TAVR TTE INTERROGATION BY ALAN MATTHEWS
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1 TAVR TTE INTERROGATION BY ALAN MATTHEWS KEYS TO ACCURATE ASSESSMENT EDWARDS SAPIEN VALVE 3 PHASES OF TAVR TTE Evaluation (Qualifying) Placement (Intraoperative) Follow-up (Post-Op) GOALS High quality TTE to qualify for TAVR Thorough Intraoperative assessment Reproducible post-op assessment 1
2 You go to a different Dr. and achieve the goal of your life QUALIFYING PARAMETERS (SEVERE STENOSIS) 1) Aortic Jet Velocity >4.0 m/s 2) Mean Aortic Gradient >40 mmgh 3) AVA (Continuity Equation) <1.0 cm 2 4) Velocity Ratio <0.25 KEYS TO PROPER PARAMETER ASSESSMENT LVOT DIAMETER Zoom 2D PLAX in mid-systole Native Valve: Annulus Measure 3 times Show extent & location of AV/LVOT (Calcium location Correlates with PVL) 2
3 SPECTRAL DOPPLER PW & CW Baseline and scale should be adjusted so the signal size is 1/2 to 2/3 the size of the vertical axis (accurate VTI) Intercept angle as parallel to flow as possible (angle within 15 degrees of parallel will have less than 5% underestimation of velocity) Fine linear signals at the peak should not be included Trace the outer edge of the dark signal KEYS TO PROPER PARAMETER ASSESSMENT LVOT VELOCITY Pulsed-wave Doppler Move sample volume from LV side of valve and move into LVOT along the septum (5 or 3 chamber) Laminar flow curve with well defined peak Low filter setting (Visualize signal to the baseline) 3
4 LVOT VELOCITY KEYS TO PROPER PARAMETER ASSESSMENT AORTIC VALVE VELOCITY Continuous-wave Doppler (combined imaging transducer) Multiple acoustic windows (5C, ALAX) Use color Doppler prior to placement of cursor (ensures flow through the valve) Positioning (Parallel alignment, supine for 5C) KEYS TO PROPER PARAMETER ASSESSMENT CONTRAST ENHANCED DOPPLER Microbubble Contrast can be used to give a fuller aortic valve velocity signal for tracing The use of contrast will create more noise with spectral Doppler Gain and reject should be adjusted to reduce the increase of noise from contrast 4
5 MICROBUBBLE CONTRAST ENHANCED SIGNAL MICROBUBBLE CONTRAST ENHANCED SIGNAL KEYS TO PROPER PARAMETER ASSESSMENT AORTIC VALVE VELOCITY Dedicated transducer (Pedof probe) Multiple windows (Apical, SSN, RSB) Positioning: Apical (LLD), SSN (Supine), RSB (RLD) 5
6 TAVR INTRAOPERATIVE TTE BASELINE IMAGING Done just prior to Valve placement in the OR Assess: LV function AI & MR Pericardial effusion if present Assess: TAVR INTRAOPERATIVE TTE Paravalvular leak (PVL) Pericardial Effusion LVOT Diameter (Pre-Stent) LVOT & Aortic valve gradients LV function AI & MR TAVR TTE PARAVALVULAR LEAK (PVL) Causes Heavy calcification between tissue & prosthesis Degree of calcification correlates with degree of PVL Underexpansion of the valve Aortic root rupture 6
7 TAVR TTE PARAVALVULAR LEAK (PVL) Intraoperative Multiple images with varying angulation Multiple Windows PLAX, PSAX, 5C, ALAX Balloon Valvuloplasty may be performed to eliminate PVL Stent is cylindrical and extends further into the LVOT than a conventional surgical sewing ring Occurs outside the circumference of the stent 7
8 TAVR TTE LVOT DIAMETER Measure proximal to the stent in the PLAX (Pre-stent) Increases reproducibility for follow-up studies SEWING RING / TAVR VALVE 8
9 TAVR TTE LVOT VTI Flow acceleration at 3 different levels of the valve Pre-Stent (Lowest Velocity) In-stent Pre-cusp In-stent Post-cusp (Highest Velocity) TAVR TTE LVOT VTI Pre-Stent In-stent Pre-cusp In-stent Post-cusp Pulse Wave Doppler TAVR TTE LVOT VTI Sample volume Pre-Stent same location as LVOT diameter Place sample volume with Full Screen 2D image before switching to pulse wave Doppler. Inadvisable to move sample volume from LV side of valve and move into LVOT Can result in In-stent sampling, will overestimate LVOT VTI 9
10 TAVR TTE LVOT VTI TAVR TTE FOLLOW-UP Paravalvular leak (PVL), AI & MR LVOT Diameter (Pre-Stent) LVOT VTI Pre-stent In-stent pre-cusp PW Assess Calcification REFERENCES JASE Vol. 25, Issue 6, p June19, 2012 JASE Vol. 28, Issue 4, p Jan. 2, 2015 JASE Vol. 25, Issue 6, p March 19, 2012 JASE Vol. 22, Issue 1, p1-23 Jan JASE Vol. 24, Issue 9, p Sep
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AIMI-HF PROCEDURE MANUAL TECHNICAL GUIDE FOR ECHOCARDIOGRAPHY. MHI Core Laboratory E. O Meara - J.C. Tardif J. Vincent, G. Grenier, C.
AIMI-HF PROCEDURE MANUAL TECHNICAL GUIDE FOR ECHOCARDIOGRAPHY MHI Core Laboratory E. O Meara - J.C. Tardif J. Vincent, G. Grenier, C. Roy February 2016 Montreal Heart Institute HF Research Aude Turgeon,
Percutaneous Therapy for Calcific Mitral Valve Disease
31 st Annual State of the Art Echocardiography San Diego, CA February 18, 2018 5:00 5:15 PM 15 min Percutaneous Therapy for Calcific Mitral Valve Disease Muhamed Sarić MD, PhD, MPA Director of Noninvasive
Edwards Sapien. Medtronic CoreValve. Inoperable FDA approved High risk: in trials. FDA approved
Transcatheter Aortic Valve Replacement Symptomatic Aortic Stenosis Asymptomatic Juan Crestanello, MD Interim Director, Division of Cardiac Surgery Associate Professor Division of Cardiac Surgery The Ohio
Successful Transfemoral Edwards Sapien Aortic. Valve Implantation in a Patient with Previous. Mitral Valve Replacement
Advanced Studies in Medical Sciences, Vol. 2, 2014, no. 1, 37-45 HIKARI Ltd, www.m-hikari.com http://dx.doi.org/10.12988/asms.2014.31213 Successful Transfemoral Edwards Sapien Aortic Valve Implantation