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1 Echo for TAVR Sunil Mankad, MD, FACC, FCCP, FASE Associate Professor of Medicine Mayo Clinic College of Medicine Director, Transesophageal Echocardiography Associate Director, Cardiology Fellowship Mayo Clinic, Rochester, MN ACC Governor,
2 DISCLOSURE Relevant Financial Relationship(s) None Off Label Usage None
3 Overview TAVR Background/Outcomes Pre-procedural imaging Peri-procedural imaging Follow-up imaging
4
5 87 Year Old Man with NYHA Class IV Dyspnea Physical Exam Past Medical History BP 96/67 HR 60 CABG: age 69 JVP: elevated Redo CABG: age 81 Carotids: tardus and Atrial Fibrillation parvus HTN Heart: Single Hyperlipidemia component S2, 3/6 OSA late-peaking SEM, 2/6 HSM at apex CKD (baseline Cr 2.5) Lungs: bibasilar Remote tobacco use crackles Mild cognitive Ext: 2+ edema impairment
6 87 Year Old Man with NYHA Class IV Dyspnea Meds: Statin ACE-I Beta Blocker Diuretic Nitrate Coumadin PPI Abnormal Labs: Hgb: 11.3 g/dl Cr: 2.6 mg/dl INR: 2.5 BNP 1655 pg/ml
7 EKG
8 CXR
9 Echocardiogram LV Ejection Fraction = 20-25% Aortic valve area = 0.58 cm 2 Mean aortic valve gradient = 65 mmhg Moderate to Severe MR Moderate TR Aortic Valve Long-axis View Aortic Valve Short-axis View
10 Cardiac Catheterization LIMA LAD patent SVG R-PDA patent 100% occluded LAD, LCX, and RCA Nothing to revascularize
11 Summary 87 year old man Severe AS with Class IV symptoms, LV dysfunction, and multiple comorbidities 2 prior CABG operations Creatinine = 2.6 mg/dl Options? What is the risk of surgery?
12 Online STS Risk Calculator Risk of Mortality = 20.1% Risk of Morbidity or Mortality = 68.9% Risk of Long Length of Stay = 39.4% Risk of Permanent Stroke = 8.1% Risk of Renal Failure = 31.3%
13
14 Screening For Vascular Access
15 Transfemoral and Transapical Transfemoral Transapical
16 Deploying the Valve
17 Rapid Ventricular Pacing
18 Pre-AVR MG=65 mmhg, AVA=0.5cm2 Our Patient Post-AVR MG=9mmHg, AVA=2.1cm2
19 Presented by Michael Mack, MD at ACC 2015
20 ACC 2015
21 ACC 2015
22 Neurologic Events 30 Days 1 Year Outcome TAVR (N = 348) AVR (N = 351) TAVR (N = 348) AVR (N = 351) All Stroke or TIA no. (%) 19 (5.5) 8 (2.4) (8.3) 13 (4.3) 0.04 TIA no. (%) 3 (0.9) 1 (0.3) (2.3) 4 (1.5) 0.47 All Stroke no. (%) 16 (4.6) 8 (2.4) (6.0) 10 (3.2) 0.08 Major Stroke no. (%) 13 (3.8) 7 (2.1) (5.1) 8 (2.4) 0.07 Minor Stroke no. (%) 3 (0.9) 1 (0.3) (0.9) 2 (0.7) 0.84 Death/maj stroke no. (%) 24 (6.9) 28 (8.2) (26.5) 93 (28.0) 0.68
23 Sapien Valve CoreValve Balloon Expandable Self Expandable
24 Primary Endpoint: 1 Year All-cause Mortality Surgical Transcatheter 19.1% 14.2% 4.5% P = 0.04 for superiority 3.3% 24
25 2-Year All-cause Mortality
26 All Stroke
27 Pre-Procedural Planning Echo Check List Confirm trileaflet AV morphology Presence/degree of AR, MR, TR LV/RV function Presence of basal septal hypertrophy/lvot obstruction Presence of pericardial effusion Exclude LA or LV thrombus
28 Intra/post Procedural Objectives Ensure proper prosthesis placement Assess prosthesis position & function after deployment Assess ventricular function Identify immediate post deployment complications
29 Echo for TAVR Objectives Assess atherosclerosis Select device size Assess landing zone site for suitability of valve deployment/potential complications Guide valve deployment & monitor/assess periprocedural complications
30 Echo for TAVR Assess atherosclerosis Select device size Assess landing zone site for suitability of valve deployment/potential complications Guide valve deployment & monitor/assess periprocedural complications
31 Atherosclerosis in the Thoracic Aorta
32 Echo for TAVR Objectives Assess atherosclerosis Select device size Assess landing zone site for suitability of valve deployment/potential complications Guide valve deployment & monitor/assess periprocedural complications
33 Measurement of Annulus Diameter Undersized prostheses Periprosthetic AR Device migration Prosthesis-patient mismatch Oversized prostheses Underexpansion with central regurgitation Annular rupture Coronary ostial obstruction
34 Sizing of Aortic Annulus Pre-TAVR Question: How do you do it? 1.2D TEE 2.3D TEE 3.CT 4.Both 5.Other
35 Early TAVR Method: 2D Echo Journal of the American Society of Echocardiography 2011; 24:
36 Conclusions: In patients referred for TAVI, measurements of the aortic annulus using TTE, TEE, and MSCT were close but not identical, and the method used has important potential clinical implications on TAVI strategy. In the absence of a gold standard, a strategy based on TEE measurements provided good clinical results.
37 Conclusions: The CT-measured aortic annulus diameter, assessed as the calculated average diameter of planimetric annulus area, seems to provide adequate dimensions similar to operative measurements...
38
39 Variability of 2D TEE Jilaihawi H et al. JACC 2013
40 Virtual Ring J Am Coll Cardiol Img. 2012;5(4):
41 Limitations of X-plane TEE Jilaihawi H et al. JACC 2013
42 Prediction of Significant Periprosthetic AR Jilaihawi H et al. JACC 2013
43 Prediction of Significant Periprosthetic AR Jilaihawi H et al. JACC 2013
44 Jilaihawi H et al. JACC 2013
45 3D TEE
46 J Am Soc Echocardiogr 2013;26;
47 Hahn RT et al. J Am Soc Echocardiogr 2013;26;
48 GE: 4D Auto AVQ (Aortic Valve Quantification) with 4D TEE Advanced Automation = Consistency and Reproducibility 4D Auto AVQ
49 Siemens: Fully Automated Measurements
50 Hinge to Coronary Ostium Distance
51 Aortic Root
52 Echo for TAVR Objectives Assess atherosclerosis Select device size Assess landing zone site for suitability of valve deployment/potential complications Guide valve deployment & monitor/assess periprocedural complications
53 It is all about the landing zone!
54 It is all about the landing zone!
55 Risk of Periprosthetic AR Asymmetric cusp calcification Oval shaped annulus Device landing zone calcification
56 It is all about the landing zone! Dr. Lester and the Mayo Heart Team
57 Posterior Calcification: CorValve
58 Echo for TAVR Objectives Assess atherosclerosis Select device size Assess landing zone site for suitability of valve deployment/potential complications Guide valve deployment & monitor/assess periprocedural complications
59 TEE During TAVR Procedure
60 God Result
61 Periprosthetic AR Associated Morphologic Risk Factors Large aortic annulus Undersized prosthesis Asymmetric cusp calcification LVOT calcification Prominent septal bulge Low valve deployment
62 How Much Periprosthetic Aortic Regurgitation? 1. Mild 2. Mild-moderate 3. Moderate 4. Severe
63 PARTNER Criteria for Grading Aortic Regurgitation
64 >30%
65 It s not so easy sometimes!
66 Final Aortogram: Mild AR QuickTime and a YUV420 codec decompressor are needed to see this picture.
67
68 2 nd Balloon Inflation
69 Final Regurgitation Grade N = 258 Redilation 5% Second valve 4%
70 Risk of Periprosthetic AR Asymmetric cusp calcification Oval shaped annulus Device landing zone calcification
71 TAVR Nirvana Scale Paravalvular Regurgitation Nirvana Annular Rupture Undersized Prosthesis Oversized Prosthesis Adapted from Kevin Greason, MD
72 Pulse Doppler Descending Thoracic Aorta
73 Pressure Half Time Aortic Regurgitation Mild AR >400 msec Severe AR <250 msec Oh et al: The Echo Manual
74 Guidewire Induced Prosthetic AR
75 Other Post Valve Deployment Complications Cardiac perforation (effusion/cardiac tamponade) Rupture of aortic root or annulus Traumatic VSD/septal hematoma Avulsion of Asc Ao intima New /worsening TR
76 Intra-procedural Hypotension What to Look For Severe AR (usually periprosthetic but may be prosthetic) Cardiac tamponade Aortic rupture VSD Severe MR LV dysfunction
77 TAVR: Too Low
78 TAVR: Too Low
79
80 79-year-old male Severe Symptomatic Aortic Stenosis Cohort B patient AVA 0.9 cm2, AV MG 54 mmhg LVOTd 2.4 cm LV EF 67%
81 79-year-old male for TAVR
82 Try and Try Again
83 79-year-old male S/P TAVI
84 Acute Thrombus
85
86 Aortic Dissection Post-TAVR
87 TAVR: Long-Term Follow-up TTE At Discharge 30 Days 6 Months 12 Months Yearly, thereafter TTE/TEE Clinical change on exam Clinical deterioration
88
89 Echo Findings Aortic Valve Gradients Mean and Peak Gradient As-Treated Trial Arms (mmhg) Peak Gradient - AVR Peak Gradient - TAVR Mean Gradient - AVR Mean Gradient - TAVR 0 TAVR n = 327 Baseline 30 Days 6 Months 1 Year AVR n = 301 TAVR n = 287 AVR n = 231 TAVR n = 246 AVR n = 170 TAVR n = 227 AVR n = 159
90 Mild-moderate Periprosthetic AR
91 Moderate Periprosthetic AR
92 Continuity Method Calculate SV LVOT Measure LVOT diameter Obtain PW Doppler signal in LVOT Trace LVOT TVI Calculate LVOT SV SV LVOT = CSA LVOT x TVI LVOT
93 Continuity Method Calculate SV MV Measure diameter of mitral annulus Obtain PW Doppler signal at level of mitral annulus Trace MV annulus TVI Calculate mitral valve SV SV MV = CSA MV x TVI MV
94 Calculation of Regurgitant Volume SV MV = CSA MV x TVI MV SV LVOT = CSA LVOT x TVI LVOT RV MR = SV MV - SV LVOT RV AR = SV LVOT - SV MV
95 Calculation of ERO Obtain optimal regurgitant jet with CW Doppler Use alternate windows to be parallel to flow Trace regurgitant TVI ERO = RV / regurgitant TVI AR ERO AV = RV AR / AR TVI
96 Echo for TAVR Conclusions: Assess atherosclerosis Select device size Assess landing zone site for suitability of valve deployment/potential complications Guide valve deployment & monitor/assess periprocedural complications Long-term follow-up
97 Before I came here I was confused about this subject. Having listened to your lecture I am still confused. But on a higher level -Enrico Fermi
98 Thank
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