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Echo for transcatheter valve therapies - Copy.pptx

  1. Echo for new transcatheter interventions for valvular heart disease 1
  2. Echocardiography for transcatheter aortic valve implantation • currently being assessed in the treatment of patients with severe aortic stenosis who are at high risk from conventional open surgery • Procedural success rates of 75–88% have previously been published, in association with reduction in aortic valve mean pressure gradients from 37–46 to 9 mmHg 2
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  4. CoreValve prosthesis 4
  5. • prosthetic size is determined by the external diameter of the ventricular end the 26 and 29 mm size prostheses have mid-portion diameters of 22 and 24 mm, aortic end-diameters of 40 and 43 mm, and prosthetic lengths of 55 and 53 mm, respectively 5
  6. Edwards–Sapien prosthesis 6
  7. • Valve size is determined by the external diameter of the cylinder-the 23 and 26 mm prostheses have relatively short lengths of 14.2 and 16.1 mm, respectively • ventricular two-thirds of the prosthesis has a skirt to prevent paravalvar regurgitation-the coronary ostia must therefore be at least 10 or 11 mm, respectively, above the AVA to avoid obstruction by the skirt 7
  8. • SOURCE registry • Overall short term procedural success 93.8% • 30 day mortality was 6.3%(transfemoral) & 10.3%(trans apical) 8
  9. Role of echocardiography in anatomical case selection • patients with severe aortic stenosis, defined by an AV effective orifice area (EOA) of <1 cm2, mean AV gradient of >40 mmHg, or AV peak systolic velocity of >4 m/s. • CoreValve-EOA of <1 cm2 • Edwards-EOA of < 0.8 cm2. unicuspid and bicuspid valves are contraindicated 9
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  13. Aortic root geometry CoreValve • 26 mm - native AVA 20–23 mm, SOV of 27 mm, STJ 40 mm, and AVA-coronary ostial distance of 14 mm. • 29 mm : AVA 24–27 mm, SOV 28 mm, STJ or ascending aorta of 43 mm, AVA-coronary ostial distance of 14 mm Edwards–Sapien • 23 mm - native AVA 18–21mm , and an AVA coronary ostial height of >10 mm. • 26 mm -AVA diameter of 22–24.5 mm and an AVA-ostial height of >11 mm 13
  14. • Undersizing – device migration , PVR, mismatch • Oversizing – vascular access complications, difficult native valve crossing, underexpansion (folds)-central AR 14
  15. • Length of the cusps measured in long axis view. • Rt coronary ostial-annular distance measured by 2d TEE • Characteristics of asc aorta ,arch & des thoracic aorta 15
  16. • SOV diameter and AVA-ostial height requirements-reflect the clearance necessary to avoid occlusion of the coronary ostia by TAVI-displaced native valve material or the prosthetic skirt • STJ and ascending aorta diameters are specific for ensuring that the aortic end of the CoreValv has sufficient anchorage to prevent embolization 16
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  18. Subaortic geometry • CoreValve Inc. recommends that the implantation should not be performed if subaortic disease is sufficient to cause stenosis or if the septal wall thickness of >17 mm 18
  19. • co-exist with AV stenosis and take the form of protruberant calcification extending from the AVA into the LVOT or the anterior mitral leaflet, or moderate–severe hypertrophy of the septal walls - risk of low deployment and its complications • HOCM- contraindicated ( prosthesis displacement). 19
  20. • Mitral regurgitation of more than grade 2 severity is a contraindication for CoreValve- LV component of the prosthesis can potentially interfere with mitral function by disrupting the secondary chordae or restricting anterior leaflet mobility 20
  21. • Stress TTE is used to diagnose the flow-limitation in proximal coronary stenoses of 70% (CoreValve exclusion) or large areas of ischaemic burden (Edwards exclusion) that will exclude patients 21
  22. • LV ejection fraction of <20% is a TAVI contraindication • Patients with low ejection fractions but mean AV gradients of >40 mmHg at rest, may still have sufficient contractile reserve to undergo valve replacement 22
  23. • Those patients with low ejection fractions and mean gradients of <40 mmHg can be risk stratified by Dobutamine stress echocardiography the subset with LV contractile reserve during stress may be suitable for TAVI 23
  24. • detecting the sources of cardiovascular embolism, and the procedure should not be performed in patients with thrombus in the left heart chambers 24
  25. Role of echocardiography in procedural guidance • Marking the position of lv apex to guide thoracotomy. • 2 views • Surgeon & echocardiorapher on the same side • No movement after marking 25
  26. AV Crossng AV crossing points can be imaged in the 30–50o AV short-axis and 110– 150°long-axis scan planes. Biplane or X-plane TOE can be helpful in identifying the appropriate approach to the orifice, particularly when combined with fluoroscopic data 26
  27. BAV • Successful or unsuccessful inflation and de-waisting of the balloon is documented • Systolic motion of the balloon caused by LV ejection should not be seen during balloon inflation and deflation. • Full deflation should be confirmed prior to retrieval. • In patients with small roots, native valve material can cause posterior root tenting • TEE to know stable position & if cor ostia are near 27
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  29. Deployment • CoreValve prosthesis requires precise placement with the ventricular end 5–10 mm below the native AVA-easily identified on TOE. • As the delivery catheter is withdrawn, TOE is used to closely observe the emergence and expansion of the ventricular end of the prosthesis. • The device has a high radial force at its LV end and may forcefully descend into the LVOT as it expands against the rigid AVA. • The partially deployed prosthesis may therefore adopt a low position that may affect mitral valve function. 29
  30. Prosthesis too low • Impinge on MV apparatus • Native valve cusps fold over the top Prosthesis too high • Migrate in aorta • Obstruct ostia • Signif pvr 30
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  33. Manual adjustment in the position is required so that the LV rim of the prosthesis covers ,50% of the anterior mitral leaflet and lies above the attachment of the secondary chordae to the leaflet The aortic end is then deployed and the pros 33
  34. • Smaller than expected dimensions indicate suboptimal expansion, and prosthetic balloon valvuloplasty can be performed. • Valvuloplasty should be avoided if TOE shows the presence of native valve material adjacent to the coronary ostia. 34
  35. • Edwards–Sapien prosthesis is manipulated across the AV to a position parallel to the long axis of the root within the AVA. • The device may migrate towards the aorta for up to 5 mm during deployment, and the optimal position of the prosthesis requires the ventricular end to be positioned up to 2 - 4 mm below the native AVA, a point just ventricular to the anterior mitral leaflet hinge. • The aortic end should be close to the tips of the native AV leaflets 35
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  37. COMPLICATIONS: • Coronary Occlusion, Mitral valve dysfunction, Prosthetic dysfunction, Loss of blood, Cardio-Aortic Trauma, and Stroke 37
  38. • Perioperative cardiopulmonary resuscitation for loss of cardiac output may be expected in 11% of patients • Rapid ventricular pacing may induce ventricular fibrillation in 2.5% of cases. • Myocardial infarction or coronary occlusion is seen in 1.5% of CoreValve and 2% of Edwards TAVIs. • Aortic dissection and perforation is seen in 1.4to 2% of cases. • Acute vascular injury may be expected in 1.9 to 6% of procedures. • Bradyarrhythmias resulting in permanent pacing have not been reported following the Edwards implant, but this is an outcome in 11% of CoreValve implants 38
  39. • Early assessment of PVR is crucial ( undersized prosthesis) • Significant transvalvular aortic regurgitation suggests overexpansion of the prosthesis, which may require deployment of a second prosthetic valve within the first. 39
  40. • Following prosthetic valve deployment, TEE can immediately assess prosthetic valve position in relation to the LV outflow tract and aortic valve plane , prosthetic valve leaflet mobility, valve area, and gradients and presence of central and PV regurgitation 40
  41. Paravalvular AR • occur if the fabric cuff is not approximated to the plane of the annulus. • Even with correct device positioning, AR may occur at sites adjacent to areas of leaflet compression where accumulated nodular calcium and leaflet tissue mean that a snug seal cannot be obtained. 41
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  43. • graded higher by TEE than by early postprocedural TTE. • due to interpretative differences between the 2 imaging techniques, • restitution of leaflet shape after initial balloon deformation • thrombosis in the zone between the crushed aortic valve leaflet and stent 43
  44. • traditional echocardiographic approaches to quantitating paravalvular AR may be limited • vena contracta of the paravalvular AR jet is either crescentic in shape or consists of multiple small jets • An ideal solution would be to volumetrically determine regurgitant fraction and regurgitant volume • Pressure half-time determination of AR severity is limited in that it reflects aortic and ventricular compliance as well as orifice area, and like the other techniques, is unvalidated in this setting 44
  45. • most common site of regurgitation is in relation to the posterior aspect of the stent -may occur in any part of the circumference of the annulus 45
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  47. EVALUATION OF HYPOTENSION • TEE provides a rapid early assessment of changes in global left ventricular systolic function, mitral regurgitation, and the presence or absence of regional wall motion abnormalities 47
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  49. FOLLOW UP • Calculation of EOA or other indices of valve opening (ratio of pre to post valvular velocities) • Flow acceleration in stent prox to valves ( overestimation of valve areas) • Accurate quantification of AR ( central & PVR) • Central (<25% , 26 – 64% ,>65%) • PVR (<10%, 10- 20%, >20%) • Excessive rocking of the prosthesis (>40% dehiscence) 49
  50. PERCUTANEOUS TRANSCATHETER REPAIR OF PVR CAUSES Dehiscence of sutures Infection Annular calcification Friable tissue at site of suturing • common in mitral • Rashkind umbrella, cardioseal device, amplatzer septal occluder, duct occluder • Defects are irregular & multiple ( so 3DTEE ) • Significant hemolysis 50
  51. Echocardiography in paravalvular leak repair • seen with mechanical and bioprosthetic valves • Interrogation in multiple angles including off-axis views is required to determine the location and severity of the regurgitation • Doppler flow outside the sewing ring of the valve, often in an eccentric direction 51
  52. • Because of artifacts and reverberations, prosthetic MV PV regurgitation, however, may be missed on TTE, and TEE is required for diagnosis, location, and assessment of severity • TEE helps evaluate contraindications to percutaneous closure of PV leaks, such as mechanical instability of the prosthetic valve intracardiac thrombus endocarditis 52
  53. • Actual area of dehisence as echo dropout outside the sewing ring. 53
  54. • Location of dehiscence is best described in relation to internal landmarks like LAA, AV & crux of heart. 54
  55. • Jet area & jet width are the commonly used parameters • Flow convergence area in aortic root is carefully sought. • PW of pulm veins pattern is useful (systolic retrograde flow) • Transgastric view , valve ring in short axis , provides enface view of entire circumference • 3D TEE 55
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  58. • Aortic prosthetic PVR • 2D TEE less successful. • Anterior aspect of the valve ring is frequently obscured • Location of the coronary ostia are routinely assessed 58
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  65. • If the dehiscence is large ( >25% of circumference) single device is insufficient & high risk of device embolisation , rocking 65
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  68. MANAGEMENT OF MS-Mitral Balloon Valvuloplasty • May delay or avoid surgery • 80% patients have long term relief of symptoms • 7% restenosis rate at 7 years • ECHO to determine ‘pliability’,MR • Wilkins score, cormier’s method
  69. Guiding the Procedure and Detecting Acute Complication • During the percutaneous valvotomy procedure, echo-Doppler studies can be  Valuable in helping guide the transeptal puncture.  Assessing acute complications such as  Atrial or ventricular perforation with tamponade  Acute mitral regurgitation  Valvular disruption.
  70. Evaluating the short- and long-term results of the intervention.  Immediate Complications  Mitral regurgitation 1. In 50% doesn’t change , by 1 grade in another 33% , by 2 grades in remainder 2. No preprocedure clinical. hemodynamic. or morphologic characteristic is useful in predicting patients in whom regurgitation is likely to appear or increase 3. Large balloon diameters did increase regurgitation  ASD 1. 15-89%(ECHO> hemodynamic series)
  71. Evaluating the short- and long-term results of the intervention.  Assessment of valve area • Planimetry ideal , half time shoudnt be used  Long term results • Assessment can be done by all methods with predictors of restenosis being echo score and valve area following procedure
  72. ECHOCARDIOGRAPHY IN MV REPAIR • provides accurate quantification of MR severity and is able to determine etiology of MR as degenerative, ischemic, or functional • Quantitative assessment of MR by vena contracta and measurement of effective regurgitant orifice area and regurgitant volume is now the gold standard for MR quantitation 72
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  75. • PERCUTANEOUS ANNULOPLASTY TECHNIQUES • To revert mitral leaflet coaptation abnormalities & asso MR • Functional or ischemic MR • Annular dilation or deformation is predominant • Symmet leaflet tethering due to LV remodelling or leaflet coaptation loss due to annular dilation 75
  76. NOT SUITABLE • Extreme asymmetrical tethering • Struc MV abnorm • Prolapse , flail, rupture chordae, fibrotic &calcific restriction, annular calcification 76
  77. • CS annuloplasty – reshapes the AP annular dimension to correct leaflet apposition –coaptation abnormality • Anat relation between CS & post annulus • Placing device in CS to attempt sept- lat diameter red & annulus clinching • TTE and TEE - determine acute or chronic mitral annular diameter reduction with coronary sinus stent placement and its effect on MR severity. • assessment of coronary sinus length and its relation to the mitral annulus and to the circumflex coronary artery remains difficult by TEE (CT scan) 77
  79. • MITRACLIP system is a polyester fabric-covered cobalt chromium implant with 2 arms. • Functional MR ( flail or prlapsed leaflets) & degenerative MR (tethered leaflets) • Tissue bridge bet leaflets , limits annular dilat • Restrains LV wall by restricting LV dilat Clinical indications • High risk for surgery • Previous cardiac surgery • Who decline surgery 79
  80. • TTE often provides limited information on valve reparability. • Three dimensional TTE may improve MV assessment although resolution of 3D TTE remains an important limitation • MR jet origin in the short-axis-evaluate location and severity of pathology and complements information obtained by long-axis views • screening by echocardiography involves measurement of coaptation depth and coaptation length in ischemic MR and of flail gap and flail width in degenerative MR 80
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  84. • Percutaneous MV repair technique by the edge-to-edge technique aims to repair MR originating from the A2 and P2 scallops of MV rather than commissures or posteriorly or anteriorly located MV scallops. • TEE evaluates location of diseased mitral scallop/s by using 2D and color Doppler in multiple imaging planes by location of flow convergence and by assessment of site of origin of MR jet. 84
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  89. • Puncture site should sit 3.5 – 4.0 cm above the leaflets 89
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  95. • percutaneous MV repair is the edge-to-edge technique, which creates a double MV orifice replicating the surgical intervention • success rate of the technique is high (80% to 90%), and the degree of MR can be reduced to mild in two-thirds of cases 95
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  97. TEE -confirms the final MR grade and size of residual atrial septal defect detection of procedural complications – • Leaflet tear • Partial dehiscence of clip • development of thrombus on catheters • pericardial effusion (atrial wall perforation) • tangling of device with chordae. • Mirtal stenosis • Residual MR severity during follow-up, device stability and effect on LV size and function, and pulmonary artery pressure 97
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  99. • MR severity during follow-up, device stability and effect on LV size and function, and pulmonary artery pressure • Colour doppler using semiquantitative tech based on regurg jet dimen & use of 3D TEE to planimeter regurg orifices are best suited for long term followup 99
  100. THANK U 100