*Core lab for numerous trials, for which I receive no direct compensation from sponsors.

Transcription

1 Rebecca T. Hahn, MD, FACC, FASE Director of Interventional Echo Professor of Medicine Columbia University Company Abbott Vascular Gore&Assoc NaviGATE Medtronic Boston Scientific GE Medical Philips Healthcare Nature of Affiliation Consultant/Advisory Board Unlabeled Product Usage None Speaker None *Core lab for numerous trials, for which I receive no direct compensation from sponsors. 1

2 Parameter TTE TEE Sedation during None required (sedation for procedure General anesthesia, monitored TAVR only) anesthetic care or conscious sedation Imaging Advantages Standard windows for assessing ventricular Higher resolution with high frame rates and valvular structure & function for 2D and 3D imaging Pre-procedural imaging may avoid complications (i.e. paravalvular regurgitation, annular/aortic rupture, coronary occlusion) Immediate, accurate intra-procedural diagnosis of complications Imaging Disadvantages Image quality dependent on patient factors Special windows required for assessing (i.e. chest morphology, lung hyperinflation, ventricular and valvular structure & suboptimal patient positioning) function Procedural delay during image acquisition Image quality dependent on patient (to minimize radiation exposure to imager) factors (i.e. calcific acoustic shadowing, Non-continuous imaging during procedure cardiac position relative to esophagus Low resolution with low frame rates for 2D and stomach) and 3D imaging Probe interference with fluoroscopic Limited imaging windows for nontransfemoral access routes probe) imaging (minimized by articulation of Other Advantages Early recovery and discharge Continuous imaging throughout procedure, irrespective of access route Other Disadvantages Possible higher radiation exposure to Need for post-procedure monitoring imager (Note: may not be different than for TTE) Interference with sterile field Trauma to oropharynx, esophagus or stomach Retroflexion Anteflexion Right Flexion Left Flexion Left+Ante Right+ Ante Continuous Imaging is KEY to early detection of complications 2

3 DOI: /j.echo Figure 4 Figure 5 Pre-procedural Imaging Journal of the American Society of Echocardiography DOI: ( /j.echo ) Copyright 2017 American Society of EchocardiographyTerms and Conditions 3

4 DOI: /j.echo Post-procedural Imaging Figure 8 Figure 12 Journal of the American Society of Echocardiography DOI: ( /j.echo ) Copyright 2017 American Society of Echocardiography Terms and Conditions 4

5 DOI: /j.echo An 80-year-old female with a past medical history of Severe mitral stenosis status-post valvuloplasty in Moscow in 1963 Atrial fibrillation on Coumadin Hypertension Chronic kidney disease Complained of increased dyspnea on exertion and fatigue that started six months prior and had progressively worsened. 5

6 Pre-procedural transthoracic echocardiogram showed: Rheumatic mitral valve with stenosis and a mitral valvuloplasty score of 9 (Mobility = 2, Leaflet thickness = 2, Subvalvular thickening = 4 and Calcification = 2) Mean gradient 5 mmhg Heavily calcified aortic valve. Severe aortic stenosis Peak/mean gradients of 96.4/43.8mmHg Ejection fraction 65-70% Given the findings on transthoracic echocardiogram the plan was to perform a transcatheter aortic valve implantation (TAVI). Mitral valve area of 1.2 cm 2 by continuity equation Dense smoke in markedly dilated LAA (no MR) Intra-procedural TEE showed: Severe mitral stenosis by multiple methods Dense smoke in the LAA consistent with very slow flow but no thrombus No mitral regurgitation Mitral valve area of 1.35 cm 2 by 3D planimetry In light of TEE findings, an intra-procedural decision was made to perform a percutaneous balloon mitral valvuloplasty (PBMV) prior to TAVR 6

7 Valvuloplasty Valvuloplasty Percutaneous balloon mitral valvuloplasty was performed using a 23mm Inoue balloon. Two inflations were performed resulting in lateral commissural fracture and improved valve opening Pre-PBMV Post-PBMV Planimetered MVOA= 1.7 cm 2 Single jet of mild mitral regurgitation was seen (EROA by 3D = 13mm 2 ) Smoke resolved 7

8 Pre-PBMV Post-PBMV MG 9.1 mmhg MG 4.9 mmhg Annular perimeter = 67 mm Annulus-to-left main distance of 10.7mm and a left coronary cusp (LCC) length of 14.5 mm with a sinus of Valsalva (SOV) diameter of 2.85 cm. A 26mm Evolut-R selected Significant discordance L Main and LCC, small SOV 8

9 During BAV the left main coronary ostium was covered by the left coronary cusp (yellow arrow) on TEE with slow/faint filling was seen on contrast injection (red arrow). 20mm Z-Med II balloon 6F JL 3.5 6F Guideliner 3.5 x 15mm DES placed in mlad 9

10 Evolut-R 26mm ST elevations noted on monitor Evolut-R 26mm Marked reduced flow in LM ostium 10

11 Urgent stent deployment in LM Deployed at 12 atm ST segments rapidly resolved and no wall motion abnormalities were detected 11

12 Final AR Assessment 2+ AR No Post-dilatation was performed 83 year-old man Class III heart failure Known Severe AS for 2 years with preserved EF PV 4.5 m/s MG 43 mmhg AVA 0.7cm 2 EF 55%, Moderate MR. Mild phtn. Type II DM, CKD on HD, Morbid obesity, OSA on BiPAP TAVR/SAVR were deferred in the past since he had Stevens- Johnson syndrome when exposed to contrast dye, twice. In the past 5 months experienced increased fatigue after HD and was requiered to start on Midodrine. STS 13% 12

13 26 mm vs 29 mm valve 13

14 Trivial agitated bubbles in the LV during BAV Good Annular Sealing Aorta stretching 14

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16 Trivial PVL No central Ao Regurgitation AVA 2.33 cm2 PV 1.6 m/s P/MG: 11/5 mmhg DI 0.44 Mild MR (No change during procedure) HPI: 84 y/o F with Diastolic HF (NYHAIV,EF 50%), Aortic insufficiency, ESRD(on HD MWF, LUE AV fistula;still makes some urine),copd(no intubations), HTN, hyperlipidemia, anemia, h/o GIB 2/2 to high consumption of NSAIDS(pt now reports allergy to ASA/NSAIDS Experiencing increasing episodes of SOB, resulting in increased hospitalizations, on 2/5/18 pt presented to Outside Hospital ED c/o SOB was admitted Echo showed worsening aortic regurgitation 16

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18 3D EROA = 50 mm2 PISA EROA = 40 mm2 Quantitative Doppler EROA = 51 mm2 18

19 Repositioning required: Pacing used 19

20 Complete Heart Block with lower position Original Pacemaker Dislodged Removal of first Pacer 20

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