Another great session and over 60 attendees held out for the fully 4 hours on Zoom. My personal thanks Margot for arranging CPD points and of course the meeting- she failed to send out the coffee to each presenter via Uber-Eats…. Next time Margot.
Session 1: ASD
Beautiful imaging was shown in the assessment and of course treatment phase of ASD closure by Saleha.
No one has done any ASD closure under LA and TTE- that is done in China by one operator- personally, I cannot attain that skill set- Lest stick with doing it using GA and TOE guidance.
Does 3D help? Yes it does. It assessing more challenging rims. Bushra and Saleha showed amazing images.
Do you balloon size- still controversy- some do, and some don’t- pros and cons to both. Balloon sizing means you will likely use a larger device than if you don’t size- so less displacement, and possibly more erosion- no one really can be sure. Shak sizes, as do I.
What can’t be closed- there is of course guidance on when it is too late- Irreversible Pulmonary HT has occurred- but not on margins- we all agreed the inferior margin was the challenging one-Hard to see, and a lack of support likely to lead to the device being lost. Remember-there is always a surgical option. Bravado has no place in medicine! Alain showed some tricky cases. Sophie summarised the issues. Salim showed a tricky case. As an adult cardiologist as soon as the echo image is flipped over, I am lost!
Devices were discussed- Most felt that the Figulla offered some advantages over other devices, but all had a place in the market.
Session 2: TAVI
TAVI is moving fast- the size of the team has reduced and the procedure is more streamlined than it was. Neil showed the dramatic reductions in personnel.
Do we need an anaesthetist in the room- I have one, some don’t- I have access to one, and their sedation stills (we don’t do GA) is helpful- if the procedure is getting “frisky”, then them controlling the “top end” and us focussing on the procedure is helpful. Nurse lead sedation is commonly used now.
Do we need to do it in a surgical center- we have saved 3 lives in the last year by emergency surgery. Big debate is- if the centre has a4-8 week waiting list, should you do it in a non surgical centre- No. If the centre has a 6 month waiting list, then there will be more deaths on the waiting list than will be in the cath lab. Phil summed it up well.
Alternative access – transfemoral gives the best results- all centres need an alternative and in the UK that seems to be: Transfemoral, then Transaxillary, then Transapical, then transcaval. I showed a Transcaval case- works well when it goes well.
Who to treat? Look at the European and US guidelines- low risk, “surgical” cases could now be considered for TAVI. You need an MDT approach- the patient might want “less invasive” but may not understand pacemakers, paravalvar leaks, longevity issues. Having said that, after EST, I did a 63 year old man with a bicuspid valve who was a surgical candidate as he was scared to death of catching COVID post surgery. It did take a 1 hour consent process to be sure he, and his family were clear about the options.
Paravalvar Leaks and AFR devices:
AFR, the atrial flow regulator clearly has a place in severe Pulmonary HT when the patient is getting pre-syncope – in other cases, Jo showed what can be done- but confired that referrasl in are very slow to come- the data is there, the belief is not- and you CAN give a GA to a PHT pt safely. Matt showed its use in complex congenital heart disease. It is a good device.
AFR in heart failure- it has just not got any traction yet. I think we need more noise about this!
Paravalvar leak- each surgical centre I am sure should have one person doing it-The UK is looking at the data again- it is remarkable that a procedure that clearly works, and is safer than redo-surgery in most cases, might be asked to be validated in a RCT against surgery. I would personally have difficulty in sending patienst to such a trial. Lets see.
If you are doing these cases, then superlative, 3D, TOE imaging is key, and pre planning with CT. Bushra as ever showed some amazing images. We showed one of our cases that was we thought a one in a million case. It never is. Jon and Shak said that had seen that sort of thing it before! That case will be presented this week by one of my fellows if you missed it at EST ( Percutaneous Closure of Severe Mitral Regurgitation Secondary to an LVOT to LA Fistula )
Overall, a great day, and great education for all-including of course the panellists!
See you next time!