Procedural Guidance of TAVR: How to Assure it Goes Right and What to Do If It Doesn t

Transcription

1 Procedural Guidance of TAVR: How to Assure it Goes Right and What to Do If It Doesn t James D. Thomas, M.D., F.A.C.C. Department of Cardiovascular Medicine Heart and Vascular Institute Cleveland Clinic Foundation Cleveland, Ohio, USA Conflicts: None MR2010:1

2 MR2010:2

3 What is the Role of Imaging in TAVR?? Pre-procedural Severity of AS, cusp anatomy, annular size, vascular access Intra-procedural Guidance of intervention Recheck all measurements, positioning of balloon and valve Intra-procedural Assessment of complications Regurgitation, LV dysfunction, device displacement, tamponade, MR, SAM Post-procedural Pretty standard follow-up for AVR Will need to be vigilant for several years, as we are defining the natural history at this time MR2010:3

4 Highly Recommended J Am Soc Echocardiogr 2011; 24: MR2010:4

5 Highly Recommended JACC 2012 MR2010:5

6 What is the Role of Imaging in TAVR?? Pre-procedural Severity of AS, cusp anatomy, annular size, vascular access Intra-procedural Guidance of intervention Recheck all measurements, positioning of balloon and valve Intra-procedural Assessment of complications Regurgitation, LV dysfunction, device displacement, tamponade, MR, SAM Post-procedural Pretty standard follow-up for AVR Will need to be vigilant for several years, as we are defining the natural history at this time MR2010:6

7 Severe AS Criteria for TAVR Peak velocity of 4 m/sec or mean gradient > 40 mmhg AND Valve area < 0.8 cm 2 or indexed area < 0.5 cm 2 /m 2 Dobutamine acceptable to achieve gradients Calcified, trileaflet valve Trials have excluded bicuspid and unicuspid valves 1-2% ambiguous even by path! Sometimes pretty tough! MR2010:7

8 CT Can Help with Cusp Anatomy Bicuspid Valve MR2010:8

9 Sapien Valve Annular Sizes Device size Annular size 23 mm mm 26 mm mm 29 mm mm Core Valve Device size Annular size 26 mm mm 29 mm mm 31 mm mm MR2010:9

10 Assessing Annular Size More challenging than you d think The annulus is not circular Medial-lateral distance ~10% more than A-P, but variable Need 3D guided imaging for accuracy TEE with x-plane and CTA are best Overlying Ca++ can be challenging to find true annulus MR2010:10

11 Chest-Abdomen-Pelvis CT for Access Vessels Must be 7 mm or Larger Suitable Unsuitable MR2010:11

12 MR2010:12

13 What is the Role of Imaging in TAVR?? Pre-procedural Severity of AS, cusp anatomy, annular size, vascular access Intra-procedural Guidance of intervention Recheck all measurements, positioning of balloon and valve Intra-procedural Assessment of complications Regurgitation, LV dysfunction, device displacement, tamponade, MR, SAM Post-procedural Pretty standard follow-up for AVR Will need to be vigilant for several years, as we are defining the natural history at this time MR2010:13

14 Patient #1 R.M. 90 yo Man 90 year-old male Severe aortic stenosis with NYHA Class III symptoms Past Medical History: Coronary Artery Disease with CABGx4 in 1998 Right Carotid Endarterectomy Atrial fibrillation Hypertension Marked Thoracic Kyphosis MR2010:14

15 Echocardiography 21 mm MR2010:15

16 Valve Deployment MR2010:16

17 Result Patient is playing golf 1 year later! MR2010:17

18 Positioning the Device It s Harder Than you Think! ACC TAVR Expert Consensus, JACC 2012 MR2010:18

19 What is the role of Live 3D TEE in guiding TAVR?? MR2010:19

20 Live 3D Guidance of TAVR Placing device relative to annulus MR2010:20

21 Live 3D Guidance of TAVR Rapid pacing balloon inflation of bioprosthesis MR2010:21

22 Post-Deployment Assessment Leaflet motion after TAVR MR2010:22

23 2-3+ AR, Δp = 54/38 mmhg 1+ AR, Δp = 12/8 mmhg MR2010:23

24 What is the Role of Imaging in TAVR?? Pre-procedural Severity of AS, cusp anatomy, annular size, vascular access Intra-procedural Guidance of intervention Recheck all measurements, positioning of balloon and valve Intra-procedural Assessment of complications Regurgitation, LV dysfunction, device displacement, tamponade, MR, SAM Post-procedural Pretty standard follow-up for AVR Will need to be vigilant for several years, as we are defining the natural history at this time MR2010:24

25 Assessment of Post-TAVR Complications You Have SECONDS to Figure Out What s Wrong! Severe AR from Paravalvular leak (may need reballooning) Leaflet stuck open (gentle probe with soft wire vs valve in valve redo) Displacement of device into LV or aorta LV dysfunction Regional: consider coronary occlusion Global: may be post-deployment stunning Pericardial effusion/tamponade Severe MR LVOT obstruction Dissection MR2010:25

26 The Constellation of Mild-Moderate AR MR2010:26

27 The Constellation of Mild-Moderate AR A1, A2: Trivial paravalvular AR B: Trivial valvular AR C: Moderate paravalular AR (resolved with reballooning) MR2010:27

28 Kodali SK. N Engl J Med 2012; On-line 3/26/12 MR2010:28

29 Severe Valvular AR What s Going On? Severe AR Marked flow reversal in descending aorta MR2010:29

30 Severe Valvular AR One Leaflet is Stuck Open! Leaflet in LCC position does not close Required redo valve-in-valve TAVR MR2010:30

31 Did We Deploy the Valve a Little Low?? Moderate Paravalve AR Well let s hope for the best. MR2010:31

32 Uh, oh is it slipping a little lower?? Now Severe Valvular AR Hang on, hang on MR2010:32

33 Now We ve Got a Mess TAVR Embolization into LV It tumbled and tumbled around the LV MR2010:33

34 An Hour Later: Back in the LVOT But It s UPSIDE DOWN! Leaflets open due to the AR. Remarkably, BP could be supported, and it was off to the OR. MR2010:34

35 Intraoperative Views TAV Retrieved and #25 CE Valve Implanted Moderate LV dysfunction, mild paravalve AR. Pt alive and active 3 years later, age 92! MR2010:35

36 MR2010:36

37 82 yo woman Spinal stenosis Δp > 100 mmhg AVA = 0.5 cm 2 MR2010:37

38 Echo : AVR Deployment MR2010:38

39 Percutaneous Aortic Valve Replacement Looked like a good result, but. MR2010:39

40 Echo Post Deployment Pt Hypotensive and in Distress Only the inferior wall is moving.. MR2010:40

41 Echo Post Deployment Left main appears blocked with no color flow seen MR2010:41

42 LMT Obstruction CPR in Progress MR2010:42

43 TandemHeart Inserted RAO Projection LAO Projection LA cannula LA cannula TEE Probe TEE Probe MR2010:43

44 Tandem Heart MR2010:44

45 Final Result Stents in the Left Main MR2010:45

46 Echo after LMT Stenting MR2010:46

47 1 month F/U MR2010:47

48 1 Year Follow Up MR2010:48

49 What Else Can Go Wrong?? Aortic dissection Courtesy of Dr. Chirojit Mukherjee MR2010:49

50 What Else Can Go Wrong?? Severe MR from misdirected applicator Courtesy of Dr. Chirojit Mukherjee MR2010:50

51 What Else Can Go Wrong?? Severe MR from perforated AML Courtesy of Dr. Chirojit Mukherjee MR2010:51

52 MR2010:53

53 What is the Role of Imaging in TAVR?? Pre-procedural Severity of AS, cusp anatomy, annular size, vascular access Intra-procedural Guidance of intervention Recheck all measurements, positioning of balloon and valve Intra-procedural Assessment of complications Regurgitation, LV dysfunction, device displacement, tamponade, MR, SAM Post-procedural Pretty standard follow-up for AVR Will need to be vigilant for several years, as we are defining the natural history at this time MR2010:54

54 Kodali SK. N Engl J Med 2012; On-line 3/26/12 MR2010:55

55 TAVR 30-Day Mortality (2/2012) 10.00% 8.00% 9.30% n = % 4.00% 6.00% n = % n = % 0.00% 2.10% n = 237 CoreValve Global US CCF Global: Vancouver, PARTNER EU, SOURCE, France, UK, Belgium, Canada US: REVIVAL, PARTNER A, PARTNER B MR2010:56

56 The Future Valve-in-Valve for Prosthetic Valve Degeneration Huge population with deteriorating bioprostheses Many poor redo candidates Application to prior AVR/MVR/TVR/PVR TAVR looks set to stay! MR2010:57

57 The Future? The Present! MR2010:58

58 MR2010:59

59 TAVR is here to stay. MR2010:60

60 Echo Education Next Year! Register at Hope to see you there! MR2010:61

61 Jae Choon Ryu Poster Presentation Submit Your Work!! Huikyung Jeon MR2010:62

62 The Pacific Rim Symposium will be back!! MR2010:63

63 It s Your Choice!! MR2010:65