CARDIOLOGY GRAND ROUNDS

Transcription

1 CARDIOLOGY GRAND ROUNDS Presentation: Speakers: Percutaneous Repair of Paravalvular Prosthetic Regurgitation Paul Sorajja, MD Director of the Center for Valve and Structural Heart Disease Minneapolis Heart Institute at Abbott Northwestern Hospital John R. Lesser, MD, FACC, FSCCT, FAHA, FSCAI Senior Consulting Cardiologist, Medical Director CT/CMR, Minneapolis Heart Institute at Abbott Northwestern Hospital Date: Location: Monday, February 23, 2015, 7:00 8:00 AM ANW Education Building, Watson Room OBJECTIVES At the completion of this activity, the participants should be able to: 1. Recollect appropriate methods for evaluation and imaging of paravalvular prosthetic regurgitation 2. Recall indications for percutaneous repair of paravalvular prosthetic regurgitation 3. Describe outcomes of therapy using percutaneous repair of paravalvular prosthetic regurgitation ACCREDITATION Physicians: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Allina Health and Minneapolis Heart Institute Foundation. Allina Health is accredited by the ACCME to provide continuing medical education for physicians. Allina Health designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. Nurses: This activity has been designed to meet the Minnesota Board of Nursing continuing education requirements for 1.2 hours of credit. However, the nurse is responsible for determining whether this activity meets the requirements for acceptable continuing education. Others: Individuals representing other professional disciplines may submit course materials to their respective professional associations for 1.0 hours of continuing education credit. DISCLOSURE STATEMENTS Speaker(s): Dr. Paul Sorajja declared that he does not have conflicts of interest in making this presentation. Dr. Lesser declared the following relationship Grant/Research Support: Siemens Medical Systems. Planning Committee: Dr. Michael Miedema, and Eva Zewdie have declared that they do not have any conflicts of interest associated with the planning of this activity. Dr. Robert Schwartz declared the following relationships - stockholder: Cardiomind, Interface Biologics, Aritech, DSI/Transoma, InstyMeds, Intervalve, Medtronic, Osprey Medical, Stout Medical, Tricardia LLC, CoAptus Inc, Augustine Biomedical; scientific advisory board: Abbott Laboratories, Boston Scientific, MEDRAD Inc, Thomas, McNerney & Partners, Cardiomind, Interface Biologics; options: BackBeat Medical, BioHeart, CHF Solutions; speakers bureau: Vital Images; consultant: Edwards LifeSciences. PLEASE SAVE A COPY OF THIS FLIER AS YOUR CERTIFICATE OF ATTENDANCE

2 Presenter Disclosure Information John R. Lesser, M.D. DISCLOSURE INFORMATION: The following relationships exist related to this presentation: Siemens Medical Systems: Educational Grant, Speaker s Bureau CT with Paravalvular Leak Minneapolis Heart Institute at Abbott Northwestern Hospital Page 1

3 Paravalvular Leak Can CT help with the diagnosis? Can it help direct a percutaneous procedure? Cases have long fluoro times How do you do it? Post TAVR Dypnea 79 yo man with severe AS # 26 Sapien TAVR valve 4 months before Continued DOE with worsened EF ~ 20-25% (from ~ 35% pre TAVR) TTE performed Minneapolis Heart Institute at Abbott Northwestern Hospital Page 2

4 How to do it? Echo and CTA TTE with AI jet Ant. MV Ant. MV Mimic echo Orientation on CTA Scroll LVOT Ao Lesser JR, et al. JCCT 2015, In press. Create Angle for Fluoroscopy: S/P Edwards Magna Pericardial Valve Sagittal Coronal Axial Coronal Thick MIP Minneapolis Heart Institute at Abbott Northwestern Hospital Page 3

5 Single Plane CV Lab: No Prosthetic Valve Superimposition, PVL at Edge Caudal 25 RAO 15 Valve Struts Aligned, PVL at Edge Wire Across PVL MVR Paravalvular Leak: Where is the PVL (obscured by AVR)? RAO 31 Cr 14 S A A P R L I P Minneapolis Heart Institute at Abbott Northwestern Hospital Page 4

6 CT Provided the Basic Orientation PVL Wire Plug DK 71 yo woman had severe AS with DOE Normal LV systolic fx with normal aortic size Insignificant CAD by CA # 23 Edwards Magna bioprosthetic AVR 11/13 Minneapolis Heart Institute at Abbott Northwestern Hospital Page 5

7 TTE 3-4+ AI 1 and 6 months post-op Increasing SOB with fatigue 14 months post-op TEE CTA ordered Minneapolis Heart Institute at Abbott Northwestern Hospital Page 6

8 AP R1, Caud 20 L 9, Cuad 15 Minneapolis Heart Institute at Abbott Northwestern Hospital Page 7

9 SH 21 yo woman with prior AV canal with septal defect repair and MVR x 2 Most recent surgery 5 years before; # 25 Epic St. Jude bioprosthetic MVR Prior PPM SOB over the past 2 years while dancing or running TTE showed a 9 mm MDG with a mild paravalvular leak Stress Echo Ex time 8 ; peak HR 166; BP 120 with DP 19,920 Rest HR 81 with MDG of 15 mm and peak HR 162 with MDG of 31 Rest RVSP = 24 + RAP; Post Exercise RVSP = 50 + RAP MV ml/kg/min; no 02 desaturation Stopped for SOB Minneapolis Heart Institute at Abbott Northwestern Hospital Page 8

10 Bicycle Exercise Rest: Mitral diastolic gradient Exercise: Mitral diastolic gradient Rest mean MDG at HR 81 = 15 mmhg Peak exercise MDG at HR 162 = 31 mmhg TEE Mitral Valve MR Paravalvular leaks MVR Struts Moderate PVLs Normal LV function; Normal resting RV function Normal MV leaflet motion Cardiac CTA to understand mechanism Minneapolis Heart Institute at Abbott Northwestern Hospital Page 9

11 RV LV Leak LA RV LV LV Leak LA LA Ao LA Minneapolis Heart Institute at Abbott Northwestern Hospital Page 10

12 Thin MIP Thick Average (Dehised) Thin MIP Quantitative Volumes from Cardiac CTA Dilated LV with mild LV dysfunction Severe PVL with MR and no direct valvular calcification or degeneration # 29 bioprosthetic MVR placed with complete symptom resolution Minneapolis Heart Institute at Abbott Northwestern Hospital Page 11

13 Paravalvular Leak Evaluate all CCTA patients with a valve prosthesis for paravalvular leaks Guide paravalvular leak closure Acquire the best datasets needed to stop motion Use site of AI jet on TTE at the LV exit and mimic orientation on CT Check for areas of contrast continuity from Ao to LV Create ideal angle for crossing the defect with a wire Lesser JR, et al. JCCT 2015, In press CT: Prosthetic Valve Function Habets J, et al. Radiographics 2012;32: Minneapolis Heart Institute at Abbott Northwestern Hospital Page 12

14 Mechanical Valves: CT Visibility and Normal Angles High St. Jude, ATS, Carbomedics, Med-Hall are all visible Do not scan a Bjork-Shiley marked artifact Habets J, et al. Radiographics 2012;32: yo S/P St. Jude MVR x 2 Normal opening and closing angles on MVR Fluoroscopy in CV lab was normal Markedly elevated mitral diastolic pressure Pannus obstructs inflow without effecting valve mechanism confirmed surgically Minneapolis Heart Institute at Abbott Northwestern Hospital Page 13

15 Increasing AVR Gradient: Mean gradient 11, now 34 mmhg Opening angle: 7 degrees (Nl up to 12) Opening angle: 6 degrees Nl AVR angles with Pannus. Does not effect hinge point. Patient-Valve Mismatch vs. AVR Malfx. Minneapolis Heart Institute at Abbott Northwestern Hospital Page 14

16 Small then Moderate Gradient Increase: Mechanical St. Jude AVR AVR 1988 Mean grad 11 to 34 mmhg Pannus and Leaflet malfunction (Surgically confirmed) Concern that the leaflet will completely stick Med-Hall Valve: Increase in mean 11 to 42 mmhg in 5 yrs. Angle 65 degrees expected is 75 degrees Pannus limits tilting disc motion Minneapolis Heart Institute at Abbott Northwestern Hospital Page 15

17 Mechanical Valve Prostheses: Follow-up after Abnormal Echo Prosthetic Valve with elevated gradient or dysfunction on echo Valve mismatch nl leaflet (nl angles) and no or minimal pannus redo if severe AS and can enlarge the aortic root Nl leaflet fx with pannus severely elevated gradient and nl angles redo if severe AS Abnormal leaflet fx with pannus or thrombus Redo surgery (or lytics) to avoid catastrophic valve failure Thank You Minneapolis Heart Institute at Abbott Northwestern Hospital Page 16

18 Minneapolis Heart Institute at Abbott Northwestern Hospital Page 17