经皮主动脉瓣植入tavi教学课件

1、 TAVIXIONGRAN 2019-11-25QUIZStreetAvenueStreetAvenueHospital of UAHospital of UAHospital of UAHospital of UASummarize of TAVITranscatheter aortic valve implantation (TAVI)It was introduced as an alternative treatment in patients with severe aortic valve stenosis(AS)Cribier A, Eltchaninoff H, Bash A,

2、 Circulation 2019;106:30063008.First Case of TAVIIn 2019, Cribier et al demonstrated for the first time the feasibility of a percutaneous valve implantation in a patient with ASProviding a promising less invasive alternative treatment for valvular heart diseaseCribier A, Eltchaninoff H, Bash A, Circ

3、ulation 2019;106:30063008.two different TAVI devices are widely used the balloon-expandable Edwards SAPIEN Transcatheter Heart Valvethe self-expanding Medtronic CoreValveBoth received CE Mark approval for European commercial sale in 2019Edwards SAPIEN valve received FDA pre-market approval in the US

4、A in November 2019Two different TAVI devicesEdwards balloonexpandable delivery systemsCoreValve ReValving System ( a ) schemata and ( b ) following deployment with aortographyPatients SelectionFeasible in most patients with severe aortic stenosisGenerally utilized in patients not suitable for surgic

5、al AVR, who are likely to derive functional and survival benefitTwo risk scores are used to calculate the risk of cardiac surgery“High-risk” surgical patients Having a Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) at 30 days of greater than 10%Logistic EuroSCORE of greater than

6、 20 % LimitedDo not account for several pertinent clinical risk factors, such as previous CABG, porcelain aorta, previous chest radiotherapy, severe lung disease, and liver cirrhosisTwo risk scoresTwo risk scoresAssessments of TAVITo assess the aortic annulus dimensions and geometry, access site, an

7、d approach Transthoracic echocardiographyCoronary angiographyAortic angiographyMDCTAssessment of arterial accessThe evaluation is fundamental in the assessment of the TAVI patient in minimizing potential major vascular complicationsArterial dimensions The presence or absence of atheroma, Calcificati

8、onTortuosityAssessment of arterial accessArterial access is assessed with the combination of invasive angiography and contrast-enhanced CT Iliofemoral assessment with ( a ) angiography and ( b ) MDCTAssessment of aortic rootUsing invasive angiography and contrast MDCT evaluate root and valvular calc

9、ificationleft main height from the left coronary cusp insertion (due to risk of coronary obstruction)technical issues related to each valve type and delivery systemEuropean Heart Journal (2019) 35, 26272638Assessment of aortic root( 1 ) aortic annulus diameter, ( 2 ) sinus of Valsalva width( 3 ) asc

10、ending aorta width, ( 4 ) sinus of Valsalva heightAssessment of aortic rootAssessmentsLeft and right heart catheterizations are also performed assess the presence of pulmonary hypertension coronary ischemia and the need for revascularization prior to TAVIRequirements of TAVITAVI should be performed

11、in regional centers of excellence with a dedicated heart valve program and high procedural volumes The procedure may be undertaken in a cardiac catheterization laboratory with modifications or in a hybrid operating room equipped with high-quality fluoroscopic imagingRequirements of TAVIThe facilitie

12、s need to be large enough to accommodate sophisticated X-ray imaging integrated with echocardiography, cardiopulmonary bypass and intra-aortic balloon pump machines, and anesthesia equipment, with surgical sterility standards mandatoryTechniques of TAVITAVI is most often performed utilizing the tran

13、sfemoral retrograde approachAlternative access approaches usually reserved for patients with concomitant severe peripheral arterial diseaseTransfemoral ApproachThe common femoral artery, at the level of the femoral head,is the primary access site for the transfemoral approach owing to its relatively

14、 large size and compressibilityThe side with the largest and least diseased, tortuous, or calcified iliofemoral arteryas assessed by a screening angiogramand/or multidetector computed tomographic (CT) angiographyis selected for placement of the sheathTransfemoral ApproachThe potential site of access

15、 is assessed fi rst with fluoroscopy and/or ultrasound, and arterial access is gained by percutaneous punctureAlternatively, a surgical cutdown is utilized to access the femoral arteryA smaller percutaneous sheath is inserted into the femoral artery on the contralateral side for placement of a pigta

16、il catheter in the ascending aorta for root angiographyTransfemoral ApproachThe TAVI procedure may be performed under local or general anesthesiaFollowing balloon valvuloplasty, the valve prosthesis is passed across the aortic valve and positioned under fluoroscopic and transesophageal echocardiogra

17、phic (TEE) guidanceTransfemoral ApproachBalloon-expandable valves are deployed under rapid ventricular pacing at a rate of 160220 bpm to minimize cardiac output and therefore minimize unintentional motion of the valve during balloon dilatationTransapical ApproachThe transapical approach was first de

18、scribed in 2019 with balloon-expandable valves A sheath is placed surgically in the left ventricular apex, accessed through a small left anterolateral minithoracotomyTransapical ApproachFollowing balloon valvuloplasty, the valve prosthesis and balloon catheter are passed over a wire into the left ve

19、ntricle and positioned within the aortic annulus under fluoroscopic and transesophageal echocardiographic guidanceTransapical ApproachThis approach may be considered if the iliofemoral arterial system is of sufficiently small diameter, calcified, or tortuous and not technically suitable for delivery

20、 of the deviceAlso taken into consideration is the angulation of the aorta and archTransapical ApproachIn particular, a transverse or extremely unfolded ascending aorta may increase the diffi culty of delivery and positioning of the balloon-expandable devicesIt has been suggested that with advances in device technology and a reduction in delivery system profiles for the transarterial approach, alt