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TAVI XIONGRAN2014 11 25 1 QUIZ StreetAvenue Street Avenue HospitalofUA HospitalofUA HospitalofUA HospitalofUA SummarizeofTAVI Transcatheteraorticvalveimplantation TAVI Itwasintroducedasanalternativetreatmentinpatientswithsevereaorticvalvestenosis AS CribierA EltchaninoffH BashA Circulation2002 106 3006 3008 FirstCaseofTAVI In2002 CribieretaldemonstratedforthefirsttimethefeasibilityofapercutaneousvalveimplantationinapatientwithASProvidingapromisinglessinvasivealternativetreatmentforvalvularheartdisease CribierA EltchaninoffH BashA Circulation2002 106 3006 3008 twodifferentTAVIdevicesarewidelyusedtheballoon expandableEdwardsSAPIENTranscatheterHeartValvetheself expandingMedtronicCoreValve BothreceivedCEMarkapprovalforEuropeancommercialsalein2007EdwardsSAPIENvalvereceivedFDApre marketapprovalintheUSAinNovember2011 TwodifferentTAVIdevices Edwardsballoonexpandabledeliverysystems CoreValveReValvingSystem a schemataand b followingdeploymentwithaortography PatientsSelection FeasibleinmostpatientswithsevereaorticstenosisGenerallyutilizedinpatientsnotsuitableforsurgicalAVR whoarelikelytoderivefunctionalandsurvivalbenefitTworiskscoresareusedtocalculatetheriskofcardiacsurgery High risk surgicalpatientsHavingaSocietyofThoracicSurgeonsPredictedRiskofMortality STS PROM at30daysofgreaterthan10 LogisticEuroSCOREofgreaterthan20 LimitedDonotaccountforseveralpertinentclinicalriskfactors suchaspreviousCABG porcelainaorta previouschestradiotherapy severelungdisease andlivercirrhosis Tworiskscores Tworiskscores AssessmentsofTAVI Toassesstheaorticannulusdimensionsandgeometry accesssite andapproachTransthoracicechocardiographyCoronaryangiographyAorticangiographyMDCT Assessmentofarterialaccess TheevaluationisfundamentalintheassessmentoftheTAVIpatientinminimizingpotentialmajorvascularcomplicationsArterialdimensionsThepresenceorabsenceofatheroma CalcificationTortuosity Assessmentofarterialaccess Arterialaccessisassessedwiththecombinationofinvasiveangiographyandcontrast enhancedCT Iliofemoralassessmentwith a angiographyand b MDCT Assessmentofaorticroot UsinginvasiveangiographyandcontrastMDCTevaluaterootandvalvularcalcificationleftmainheightfromtheleftcoronarycuspinsertion duetoriskofcoronaryobstruction technicalissuesrelatedtoeachvalvetypeanddeliverysystem EuropeanHeartJournal 2014 35 2627 2638 Assessmentofaorticroot 1 aorticannulusdiameter 2 sinusofValsalvawidth 3 ascendingaortawidth 4 sinusofValsalvaheight Assessmentofaorticroot 2020 1 8 23 Assessments LeftandrightheartcatheterizationsarealsoperformedassessthepresenceofpulmonaryhypertensioncoronaryischemiaandtheneedforrevascularizationpriortoTAVI RequirementsofTAVI TAVIshouldbeperformedinregionalcentersofexcellencewithadedicatedheartvalveprogramandhighproceduralvolumesTheproceduremaybeundertakeninacardiaccatheterizationlaboratorywithmodificationsorinahybridoperatingroomequippedwithhigh qualityfluoroscopicimaging RequirementsofTAVI ThefacilitiesneedtobelargeenoughtoaccommodatesophisticatedX rayimagingintegratedwithechocardiography cardiopulmonarybypassandintra aorticballoonpumpmachines andanesthesiaequipment withsurgicalsterilitystandardsmandatory TechniquesofTAVI TAVIismostoftenperformedutilizingthetransfemoralretrogradeapproachAlternativeaccessapproachesusuallyreservedforpatientswithconcomitantsevereperipheralarterialdisease TransfemoralApproach Thecommonfemoralartery atthelevelofthefemoralhead istheprimaryaccesssiteforthetransfemoralapproachowingtoitsrelativelylargesizeandcompressibilityThesidewiththelargestandleastdiseased tortuous orcalcifiediliofemoralartery asassessedbyascreeningangiogramand ormultidetectorcomputedtomographic CT angiography isselectedforplacementofthesheath TransfemoralApproach Thepotentialsiteofaccessisassessedfirstwithfluoroscopyand orultrasound andarterialaccessisgainedbypercutaneouspunctureAlternatively asurgicalcutdownisutilizedtoaccessthefemoralarteryAsmallerpercutaneoussheathisinsertedintothefemoralarteryonthecontralateralsideforplacementofapigtailcatheterintheascendingaortaforrootangiography TransfemoralApproach TheTAVIproceduremaybeperformedunderlocalorgeneralanesthesiaFollowingballoonvalvuloplasty thevalveprosthesisispassedacrosstheaorticvalveandpositionedunderfluoroscopicandtransesophagealechocardiographic TEE guidance TransfemoralApproach Balloon expandablevalvesaredeployedunderrapidventricularpacingatarateof160 220bpmtominimizecardiacoutputandthereforeminimizeunintentionalmotionofthevalveduringballoondilatation TransapicalApproach Thetransapicalapproachwasfirstdescribedin2006withballoon expandablevalvesAsheathisplacedsurgicallyintheleftventricularapex accessedthroughasmallleftanterolateralminithoracotomy TransapicalApproach Followingballoonvalvuloplasty thevalveprosthesisandballooncatheterarepassedoverawireintotheleftventricleandpositionedwithintheaorticannulusunderfluoroscopicandtransesophagealechocardiographicguidance TransapicalApproach Thisapproachmaybeconsiderediftheiliofemoralarterialsystemisofsufficientlysmalldiameter calcified ortortuousandnottechnicallysuitablefordeliveryofthedeviceAlsotakenintoconsiderationistheangulationoftheaortaandarch TransapicalApproach Inparticular atransverseorextremelyunfoldedascendingaortamayincreasethedifficultyofdeliveryandpositioningoftheballoon expandabledevicesIthasbeensuggestedthatwithadvancesindevicetechnologyandareductionindeliverysystemprofilesforthetransarterialapproach alternativeaccessapproacheswillbelimitedtoless
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