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TAVIXIONGRAN2014-11-25TAVIXIONGRAN2014-11-25QUIZStreetAvenueQUIZStreetStreetStreetAvenueAvenueHospitalofUAHospitalofUAHospitalofUAHospitalofUAHospitalofUAHospitalofUAHospitalofUAHospitalofUASummarizeofTAVITranscatheteraorticvalveimplantation(TAVI)Itwasintroducedasanalternativetreatmentinpatientswithsevereaorticvalvestenosis(AS)CribierA,EltchaninoffH,BashA,Circulation2002;106:3006–3008.SummarizeofTAVITranscatheterFirstCaseofTAVIIn2002,

CribieretaldemonstratedforthefirsttimethefeasibilityofapercutaneousvalveimplantationinapatientwithASProvidingapromisinglessinvasivealternativetreatmentforvalvularheartdiseaseCribierA,EltchaninoffH,BashA,Circulation2002;106:3006–3008.FirstCaseofTAVIIn2002,CritwodifferentTAVIdevicesarewidelyusedtheballoon-expandableEdwardsSAPIENTranscatheterHeartValvetheself-expandingMedtronicCoreValve?BothreceivedCEMarkapprovalforEuropeancommercialsalein2007EdwardsSAPIENvalvereceivedFDApre-marketapprovalintheUSAinNovember2011TwodifferentTAVIdevicestwodifferentTAVIdevicesareEdwardsballoonexpandabledeliverysystemsEdwardsballoonexpandabledeliCoreValveReValvingSystem(a)schemataand(b)followingdeploymentwithaortographyCoreValveReValvingSystem(aPatientsSelectionFeasibleinmostpatientswithsevereaorticstenosisGenerallyutilizedinpatientsnotsuitableforsurgicalAVR,whoarelikelytoderivefunctionalandsurvivalbenefit

TworiskscoresareusedtocalculatetheriskofcardiacsurgeryPatientsSelectionFeasiblein“High-risk”surgicalpatientsHavingaSocietyofThoracicSurgeonsPredictedRiskofMortality(STS-PROM)at30daysofgreaterthan10%LogisticEuroSCOREofgreaterthan20%LimitedDonotaccountforseveralpertinentclinicalriskfactors,suchaspreviousCABG,porcelainaorta,previouschestradiotherapy,severelungdisease,andlivercirrhosisTworiskscores“High-risk”surgicalpatientsTworisk

scoresTworisk

scoresAssessmentsofTAVIToassesstheaorticannulusdimensionsandgeometry,accesssite,andapproachTransthoracicechocardiographyCoronaryangiographyAorticangiographyMDCTAssessmentsofTAVIToassesstAssessmentofarterialaccessTheevaluationisfundamentalintheassessmentoftheTAVIpatientinminimizingpotentialmajorvascularcomplicationsArterialdimensionsThepresenceorabsenceofatheroma,CalcificationTortuosityAssessmentofarterialaccessTAssessmentofarterialaccessArterialaccessisassessedwiththecombinationofinvasiveangiographyandcontrast-enhancedCTIliofemoralassessmentwith(a)angiographyand(b)MDCTAssessmentofarterialaccessAAssessmentofaorticrootUsinginvasiveangiographyandcontrastMDCTevaluaterootandvalvularcalcificationleftmainheightfromtheleftcoronarycuspinsertion(duetoriskofcoronaryobstruction)technicalissuesrelatedtoeachvalvetypeanddeliverysystemEuropeanHeartJournal(2014)35,2627–2638AssessmentofaorticrootUsingAssessmentofaorticroot(1)aorticannulusdiameter,(2)sinusofValsalvawidth(3)ascendingaortawidth,(4)sinusofValsalvaheightAssessmentofaorticroot(1)AssessmentofaorticrootAssessmentofaorticrootAssessmentsLeftandrightheartcatheterizationsarealsoperformedassessthepresenceofpulmonaryhypertensioncoronaryischemiaandtheneedforrevascularizationpriortoTAVIAssessmentsLeftandrighthearRequirementsofTAVITAVIshouldbeperformedinregionalcentersofexcellencewithadedicatedheartvalveprogramandhighproceduralvolumesTheproceduremaybeundertakeninacardiaccatheterizationlaboratorywithmodificationsorinahybridoperatingroomequippedwithhigh-qualityfluoroscopicimagingRequirementsofTAVITAVIshoulRequirementsofTAVIThefacilitiesneedtobelargeenoughtoaccommodatesophisticatedX-rayimagingintegratedwithechocardiography,cardiopulmonarybypassandintra-aorticballoonpumpmachines,andanesthesiaequipment,withsurgicalsterilitystandardsmandatoryRequirementsofTAVIThefaciliTechniquesofTAVITAVIismostoftenperformedutilizingthetransfemoralretrogradeapproachAlternativeaccessapproachesusuallyreservedforpatientswithconcomitantsevereperipheralarterialdiseaseTechniquesofTAVITAVIismostTransfemoralApproachThecommonfemoralartery,atthelevelofthefemoralhead,istheprimaryaccesssiteforthetransfemoralapproachowingtoitsrelativelylargesizeandcompressibilityThesidewiththelargestandleastdiseased,tortuous,orcalcifiediliofemoralartery—asassessedbyascreeningangiogramand/ormultidetectorcomputedtomographic(CT)angiography—isselectedforplacementofthesheathTransfemoralApproachThecommoTransfemoralApproachThepotentialsiteofaccessisassessedfirstwithfluoroscopyand/orultrasound,andarterialaccessisgainedbypercutaneouspunctureAlternatively,asurgicalcutdownisutilizedtoaccessthefemoralarteryAsmallerpercutaneoussheathisinsertedintothefemoralarteryonthecontralateralsideforplacementofapigtailcatheterintheascendingaortaforrootangiographyTransfemoralApproachThepotenTransfemoralApproachTheTAVIproceduremaybeperformedunderlocalorgeneralanesthesiaFollowingballoonvalvuloplasty,thevalveprosthesisispassedacrosstheaorticvalveandpositionedunderfluoroscopicandtransesophagealechocardiographic(TEE)guidanceTransfemoralApproachTheTAVITransfemoralApproachBalloon-expandablevalvesaredeployedunderrapidventricularpacingatarateof160–220bpmtominimizecardiacoutputandthereforeminimizeunintentionalmotionofthevalveduringballoondilatationTransfemoralApproachBalloon-e經(jīng)皮主動脈瓣植入課件TransapicalApproachThetransapicalapproachwasfirstdescribedin2006withballoon-expandablevalvesAsheathisplacedsurgicallyintheleftventricularapex,accessedthroughasmallleftanterolateralminithoracotomyTransapicalApproachThetransaTransapicalApproachFollowingballoonvalvuloplasty,thevalveprosthesisandballooncatheterarepassedoverawireintotheleftventricleandpositionedwithintheaorticannulusunderfluoroscopicandtransesophagealechocardiographicguidanceTransapicalApproachFollowingTransapicalApproachThisapproachmaybeconsiderediftheiliofemoralarterialsystemisofsufficientlysmalldiameter,calcified,ortortuousandnottechnicallysuitablefordeliveryofthedeviceAlsotakenintoconsiderationistheangulationoftheaortaandarchTransapicalApproachThisapproTransapicalApproachInparticular,atransverseorextremelyunfoldedascendingaortamayincreasethedifficultyofdeliveryandpositioningoftheballoon-expandabledevicesIthasbeensuggestedthatwithadvancesindevicetechnologyandareductionindeliverysystemprofilesforthetransarterialapproach,alternativeaccessapproacheswillbelimitedtolessthan30%ofTAVRproceduresTransapicalApproachInparticuTransapicalApproachContraindicationstothetransapicalapproachpreviousleftventricularsurgeryusingapatchcalcifiedpericardiumsevererespiratorydiseaseTransapicalApproachContraindiTransapicalApproachTransapicalApproachOthersAxillary/SubclavianApproachTransaorticApproachOthersAxillary/SubclavianApprComplicationsofTAVIProceduralComplicationsVascularComplicationsStrokeandNeurologicalEventsCoronaryOcclusionValveMalpositionandEmbolizationRenalImpairmentConductionDisturbanceComplicationsofTAVIProceduraComplicationsofTAVIProsthesis-RelatedComplicationsProsthesis–PatientMismatchParavalvularandValvularRegurgitationProstheticValveThrombosisandEndocarditis

ComplicationsofTAVIProsthesiTHANKSTHANKSTAVIXIONGRAN2014-11-25TAVIXIONGRAN2014-11-25QUIZStreetAvenueQUIZStreetStreetStreetAvenueAvenueHospitalofUAHospitalofUAHospitalofUAHospitalofUAHospitalofUAHospitalofUAHospitalofUAHospitalofUASummarizeofTAVITranscatheteraorticvalveimplantation(TAVI)Itwasintroducedasanalternativetreatmentinpatientswithsevereaorticvalvestenosis(AS)CribierA,EltchaninoffH,BashA,Circulation2002;106:3006–3008.SummarizeofTAVITranscatheterFirstCaseofTAVIIn2002,

CribieretaldemonstratedforthefirsttimethefeasibilityofapercutaneousvalveimplantationinapatientwithASProvidingapromisinglessinvasivealternativetreatmentforvalvularheartdiseaseCribierA,EltchaninoffH,BashA,Circulation2002;106:3006–3008.FirstCaseofTAVIIn2002,CritwodifferentTAVIdevicesarewidelyusedtheballoon-expandableEdwardsSAPIENTranscatheterHeartValvetheself-expandingMedtronicCoreValve?BothreceivedCEMarkapprovalforEuropeancommercialsalein2007EdwardsSAPIENvalvereceivedFDApre-marketapprovalintheUSAinNovember2011TwodifferentTAVIdevicestwodifferentTAVIdevicesareEdwardsballoonexpandabledeliverysystemsEdwardsballoonexpandabledeliCoreValveReValvingSystem(a)schemataand(b)followingdeploymentwithaortographyCoreValveReValvingSystem(aPatientsSelectionFeasibleinmostpatientswithsevereaorticstenosisGenerallyutilizedinpatientsnotsuitableforsurgicalAVR,whoarelikelytoderivefunctionalandsurvivalbenefit

TworiskscoresareusedtocalculatetheriskofcardiacsurgeryPatientsSelectionFeasiblein“High-risk”surgicalpatientsHavingaSocietyofThoracicSurgeonsPredictedRiskofMortality(STS-PROM)at30daysofgreaterthan10%LogisticEuroSCOREofgreaterthan20%LimitedDonotaccountforseveralpertinentclinicalriskfactors,suchaspreviousCABG,porcelainaorta,previouschestradiotherapy,severelungdisease,andlivercirrhosisTworiskscores“High-risk”surgicalpatientsTworisk

scoresTworisk

scoresAssessmentsofTAVIToassesstheaorticannulusdimensionsandgeometry,accesssite,andapproachTransthoracicechocardiographyCoronaryangiographyAorticangiographyMDCTAssessmentsofTAVIToassesstAssessmentofarterialaccessTheevaluationisfundamentalintheassessmentoftheTAVIpatientinminimizingpotentialmajorvascularcomplicationsArterialdimensionsThepresenceorabsenceofatheroma,CalcificationTortuosityAssessmentofarterialaccessTAssessmentofarterialaccessArterialaccessisassessedwiththecombinationofinvasiveangiographyandcontrast-enhancedCTIliofemoralassessmentwith(a)angiographyand(b)MDCTAssessmentofarterialaccessAAssessmentofaorticrootUsinginvasiveangiographyandcontrastMDCTevaluaterootandvalvularcalcificationleftmainheightfromtheleftcoronarycuspinsertion(duetoriskofcoronaryobstruction)technicalissuesrelatedtoeachvalvetypeanddeliverysystemEuropeanHeartJournal(2014)35,2627–2638AssessmentofaorticrootUsingAssessmentofaorticroot(1)aorticannulusdiameter,(2)sinusofValsalvawidth(3)ascendingaortawidth,(4)sinusofValsalvaheightAssessmentofaorticroot(1)AssessmentofaorticrootAssessmentofaorticrootAssessmentsLeftandrightheartcatheterizationsarealsoperformedassessthepresenceofpulmonaryhypertensioncoronaryischemiaandtheneedforrevascularizationpriortoTAVIAssessmentsLeftandrighthearRequirementsofTAVITAVIshouldbeperformedinregionalcentersofexcellencewithadedicatedheartvalveprogramandhighproceduralvolumesTheproceduremaybeundertakeninacardiaccatheterizationlaboratorywithmodificationsorinahybridoperatingroomequippedwithhigh-qualityfluoroscopicimagingRequirementsofTAVITAVIshoulRequirementsofTAVIThefacilitiesneedtobelargeenoughtoaccommodatesophisticatedX-rayimagingintegratedwithechocardiography,cardiopulmonarybypassandintra-aorticballoonpumpmachines,andanesthesiaequipment,withsurgicalsterilitystandardsmandatoryRequirementsofTAVIThefaciliTechniquesofTAVITAVIismostoftenperformedutilizingthetransfemoralretrogradeapproachAlternativeaccessapproachesusuallyreservedforpatientswithconcomitantsevereperipheralarterialdiseaseTechniquesofTAVITAVIismostTransfemoralApproachThecommonfemoralartery,atthelevelofthefemoralhead,istheprimaryaccesssiteforthetransfemoralapproachowingtoitsrelativelylargesizeandcompressibilityThesidewiththelargestandleastdiseased,tortuous,orcalcifiediliofemoralartery—asassessedbyascreeningangiogramand/ormultidetectorcomputedtomographic(CT)angiography—isselectedforplacementofthesheathTransfemoralApproachThecommoTransfemoralApproachThepotentialsiteofaccessisassessedfirstwithfluoroscopyand/orultrasound,andarterialaccessisgainedbypercutaneouspunctureAlternatively,asurgicalcutdownisutilizedtoaccessthefemoralarteryAsmallerpercutaneoussheathisinsertedintothefemoralarteryonthecontralateralsideforplacementofapigtailcatheterintheascendingaortaforrootangiographyTransfemoralApproachThepotenTransfemoralApproachTheTAVIproceduremaybeperformedunderlocalorgeneralanesthesiaFollowingballoonvalvuloplasty,thevalveprosthesisispassedacrosstheaorticvalveandpositionedunderfluoroscopicandtransesophagealechocardiographic(TEE)guidanceTransfemoralApproachTheTAVITransfemoralApproachBalloon-expandablevalvesaredeployedunderrapidventricularpacingatarateof160–220bpmtominimizecardiacoutputandthereforeminimizeunintentionalmotionofthevalveduringballoondilatationTransfemoralApproachBalloon-e經(jīng)皮主動脈瓣植入課件TransapicalApproachThetransapicalapproachwasfirstdescribedin2006withballoon-expandablevalvesAsheathisplacedsurgicallyintheleftventricularapex,accessedthroughasmallleftanterolateralminithoracotomyTransapicalApproachThetransaTransapicalApproachFollowingballoonvalvuloplasty,thevalveprosthesisandballooncatheterarepassedoverawireintotheleftventricleandpositionedwithintheaorticannulusunde

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