Pacemaker wiring and Test of rapid pacing
22F sheath in place in the LFA
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3/18/2013
23mm BAV with supra-Ao angiogram
Valve delivery (RVP 200/min)
LAO 15°
Cranial 10°
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3/18/2013
For a successful TAVI program …
•
•
•
•
•
•
•
The “Program” concept
“Heart Team” Is Essential
The Setup
Site Activation
Adjunctive Imaging
TAVI Interventionalist … Specialized Skill
Vascular Access and Closure
Surgical exposure of the femoral artery
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3/18/2013
Repair of femoral entry site
Complications
• Bleeding
• Vessel obstruction
• (Vessel rupture)
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3/18/2013
Vascular Complications - TAVI
Solutions
• Smaller profile sheaths (and new expandable
sheath systems)
24F
22F
18F
Vascular Complications - TAVI
Solutions
• Smaller profile sheaths (and new expandable
sheath systems)
• Meticulous vascular screening and team training
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3/18/2013
Vascular Complications - TAVI
Solutions
• Smaller profile sheaths (and new expandable
sheath systems)
• Meticulous vascular screening and team training
• Liberal use of alternative vascular access sites
(don’t push the envelope)
Transcatheter valve therapy
access routes
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3/18/2013
Vascular Complications - TAVI
Solutions
• Smaller profile sheaths (and new expandable
sheath systems)
• Meticulous vascular screening and team training
• Liberal use of alternative vascular access sites
(don’t push the envelope)
• Percutaneous access and closure (and new
dedicated closure devices in the future)
– Simplifies the procedure and facilitates use of conscious sedation
– Improves comfort and facilitates early ambulation (and discharge)
– Becomes comprehensive interventional non-surgical procedure –
less dependence on OR environment, anesthesia, and surgeons
Conclusions …
• TAVI has initiated a revolutionary “new
era” in Medicine and Surgery
• You are all welcome to TAVI, enjoy the
excitement, work hard for its success, and
share it all with your team.
• Patients well being is the ultimate
objective
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3/18/2013
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