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Dai H, Lutter G, Frank D, Freitag-Wolf S, Topal A, Haneya A, Sathananthan J, Puehler T. Transcatheter aortic valve resection: new mechanical devices. J Thorac Dis 2020; 12:6586-6597. [PMID: 33282360 PMCID: PMC7711357 DOI: 10.21037/jtd-20-2036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background To improve periprocedural outcomes of transcatheter aortic valve implantation (TAVI), transcatheter mechanical resection devices were tested for prior ablation of the aortic cusps. Methods Three mechanical transcatheter resection devices were tested in a series of native porcine (n=30) and reassembled calcified human valves (n=54). The resection time, the resected valve area, the number of released cusps, and the degree of surrounding tissue damage were measured. Afterwards, postmortem transapical-transcatheter-resections of the aortic valve in two humans were performed. Results In the native porcine hearts, the Aesculap II device demonstrated significantly shorter resection time compared to the R&R II and the Randstad devices (6.5±2.0 vs. 28.6±24.1 vs. 23.3±14.4 sec; P=0.001). However, it created more lesions in the surrounding tissue (P=0.002). The R&R II achieved a smaller number of resected cusps than the other two devices (2.7±0.7 vs. 1.1±0.7 vs. 2.4±0.5; P<0.001, respectively). It also resected a smaller area of the aortic valve (306.5±149.2 vs. 106.7±29.6 vs. 256.8±81.3 mm2; P=0.09) but a larger mean area of the resected fragments (110.3±41.5 vs. 160.7±29.6 vs. 111.5±43.9 mm2; P=0.01). The resection of the reassembled human valves demonstrated the same results between the devices regarding resection time (P=0.001) and resected area (P=0.016), but not fragment sizes (P=0.610). Finally, transapical-transcatheter-resection of aortic valve was performed in two cadavers. Conclusions Transcatheter aortic valve resection is feasible with variable aortic leaflet resection times and mild risk of lesions of the surrounding tissue.
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Affiliation(s)
- Huangdong Dai
- Department of Experimental Cardiac Surgery and Heart Valve Replacement, University Hospital Schleswig-Holstein, Campus Kiel, Germany.,Department of Cardiac Surgery, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Georg Lutter
- Department of Experimental Cardiac Surgery and Heart Valve Replacement, University Hospital Schleswig-Holstein, Campus Kiel, Germany.,Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Derk Frank
- Department of Cardiology and Angiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Sandra Freitag-Wolf
- Institute of Medical Informatics and Statistics, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Ayça Topal
- Department of Experimental Cardiac Surgery and Heart Valve Replacement, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Janarthanan Sathananthan
- Centre for Heart Valve Innovation, St Paul's Hospital, University of British Columbia, Vancouver, Canada.,ViVitro Labs Inc., Victoria, Canada
| | - Thomas Puehler
- Department of Experimental Cardiac Surgery and Heart Valve Replacement, University Hospital Schleswig-Holstein, Campus Kiel, Germany.,Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Germany
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Brecht R, Friedrich M, Heinisch PP, Plonien K, Akra B, Hagl C, Khoynezhad A, Lutter G, Bombien R. Transcatheter Valve Replacement: New concepts for Microsurgery inside the Heart. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ralf Brecht
- Clinic of Cardiac Surgery, University of Munich-Grosshadern, Munich, Germany
| | | | | | - Katharina Plonien
- Clinic of Cardiac Surgery, University of Munich-Grosshadern, Munich, Germany
| | - Bassil Akra
- Clinic of Cardiac Surgery, University of Munich-Grosshadern, Munich, Germany
| | - Christian Hagl
- Clinic of Cardiac Surgery, University of Munich-Grosshadern, Munich, Germany
| | - Ali Khoynezhad
- Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, CA USA
| | - Georg Lutter
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - René Bombien
- Clinic of Cardiac Surgery, University of Munich-Grosshadern, Munich, Germany
- Division of Cardiothoracic Surgery, Cedars Sinai Medical Center, Los Angeles, CA USA
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Transcatheter Valve Replacement: New concepts for Microsurgery inside the Heart. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013; 8:29-36. [DOI: 10.1097/imi.0b013e31828440e8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Transcatheter aortic valve implantation gained clinical relevance with an impressive and peerless power; however, the procedure induces unsolved complications such as paravalvular leakage, occlusion of coronary ostia, and vascular complications. The safe removal of bulky calcified valves will improve the outcome, well known through the open surgical procedure. In this article, a new stapler-based resection and implantation device as well as a new approach for valve isolation during normal heart cycle without extracorporeal circulation will be analyzed. Methods First, a novel stapler-based instrument for transapical aortic valve replacement [removal and implantation; stapler-based aortic valve replacement (StapAVR)] was constructed and analyzed in an aortic debris model. Artificial aortic valves (N = 20), containing fluorescent granules to simulate the calcification, were placed into an aortic model in anatomical supine position (DP) and right-sided lateral position (RP). With the StapAVR, resection before implantation was performed in a water-filled basin. Black light was used for debris visualization. The procedures have been digitally recorded and analyzed due to procedural times, and the debris amount in thoracic side branches. Second, an enhanced prototype of the pulmonary valve isolation chamber (PVIC) was analyzed in porcine in vitro (n = 10) and in vivo models (n = 1). This PVIC contains a microaxial pump (Impella; Abiomed, Aachen, Germany) in the central bypass channel. It was deployed through the right ventricular wall. Once the PVIC was in place, the pump was started before isolating the valve. The complete hemodynamic monitoring was digitally recorded. Results The deployment of the StapAVR in the correct position and the valve resection time took a mean (SD) of 95.8 (19) seconds in DP and 90.1 (18) seconds in RP. Fluorescent debris was found: in the left coronary artery, 22% in DP and 7% in RP; in the ascending aorta, 0% in DP and 11% in RP; in the aortic bulbous, 5% in DP and 10% in RP; in the left ventricle, 8% in DP and 14% in RP; in the brachiocephalic trunk, 4% in DP and 9% in RP; and in the descending aorta, 46% in DP and 1% in RP. Consecutive valved stent implantation was performed without complications. The PVIC deployment time in vivo was 5 minutes, replacements included. The total valve isolation time was 21 minutes, with a mean (SD) bypass flow of 2.1 (0.4) L/min. The oxygen saturation showed a median of 91% (range, 83%–97%), and the median arterial blood pressure was 69 mm Hg (systolic; range, 47–120 mm Hg) and 40mm Hg (diastolic; range, 32–56 mm Hg) without the use of inotropes or vasopressors. Electrocardiogram confirmed sinus rhythm during isolation. Conclusions The resection of the artificial valves followed by valved stent implantation was possible with the StapAVR. In vivo, the procedure will be carried out under rapid pacing and sudden vacuum; however, the results of this in vitro debris model underline the need for isolation or filter devices during transcatheter aortic valve implantation to avoid embolization. Secondly, the use of the pump-advanced PVIC showed stable heart function for 21 minutes under isolated pulmonary valve conditions. This time will be adequate to remove bulky calcifications and to implant a valved stent. Improvements of both prototypes are ongoing. Nevertheless, the presented concepts showed promising application possibilities in the future.
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Attmann T, Bombien R, Cremer J, Lutter G. eComment. transcatheter aortic valve implantation: need for continuing experimental research. Interact Cardiovasc Thorac Surg 2012; 14:380-1. [PMID: 22438409 DOI: 10.1093/icvts/ivs072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Astarci P, Glineur D, Elkhoury G, Raucent B. A novel device for endovascular native aortic valve resection for transapical transcatheter aortic valve implantation. Interact Cardiovasc Thorac Surg 2012; 14:378-80. [PMID: 22235001 DOI: 10.1093/icvts/ivr125] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We developed a novel resection device to use during transapical transcatheter aortic valve implantation (TAVI) using a circular blade. We assessed the device in 15 human cadavers by transapical approach. After the resection, the aortic annulus was measured using standard probes. A careful examination of the aortic wall, left ventricular outflow tract, coronary ostia and mitral valve was performed using an endpoint checklist, developed specifically for the new device. The resection was successfully completed in 14 out of 15 (93%) cases. All the resected leaflets and debris have been successfully evaluated in 15 out of 15 (100%) cases. One case of a bicuspid valve had a prominent calcification of the median raphe. The resection tool could only perform a partial resection. The mean duration of the resection was 45 ± 30 s. The surrounding tissue examination did not reveal any injury to the anatomical structures. Endovascular resection of the native valve using transapical approach is feasible and effective. Further developments are necessary before the definitive clinical use during percutaneous aortic valve implantation.
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Affiliation(s)
- Parla Astarci
- Department of Cardiovascular and Thoracic Surgery, University Hospital Saint-Luc, Brussels, Belgium.
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Dray X, Donatelli G, Krishnamurty DM, Dubcenco E, Wroblewski RJ, Assumpcao L, Giday SA, Buscaglia JM, Shin EJ, Magno P, Pipitone LJ, Marohn MR, Kantsevoy SV, Kalloo AN. A 2-microm continuous-wave laser system for safe and high-precision dissection during NOTES procedures. Dig Dis Sci 2010; 55:2463-70. [PMID: 20704034 DOI: 10.1007/s10620-010-1214-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
INTRODUCTION Lasers 2-microm in wavelength offer efficient tissue cutting with limited thermal damage in biological tissue. OBJECTIVE To evaluate the dissection capabilities of a 2-microm continuous-wave laser for NOTES procedures. METHODS AND PROCEDURES We conducted 18 acute animal experiments. Group 1 (three animals): transcolonic access to the peritoneal cavity (15-W transcolonic laser puncture, balloon dilation over the laser probe). Group 2 (six animals): transcolonic access with needle-knife puncture and balloon dilation. Group 3 (three animals): transgastric access to the peritoneal cavity (similar technique as group 1) followed by laser-assisted dissection of the kidney. In one animal of group 3, a therapeutic target (hematoma) was created by percutaneous puncture of the kidney. Group 4 (six animals): transgastric access (similar to the technique of group 2). RESULTS Translumenal access to the peritoneal cavity was achieved in 2-3 min in group 1 (significantly shorter than with the needle-knife-assisted technique, 4-5 min, p=0.02) and in 7-10 min in group 3 (compared to 6-17 min in group 4, p=0.88). In group 3, laser dissection of the parietal peritoneum and of perinephric connective tissue allowed access to the retroperitoneum with complete removal of a blood collection in the animal with puncture trauma. Laser dissection demonstrated good maneuverability, clean and rapid cutting, and excellent hemostasis. Peritoneoscopy and necropsy showed no damage of targeted tissue and surrounding organs. CONCLUSIONS The 2-microm continuous-wave laser system showed promising capabilities for highly precise and safe dissection during NOTES procedures.
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Affiliation(s)
- Xavier Dray
- Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
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Transcatheter valve replacement: resection and valved stent implantation in a beating heart. J Thorac Cardiovasc Surg 2010; 140:477-9. [PMID: 20346465 DOI: 10.1016/j.jtcvs.2010.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Revised: 12/23/2009] [Accepted: 01/01/2010] [Indexed: 11/23/2022]
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Bombien R, Lesche C, Lozonschi L, Feucker M, Brinkmann R, Dahmen C, Schünke M, Cremer J, Lutter G. Percutaneous Aortic Valve Replacement. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010. [DOI: 10.1177/155698451000500112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- René Bombien
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Claudia Lesche
- Institute of Micro-technology, University of Braunschweig, Braunschweig, Germany
| | - Lucian Lozonschi
- Division of Cardiothoracic Surgery, University of Wisconsin, Madison, WI USA
| | - Max Feucker
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Ralf Brinkmann
- Institute for Biomedical Optics, University of Lübeck, Lübeck, Germany
| | - Christian Dahmen
- Division Microrobotics and Control Engineering, University of Oldenburg, Oldenburg, Germany
| | - Michael Schünke
- Institute of Anatomy, Christian-Albrechts-University of Kiel, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Georg Lutter
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
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Percutaneous aortic valve replacement: emerging tractability for sufficient intracardiac resection of the aortic valve. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010; 5:55-9. [PMID: 22437277 DOI: 10.1097/imi.0b013e3181ceed96] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE : The feasibility of endovascular resection of highly calcified aortic valves has already been demonstrated by our group. Different endovascular and intracardiac tractability methods were applied. In this study, these technologies were analyzed comparing the tractability, the resection time, and the lesions in the surrounding tissue. METHODS : All aortic valve resections (seven human hearts and 21 porcine hearts) were performed using a Thulium:YAG laser (continuous wave, wavelength of 2.01 μm, 20 watts power rating). In the first resection system, the laser fiber was controlled by a free in-lying flexible endoscope (Ø 2.5 mm, length of 600 mm). The distal part of the endoscope (40 mm) was moved in one plane by proximal manual control (three degrees of freedom). The resection system was separated into defined rooms assigning one room for one tool. The fiber was controlled by the above-mentioned endoscope (*) (three degrees of freedom). The third resection system was a mechanical microactuator carrying the laser fiber (three degrees of freedom). The fourth resection system contains a rotatable inlay with defined rooms and a newly designed nitinol (NiTi) microactuator that controlled the laser fiber (four degrees of freedom). The resection time per leaflet was measured in minutes. Gross anatomy and histology in the surrounding tissue were evaluated. RESULTS : The resection time in approaches 1, 2, 3, and 4 was 5.5 ± 2.3 minutes, 7.4 ± 2.7 minutes, ± 6.6 minutes, and2.3 ± 1.2 minutes, respectively. The gross anatomy and histology of collateral damages revealed only superficial lesions of the surrounding tissue. The amount of lesions and the resection time were lower in the fourth approach with four degrees of freedom. CONCLUSIONS : This analysis demonstrated that a precise tractability with four degrees of freedom is necessary for a faster and safer endovascular resection of the aortic valve. The analysis will help to optimize the ongoing development of the endovascular and intracardiac resection technology.
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Salizzoni S, Bajona P, Zehr KJ, Anderson WD, Vandenberghe S, Speziali G. Transapical off-pump removal of the native aortic valve: a proof-of-concept animal study. J Thorac Cardiovasc Surg 2009; 138:468-73. [PMID: 19619797 DOI: 10.1016/j.jtcvs.2009.03.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 03/05/2009] [Accepted: 03/13/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study evaluates the feasibility of off-pump native aortic valve removal in preparation for transapical aortic valve replacement. Off-pump aortic valve replacement is performed by balloon predilatation of the native valve followed by insertion of a stented prosthesis. In patients with calcified annuli and cusps, particulate embolization, suboptimal prosthesis sizing, and perivalvular leaks may occur. Therefore, native valve removal may improve outcomes after transapical aortic valve replacement. METHODS The aortic cusps were sequentially removed from 10 pigs in an off-pump procedure. A temporary valve was inserted percutaneously into the ascending aorta to prevent aortic regurgitation. The electrocardiogram, coronary blood flow, and arterial, left atrial, and ventricular pressures were continuously monitored. RESULTS Removal of the aortic cusps caused a drop in diastolic arterial pressure and its equalization with left ventricular diastolic pressure. Systolic pressure decreased by 13.5%. Left atrial pressure increased by 86.0%. Coronary blood flow decreased by 39.9% and its pattern changed from mostly diastolic to mostly systolic. Electrocardiographic signs of ischemia appeared almost immediately. Percutaneous insertion of a temporary valve in the ascending aorta increased diastolic pressure and caused a tendency toward echocardiographic normalization. CONCLUSIONS Aortic valve removal in a healthy beating heart causes acute massive aortic regurgitation, hemodynamic instability, and the rapid onset of myocardial ischemia. Reduction of left ventricular volume overload, by placement of a temporary valve in the ascending aorta, mitigates myocardial distress, helps stabilize hemodynamic parameters, and may be a useful tool to allow surgical manipulations of the aortic valve and annulus during transapical aortic valve replacement procedures.
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Affiliation(s)
- Stefano Salizzoni
- Division of Cardiothoracic Surgery-Heart, Lung and Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Rahimtoola SH. The Year in Valvular Heart Disease. J Am Coll Cardiol 2009; 53:1894-908. [DOI: 10.1016/j.jacc.2009.02.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2008] [Revised: 01/21/2009] [Accepted: 02/06/2009] [Indexed: 12/01/2022]
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Bombien R. Katheterbasierte Herzklappenchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0713-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
This article contains a review of the main developments in the field of geriatric cardiology reported during 2008. The focus is on research concerning the specific characteristics of elderly patients with heart failure, arrhythmias, ischemic heart disease, and aortic valve disease.
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