Comments restricted to Sapien and Corevalve 9/12/2016. Disclosures: Core Lab contracts with Edwards Lifesciences, Middlepeak, Medtronic

Transcription

1 Para-ValvularRegurgitation post TAVR: Predict, Prevent, Quantitate, Manage Linda D. Gillam, MD, MPH, FACC, FASE Chair, Department of Cardiovascular Medicine Morristown Medical Center/Atlantic Health System Professor of Medicine Sidney Kimmel Medical College at Thomas Jefferson University Disclosures: Core Lab contracts with Edwards Lifesciences, Middlepeak, Medtronic Comments restricted to Sapien and Corevalve 1

2 Background Paravalvular regurgitation is a well recognized complication of TAVI is associated with worse outcomes Some Inconsistencies Reasons for Discrepancies Imaging Approach TTE vstee 2D vs3d Angiography Echo vs. CT Adequacy of the images Method of Assessment (echo) Color jet only Quantitative Grading scheme used (3 or 4 point) Time point Point in learning curve Valve type Site vs. core lab vs. meta-analysis 2

3 PVL and 1 yrmortality From: Incidence, Predictors, and Outcomes of Aortic Regurgitation After Transcatheter Aortic Valve Replacement: Meta-Analysis and Systematic Review of Literature (Athappan et al) J Am Coll Cardiol. 2013;61(15): Forest Plot Showing the HRs of Moderate or Severe AR on Overall Mortality (1 yr) * Copyright The American College of Cardiology. All rights reserved. Is there a difference between valves? Meta-analysis Moderate or Severe AR: CoreValve 16% Athappanet al, JACCVol. 61, No. 15,

4 Meta-analysis Moderate to Severe AR: Sapien Valve 9.1% Athappanet al, JACCVol. 61, No. 15, 2013 Meta-analysis Moderate or Severe AR O Sullivan, K et al. European Journal of Cardio- Thoracic Surgery (2013) 1 8 Predictors of PVL Pre-implantation Inadequate sizing/annular eccentricity Calcification Peri-implantation Valve undersizing Valve Position Incomplete deployment Irregular stent shape Angle of deployment Approach (apical better than TF?) 4

5 9/12/2016 Incidence, Predictors, and Outcomes of Aortic Regurgitation After Transcatheter Aortic Valve Replacement: Meta-Analysis and Systematic Review of Literature J Am Coll Cardiol. 2013;61(15): doi: /j.jacc Figure Legend: Selected Studies on Predictors of AR Post-TAVR From: Incidence, Predictors, and Outcomes of Aortic Regurgitation After Transcatheter Aortic Valve Replacement: Meta-Analysis and Systematic Review of Literature (Athapan et al) J Am Coll Cardiol. 2013;61(15): Valve Undersizing Calcification Implantation Depth The Importance of Sizing Coverage Index Prosthesis-Annular Mismatch Large Absolute Annular Size 5

6 From: Determinants of Significant Paravalvular Regurgitation After Transcatheter Aortic Valve Implantation: Impact of Device and Annulus Discongruence (Detaint et al Bichat) J Am Coll Cardiol Intv. 2009;2(9): ([prosthesis diameter TEE annulus diameter]/prosthesis diameter). We now understand importance of sizing and do it better Echo -optimized 2D, 3D CT Angiography This basal short-axis view shows the closed aortic valve Copyright 2008 American Heart Association Piazza, N. et al. Circ Cardiovasc Intervent 2008;1:

7 9/12/2016 From: Standardized Imaging for Aortic Annular Sizing: Implications for Transcatheter Valve Selection J Am Coll Cardiol Img. 2013;6(2):

8 Calcium From: Correlation of Device Landing Zone Calcification and Acute Procedural Success in Patients Undergoing Transcatheter Aortic Valve Implantations With the Self-Expanding CoreValve Prosthesis J Am Coll Cardiol Intv. 2010;3(2): Copyright The American College of Cardiology. All rights reserved. From: Correlation of Device Landing Zone Calcification and Acute Procedural Success in Patients Undergoing Transcatheter Aortic Valve Implantations With the Self-Expanding CoreValve Prosthesis J Am Coll Cardiol Intv. 2010;3(2): Copyright The American College of Cardiology. All rights reserved. 8

9 From: Correlation of Device Landing Zone Calcification and Acute Procedural Success in Patients Undergoing Transcatheter Aortic Valve Implantations With the Self-Expanding CoreValve Prosthesis J Am Coll Cardiol Intv. 2010;3(2): Figure Legend: Other studies have not confirmed the importance of calcium Location: Commissural (Gripari et al) Protruding >4 mm (Feuchteret al) Annulus (Ewe et al) Positioning Too high/ Too low 9

10 9/12/2016 Low position 10

11 Other Predictors (Deployment) Inadequate expansion Interaction with calcification Malalignment Coaxiality: Device-to-Annulus (DTA) Angle α>90⁰ (non-coaxial) α=90⁰ (coaxial) α<90⁰ (non-coaxial) annulus 11

12 Prevent Accurate Sizing Proper Positioning Tools for Diagnosis Acute: Aortography Hemodynamics Echocardiography (TEE) 12

13 Hemodynamics Sinning et al JACC 2013 Beware abnormal compliance Tools for Diagnosis Chronic: Echocardiography (TTE) TEE Aortography MRI 13

14 Echocardiography Guidelines 14

15 Integrated Approach to Echocardiographic Quantitation of AR Color jet characteristics Circumferential extent Doppler Pressure half time Flow reversal in the descending thoracic aorta Quantitative Doppler Color Jet Qualitative 15

16 Technical Tips Jets may be multiple and irregular Retrograde flow may be trapped by skirts Confirm that jet is reaching ventricle Multiple views Multiple short axis levels Multiple long axis angles Be aware of blind spots Beware of redirected jets Figure 5 Journal of the American Society of Echocardiography , 47-55DOI: ( /j.echo ) Copyright 2012 American Society of Echocardiography Terms and Conditions 16

17 9/12/2016 Color Jet Quantitative Jet width Beware of eccentric jets Vena contracta (2D vs 3D) Non circular PISA Circumferential extent Circumferential extent From: Assessment of Paravalvular Regurgitation Following TAVR: A Proposal of Unifying Grading Scheme: Pibarot et al J Am Coll Cardiol Img. 2015;8(3):

18 Circumferential Extent Multiple pinholes vs confluent defect Eccentric jets fan out The heart moves Hard to define the true regurgitant orifice Spatial resolution of TTE is limited Impact of width Most common locations (native commissures) 18

19 From: Assessment of Paravalvular Regurgitation Following TAVR: A Proposal of Unifying Grading Scheme Pibarot et al J Am Coll Cardiol Img. 2015;8(3): Moderate? Severe? Echocardiographic Quantitation of AR Quantitative Doppler Continuity Equation (SV = CSA x VTI) Reference is pulmonic valve flow Can be done with TTE (harder than TEE) AR RV = AV SV -PV SV 19

20 MRI Calculation of Regurgitant Volume and Regurgitant Fraction Sherif et al EuroIntervention 2011 Manage Acute: Reposition (if possible) Balloon post dilations Valve in valve Chronic Medical management Valve in valve Percutaneous plug Clinical Significance Severity matters Trace to mild paravalularregurgitation well tolerated Left ventricular properties matter Compliance (diastolic function) Systolic function 20

21 Post dilation 10-20% patients Reduces PVL by 1 grade in 2/3 pts Complications Annular rupture?vsd CVA Central regurgitation Conduction system dysfunction Summary Paravalvular regurgitation is common and prognostically important Accurate diagnosis in the acute peri-procedural setting facilitated by ability to correlate echo (TEE), aortography, and hemodynamics Accurate diagnosis post procedure (moderate vs. severe) may be more challenging with need to use alternative echo approaches including 3D and quantitative Doppler MRI may be helpful in some patients Summary Predictors have been identified Poor sizing Poor implantation Calcium Management includes mechanical and medical options 21

22 Changing landscape New devices New techniques for assessing/mitigating risks Thank you 22