TAVI İÇİN DEĞERLENDİRMEDE L

TAVI İÇİN
DEĞERLENDİRMEDE
L-ES ve STS SKORLAMA
SİSTEMLERİNİN YERİ
DR.ATIF AKÇEVİN
HAZİRAN 2010
Operatif Risk Değerlendirmesi
• Risk
Komorbidite
– Operative Mortalite
– Morbidite
• Kısa dönem
• Uzun dönem
Sl Vent
Fonksiyonu
Yaş
• Fayda
• Survival
• Hayat Kalitesi
Kapak Hastalığı
Kırılganlık
TAVI İÇİN UYGUN ADAYLAR
•
•
•
YÜKSEK RİSKLİ HASTALAR
YAŞ>70Y,>80 Y +
KOMORBİDİTELER-- RENAL YETM.,RESP. YETM.,LVD….
CERRAHİ KONTRENDİKASYON—PORSELEN
AORTA,GEÇİRİLMİŞ İRRADYASYON…
STS SKORU > %10
L-ES SKORU > %20.
KIRILGAN ,DEBİL HASTALAR
TRANSFEMORAL VE TRANSAPİKAL GİRİŞİME TEKNİK
UYGUNLUK
Aortic Valve Surgery
Predictive Risk Algorithms
•
•
•
•
•
•
•
STS
EuroSCORE (additive)
EuroSCORE (logistic)
Ambler (UK)
Northern New England
New York State
Providence Health System
TAVI
Hasta Seçimi
• Skorlama Sistemleri
– Euroscore
• Yaş, cinsiyet, bazı hastalıklar ve klinik durumu değerlendiren
risk skorlama sistemi
– STS
• Operasyon tipi ile alakalı, cerrahi risk skorlama sistemi
• Yüksek risk
– STS>10 %
– Euroscore>15‐20 %
Risk Skorlamaları Eksik mi?
•
•
•
•
•
•
Euroscore
Yaş, Cinsiyet
Akciğer Hastalığı, Perifer Arter Hastalığı
Nörolojik Hastalık, Böbrek Hastalığı
Eski kalp ameliyatı
Klinik Durum
• Frailty (Kırılganlık ) indeksi?????
Euroscore overestimates the actual risk in the high risk population
Osswald B, et al. European Heart Journal (2009) 30, 74–80
Variables Not Included In Risk Algorithms In Patients Undergoing AVR Previous chest radiation
Oxygen dependence Reoperative patients with open grafts
Previous tissue valve replacement
Porcelain aorta Advanced liver disease/cirrhosis
Degenerative neurocognitive disorders‐
Alzheimer’s • Frailness or debility
•
•
•
•
•
•
•
FerasKhaliel,NawwarAl‐Attar, Richard Raffoul, Laurent Lepage, Dominique Himbert, Alec
Vahanian, Patrick Nataf, HôpitalBichat, AP‐HP, University Paris 7, Paris, France
Problems with Risk Algorithms
• All risk algorithms are based on operated patients and don’t factor in “inoperable “ patients
• Outcomes other than mortality are not predicted, e.g., stroke, discharge disposition, QoL
• Many risk variables not included
Both the STS and EuroSCORE failed to demonstrate significant correlation with predicted operative mortality The STS algorithm seems more accurate in estimating the operative mortality in TAVI patients
FerasKhaliel,NawwarAl‐Attar, Richard Raffoul, Laurent Lepage, Dominique Himbert, Alec
Vahanian, Patrick Nataf, HôpitalBichat, AP‐HP, University Paris 7, Paris, France
Frailty of the elderly
• Reduction of organ reserve
– Reduced resistance to injury
– Reduced adaptability
• Reduced physical activity
• Reduced neurocognitive
function
• Depression
Clinical contraindications
• Age
• Euroscore, STS score
• Severe comorbidities
– Liver failure
– Renal failure (dialisis)
– COPD
– Neoplasia
• frialty
Technical contraindications
• Previous chest radiation
• Porcelain aorta
• Multiple previous sternotomies (esp. with open grafts)
How do you define debility or fraility ?
•Same age and predicted risk
•One passes the “eyeball test”; one doesn’t
•Fraility Index
30% of elderly patients are denied surgery
Clinical judgment and the Heart Team concept
should play a key role in selecting patients for
TAVI, whereas currently available surgical risk
score algorithms should be used to guide clinical
decision making.
Piazza N
Am Heart J. 2010 Feb;159(2):323‐9.
TAVI
AVR