Echo evaluation for TAVR. From the General Cardiologist to the Interventional Echocardiologist

Transcription

1 Echo evaluation for TAVR From the General Cardiologist to the Interventional Echocardiologist

2 Disclosures Proctoring activities for Abbott Vascular I and the HYGEIA Hospital «Heart Team» have received research and/or travel grants and/or lecture fees from: - Edwards Lifesciences - Medtronic - St Jude, Europe - ABBOTT Vascular, Europe HYGEIA Hospital Heart Team Cardiologists: M Chrissoheris, K Papadopoulos, A Halapas, K Spargias CT Surgeons: N Bouboulis, S Skardoutsos, A Tsolakis, S Pattakos Anesthesiologists: C Nastoulis, I Nikolaou Vascular Surgeons: I Belos, S Kaliafas Radiologists: F Laspas, C Mourmouris

3 Aortic Stenosis: Baseline screening echocardiogram Confirm severe valvular aortic stenosis Hemodynamic assessment (Peak / mean gradient, aortic valve area by continuity equation, coexistent aortic regurgitation Features of stenotic aortic valve (cusp number, degree of calcification) Aortic root anatomy Including LV outflow, sinuses of Valsalva and sinotubular junction Other key points Left ventricle size, function, degree of hypertrophy The mitral valve Right ventricle dysfunction and tricuspid valve Pulmonary hypertension Pericardial space

4 Aortic Stenosis Echo Criteria

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6 Echo in aortic stenosis Doppler Gradients with simplified Bernulli equation (ΔP=4v 2 ) Aortic Valve Area with use of the continuity equation Exclude subaortic stenosis Calculate aortic valve area index with use of body surface area (in cm 2 /m 2 )

7 Aortic valve morphology

8 Severe Aortic Stenosis:? Bicuspid aortic valve

9 MSCT: Confirmation of true bicuspid

10 Images of BAV cases missed by echocardiography type 1 L-R 25-50% of TTE have non-diagnostic findings for BAV morphology type 1 L-R due to severe valvular calcification Circ Cardiovasc Interv. 2013;6:

11 Age and Aortic Valve Morphology Number of cases years old years old Bicuspid Tricuspid Bicuspid Tricuspid Roberts et al. Circulation 2005;111:920-5

12 New Classification of Symptomatic Severe Aortic Stenosis ACC/AHA Guidelines on Valvular Heart Disease (2014)

13 Severe High Gradient Aortic Stenosis (D1) J Am Coll Cardiol. 2012;60(19): doi: /j.jacc

14 Severe High Gradient Aortic Stenosis (D1) AVA 1.0 cm 2 (or AVAi 0.6 cm 2 /m 2 ) Aortic Vmax 4 m/s Mean ΔP 40 mm Hg

15 Elevated transvalvular velocities: Is it the valve or the left ventricle? 88 year old female Dyspnea on exertion NYHA III-IV Referred for screening due to severe aortic stenosis

16 Hypertrophic obstructive cardiomyopathy, moderate AS (1.2cm 2 ), not requiring intervention

17 Referral for severe aortic stenosis 81-year-old male NYHA III dyspnea on exertion History of coronary artery disease CABG in 1997(x2 vessels) Examination: Loud holosystolic apical murmur (4/6)

18 Severe MR due to P2 prolapse / flail

19 3D-Multiplannar Reconstruction: Aortic Valve

20 Continuous Wave Doppler Interrogation of the aortic valve Α. Severe AS Β. Mild AS

21 3D-Planimetry of the Aortic Valve AVA 1.27cm 2

22 Echocardiography LV ejection fraction 58%, mildly dilated LVEDD 59mm LVEDV 161ml (LVEDVi 85ml/m 2 ) Mitral valve with severe regurgitation due to prolapse / flail posterior leaflet at the P2 segment ERO 42mm 2 R VOL 68ml, RF 73% spap 67mmHg 3-cusp aortic valve with moderate stenosis / low gradients

23 Right and Left Heart Catheterization: Hemodynamics Pulmonary capillary wedge tracing Simultaneous LV and Aortic Tracing

24 Right and Left Heart Catheterization: Pulmonary capillary wedge tracing: Giant V- Waves Hemodynamics Simultaneous LV and Aortic Tracing: Peak to Peak ~10mmHg

25 Final Fluoroscopic Appearance

26 Final Result Mild residual MR Mean Gradient 4-5mmHg

27 Echocardiography at 3 months

28 Severe Symptomatic AS Low Flow / Low Gradient with EF J Am Coll Cardiol. 2012;60(19): doi: /j.jacc

29 Severe Symptomatic Low-Flow / Low- Gradient with EF AVA 1.0 cm 2 (or AVAi 0.6 cm2/m2) Aortic Vmax <4 m/s Mean ΔP <40 mm Hg Dobutamine stress echo: AVA 1.0 cm2 with Vmax 4m/s at any flow rate

30 From: Low-Flow, Low-Gradient Aortic Stenosis With Normal and Depressed Left Ventricular Ejection Fraction J Am Coll Cardiol. 2012;60(19): doi: /j.jacc Date of download: 10/20/2014 Copyright The American College of Cardiology. All rights reserved.

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33 The Patient 75 year-old male, dyspnea, NYHA IV Hospitalization for heart failure decompensation Coronary artery disease, CABG x 1 (2005) Echocardiography with LVEF 20% Aortic stenosis Mean gradient 25mmHg, AVA 0.9cm 2 Comorbidities: Obesity, chronic atrial fibrillation, pacemaker

34 Echocardiography

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36 Flow Velocities Across Aortic Valve: At Rest V MAX 2.9m/s, PG 34, MG 21mmHg, AVA 0.74cm 2

37 Dobutamine Stress Echo: Peak Dose of 30mcg/kg/min

38 Dobutamine Stress Echocardiography: Rest

39 Dobutamine Stress Echocardiography: Peak Infusion 30mcg/kg/min V MAX 3.8m/s, PG 56, MG 31mmHg, AVA 0.9cm 2

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41 Echocardiography post TAVR

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43 N=149 patients with Low Gradient AS (AVA <1.0cm 2, MG<40mmHg, EF<40%) vs with High Gradient AS Similar procedural success and TAVI related complications

44 TAVI in Low-Flow, Low-Gradient AS: Survival at 30-days and 1-year

45 TAVI in Low Flow Low Gradient AS Patients: Clinical Benefits

46 N=50 patients with LVEF 35% (Group A) Vs N=334 patients with LVEF >35% (Group B) B A

47 TAVR in patients with severe LV dysfunction: Mid term follow up N=50 patients with LVEF 35% (Group A) Vs N=334 patients with LVEF >35% (Group B) B A

48 Low-Flow, Low-Gradient Aortic Stenosis With Normal Left Ventricular Ejection Fraction J Am Coll Cardiol. 2012;60(19): doi: /j.jacc

49 Paradoxical Aortic Stenosis 77 year old female NYHA III dyspnea, Vmax 3.4m/s, MG 30mmHg,, EF 65%, peak to peak gradient 35mmHg

50 Paradoxical Aortic Stenosis

51 Severe Aortic Stenosis with low gradients, despite normal EF AVA 1.0cm2 ( 0.6cm 2 /m 2 ) EF 50% Vmax 4.0 m/sec Mean Gradient 40mmHg Note: If uncontrolled hypertension, then medical therapy should first be initiated, before gradients are evaluated

52 Case Example of Paradoxical Low Flow Severe AS with Normal EF 57 y.o. male CCS III EF 72%, concentric LVH PG 38 / MG 22mmHg AVA 0.99cm 2 SVi 30ml/m 2 Zva 5.73mmHg/ml/m 2 Peak-to-peak 25mmHg

53 Severe Aortic Stenosis with low gradients, despite normal EF

54 Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P. Paradoxical low flow, low gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation 2007;115:

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57 Baseline Left Ventricular Function

58 Patient Screening for TAVR: Echocardiography Left ventricular systolic function Ejection fraction Degree of LVH Regional wall motion abnormalities Global longitudinal strain

59 Left Ventricle Function: EF Poor LV function, anticipate need for inotropic support, dysrhythmias, stunning and acute hemodynamic deterioration post rapid pacing

60 TAVR in Patient with Low EF Patient 84 year-old male Ischemic cardiomyopathy EF 25% Low-flow, low-gradient AS NYHA III-IV Peripheral arterial disease Euroscore 58.6% TF TAVR / Sapien XT 26mm Valve Deployment

61 LV stunning post rapid pacing LV stunning post rapid pacing Recovery CK-MB 36ng/ml, Troponin (I) 6ng/ml

62 Prevalence of LV systolic dysfunction in patients undergoing TAVR Prevalence of LV systolic dysfunction N=371 LVEF 35% LVEF 36-49% LVEF 50% 13% of TAVI patients with LVEF 35% 20% with LVEF 36-49% Source: HYGEIA Hospital THV database

63 Left Ventricle Function: EF Hyperdynamic LV function, severe LVH Patient will require volume loading and vasopressors AVOID inotropes

64 Hyperdynamic LV syndrome post AVR

65 Hyperdynamic LV syndrome post TAVR Rx with temporary RV pacing

66 LV Assessment: Other Considerations Septal bulge / sigmoid septum Apical thrombus

67 The Aortic Annulus Annulus is the virtual ring that connects the basal attachments of the aortic cusps The annulus is ellipsoid in shape

68 Annulus sizing critical Underestimate Patient-Prosthesis Mismatch Paravalvular leak Device migration Overestimate Injury to the aortic root / rupture Sinus width Coronary ostia distance from annulus Risk of coronary occlusion The Aortic Root

69 Aortic Root and Ascending Aorta

70 In the old days annulus sizing by 2D TTE Transthoracic Parasternal Long Axis Zoom, high frequency Measure from point of insertion of noncoronary cusp to anterior mitral leaflet to the insertion of the right coronary cusp to interventricular septum

71 Courtesy of Dr. Piazza and Prof. Lange, German Heart Center, Munich Germany

72 Mean = 1.29 ± 0.11 Distribution of D max /D min from 164 TAVI patients Courtesy of Dr. Piazza and Prof. Lange, German Heart Center, Munich Germany

73 Perimeter: linear distance of tracing around the aortic annulus perimeter derived mean diameter Area: area contained within tracing around the aortic annulus area derived mean diameter Major & Orthogonal Minor Diameters: linear distances through the center of the aortic annulus Mean Diameter: calculated mean of major and minor diameters

74 Determination of annulus size by 3D TEE

75 Direct comparison of MDCT and 3D TEE

76 Assessing Coronary Ostia 3D-TEE

77 Mitral Valve Function

78 Mitral Valve Establish baseline mitral valve function Deep TAVI implantation may interfere with the anterior leaflet of the mitral valve and induce mitral stenosis or insufficiency

79 CoreValve Interference with the anterior MV leaflet Journal of the American Society of Echocardiography Volume 24, Issue 9, Pages , September 2011

80 Severe Aortic Stenosis and Mitral Regurgitation

81 The Patient 81 year-old male, NYHA IV Multiple admissions for heart failure decompensation, high doses of diuretics, cardiac cachexia Comorbidities: Chronic kidney disease, diabetes mellitus (on oral meds), chronic atrial fibrillation Severe aortic stenosis

82 LV-EF 35% Severe aortic stenosis PG 53mmHg MG 32mmHg AVA 0.5cm 2 spap 52mmHg Significant mitral regurgitation (3+) RV dysfunction with severe (3+) tricuspid regurgitation Echocardiography

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84 Echocardiography: Continuity Equation

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90 TAVI and Moderate / Severe Mitral Regurgitation Prevalence

91 Circulation. 2013;128:

92 Mitral Regurgitation Changes After TAVR

93 Ν=1007 patients for TAVR with CoreValve Mitral regurgitation None / mild in 66.5% Moderate in 24% Severe in 9% Circulation. 2013;128:

94 Factors predictive of improvement Functional MR No severe pulmonary hypertension No atrial fibrillation

95 RV Dysfunction Severe pulmonary hypertension from left sided valvular heart disease or from systolic LV dysfunction Underlying chronic lung disease

96 Prevalence of Chronic Lung Disease and Pulmonary Hypertension (spap>50mmhg) Chronic Lung Disease (38%) Pulmonary Hypertension (50%) yes no yes no Source: HYGEIA Hospital THV database

97 Interventional Echocardiography for TAVR

98 Echo Modalities for TAVR

99 Interventional Imaging Recommendations Echographer needs to be familiar with procedural steps, valve characteristics and anticipate problems If TEE is utilized procedure can be monitored throughout If TTE then imaging can only be done during breaks in the procedure to answer specific questions and at the end to evalutate result Hahn RT et al. J Am Coll Cardiol Img 2015;8:261 87

100 TAVR Complications Echographer needs to understand potential TAVR complications Early identification Especially when patient is hemodynamically unstable

101 Echo guidance during TAVR positioning Most commonly TAVR under fluoroscopic and angiographic guidance Occasionally echo may be needed for positioning e.g. no fluoroscopic calcium markers, need to avoid contrast injections

102 Valve in valve for stentless bioprosthesis failure 74 year-old male savr (3/2012) Solo-Freedom 23mm EF 45% Severe Valve Dysfunction Flail Leaflet, AR 4+ NYHA IV Multiple heart failure admissions Inoperable Referred for Valve in Valve

103 Selection of CoreValve 29mm prosthesis Valve in Valve: Annulus Sizing Comparison of 3D-TOE and MDCT 3D TEE : Aortic Root Multiplanar Reconstruction : Area of Annulus 530mm 2 MDCT : Aortic Root Multiplanar Reconstruction : Area of Annulus 492mm 2

104 Valve in Valve: Baseline Aortography with AR 4+

105 Valve in Valve: CoreValve 29mm positioning and release

106 Valve in Valve: Final Result

107 Echo for evaluation of mechanism of regurgitation post TAVR

108 Mechanism of Paravalvular Regurgitation Malapposition High position Low position Undersizing JACC Vol. 59, No. 13, 2012:

109 Mechanism of Paravalvular Regurgitation (II) Prosthesis too small Position too high Position too low Malapposition due to calcified annulus

110 Paravalvular Echo Assessment STENOSIS REGURGITATION

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112 PAR due to high TAVR implantation 87 year old female NYHA III dyspnea Severe AS (PG 81mmHg) COPD Euroscore 25% Transfemoral approach, Sapien XT 23mm Echo: Moderate to Severe LVH

113 Baseline Echocardiography Cocentric LVH Septal Bulge PLAX Zoom on Aortic Valve

114 MDCT: Annulus and LVOT Measurements Annulus LVOT

115 TAVI: Movement during deployment

116 3D-TEE:Severe Regurgitation due to high position

117 Valve-in-Valve Valve in Valve: Sapien XT 23mm Elimination of Aortic Regurgitation Note: Transaortic approach

118 POST-VIV TEE IMAGING LONG AXIS LONG AXIS WITH COLOR

119 Post Dilation for Paravalvular Leak due to Under Expansion of Valve Stent

120 Baseline MDCT MDCT Severely Calcified Valve

121 Severe Aortic Regurgitation TEE Severe paravalvular and moderate transvalvular Regurgitation Valve malaposition due to annulus calcium with severe PAR and transvalve regurgitation: Leaflet Dysfunction?

122 Severe Paravalvular Regurgitation Valve not well apposed to the annulus Calcium deposits not allowing stent frame to fully expand

123 TEE Imaging

124 Post-Dilatation: Nucleus 25x40mm Nucleus 28x40mm

125 Follow Up Resolution of transvalvular regurgitation and persistence of moderate PAR Clinical course uneventful, discharge home and doing well on clinical follow up with residual 2+ paravalvular regurgitation

126 Valve in Valve for Deep Positioning of Self Expanding Bioprosthesis

127 Severe par due to very low position

128 Hemodynamics of severe par

129 Valve in Valve (in valve)

130 Resolution of par

131 Echo for evaluation of aortic root post TAVR

132 Patient Aortography 81 year-old female Severe AS (PG 135mmHg) Coronary disease DM-II NYHA IV LE 27%, STS 7% TF TAVR SAPIEN XT 23

133 Edwards 20x40 BAV (x1) TAVR SAPIEN XT 23mm

134 Annulus Rupture Aortic Root Hematoma Small Pericardial Effusion

135 Annulus Rupture: Outcome Follow up echo day 3 Tamponade on day 6

136 Aorto-RV fistula 86 year old female Severe Aortic Stenosis PG 107 / MG 76mmHg, LVEF 35-40% Dyspnea on mild exertion, NYHA III Coronaries without stenosis EKG with RBBB Comorbidities Advanced renal failure (GFR 22.5 cc/min) Euroscore: 38.6% ; STS mortality: 9.1%

137 ECHOCARDIOGRAPHY pre TAVI Densely Calcified Aortic Valve Annulus 18 mm

138 TRANSFEMORAL TAVI BAV w aortography Sapien XT implantation Post aortography 16 French E-Sheath, E-Novaflex delivery system Balloon Valvuloplasty with 20x40mm Sapien XT 23 mm (annulus 18mm) Aortography: Minimal paravalvular AR

139 ECHOCARDIOGRAPHY Mild paravalvular aortic regurgitation Continuous flow at membranous septum

140 Membranous VSD / Aorto-RV fistula Color Flow at 4 days Color Flow at 30 days

141 Echo for evaluation of hemodynamic instability

142 The Patient 86 year old male Severe aortic stenosis Admitted with decompensated heart failure, low output state and acute pulmonary edema Critical Care with inotropic and vasoactive agents for support Refractory pulmonary edema Transfer for urgent TAVR

143 Baseline Echocardiography Peak 64mmHg / mean gradient 40mmHg AVA 0.6cm 2 AR grade 1+ Ejection fraction 50% MR grade 2-3+

144 Invasive Hemodynamic Assessment Severe aortic stenosis, peak to peak gradient ~100mmHg Marked elevation of LV diastolic filling pressures, LVEDP ~35-40mmHg

145 BAV: Edwards Balloon 20x40

146 Post BAV Aortography

147 Transthoracic Echo post BAV

148 CoreValve Deployment

149 Transesophageal Echo

150 Severe MR Stunning of left ventricle due to period of low flow Dysynchrony due to pacemaker rhythm No evident interference between CoreValve and mitral valve

151 Pacemaker CRT Implantation CRT OFF CRT ON

152 24hrs: Paravalvular AR 1-2+

153 Hospital Course ICU admission CRT pacemaker at 24hrs Repeat TEE for MR reassessment => MR grade improved Transfer to medical ward on day #2 post TAVR No neurologic deficits Discharge home on day #6 post TAVR

154 In Summary Echocardiography is the first stop imaging modality for accurate evaluation of aortic stenosis Even more, it is an indispensable tool during transcatheter interventions for guidance and evaluation of the results