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TAVIXIONGRAN2014-11-25整理pptQUIZStreetAvenue整理pptStreet整理pptAvenue整理pptHospitalofUA整理pptHospitalofUA整理pptHospitalofUA整理pptHospitalofUA整理pptSummarizeofTAVITranscatheteraorticvalveimplantation(TAVI)Itwasintroducedasanalternativetreatmentinpatientswithsevereaorticvalvestenosis(AS)CribierA,EltchaninoffH,BashA,Circulation2002;106:3006–3008.整理pptFirstCaseofTAVIIn2002,

CribieretaldemonstratedforthefirsttimethefeasibilityofapercutaneousvalveimplantationinapatientwithASProvidingapromisinglessinvasivealternativetreatmentforvalvularheartdiseaseCribierA,EltchaninoffH,BashA,Circulation2002;106:3006–3008.整理ppttwodifferentTAVIdevicesarewidelyusedtheballoon-expandableEdwardsSAPIENTranscatheterHeartValvetheself-expandingMedtronicCoreValve™BothreceivedCEMarkapprovalforEuropeancommercialsalein2007EdwardsSAPIENvalvereceivedFDApre-marketapprovalintheUSAinNovember2011TwodifferentTAVIdevices整理pptEdwardsballoonexpandabledeliverysystems整理pptCoreValveReValvingSystem(a)schemataand(b)followingdeploymentwithaortography整理pptPatientsSelectionFeasibleinmostpatientswithsevereaorticstenosisGenerallyutilizedinpatientsnotsuitableforsurgicalAVR,whoarelikelytoderivefunctionalandsurvivalbenefit

Tworiskscoresareusedtocalculatetheriskofcardiacsurgery整理ppt“High-risk”surgicalpatientsHavingaSocietyofThoracicSurgeonsPredictedRiskofMortality(STS-PROM)at30daysofgreaterthan10%LogisticEuroSCOREofgreaterthan20%LimitedDonotaccountforseveralpertinentclinicalriskfactors,suchaspreviousCABG,porcelainaorta,previouschestradiotherapy,severelungdisease,andlivercirrhosisTworiskscores整理pptTworisk

scores整理pptAssessmentsofTAVIToassesstheaorticannulusdimensionsandgeometry,accesssite,andapproachTransthoracicechocardiographyCoronaryangiographyAorticangiographyMDCT整理pptAssessmentofarterialaccessTheevaluationisfundamentalintheassessmentoftheTAVIpatientinminimizingpotentialmajorvascularcomplicationsArterialdimensionsThepresenceorabsenceofatheroma,CalcificationTortuosity整理pptAssessmentofarterialaccessArterialaccessisassessedwiththecombinationofinvasiveangiographyandcontrast-enhancedCTIliofemoralassessmentwith(a)angiographyand(b)MDCT整理pptAssessmentofaorticrootUsinginvasiveangiographyandcontrastMDCTevaluaterootandvalvularcalcificationleftmainheightfromtheleftcoronarycuspinsertion(duetoriskofcoronaryobstruction)technicalissuesrelatedtoeachvalvetypeanddeliverysystemEuropeanHeartJournal(2014)35,2627–2638整理pptAssessmentofaorticroot(1)aorticannulusdiameter,(2)sinusofValsalvawidth(3)ascendingaortawidth,(4)sinusofValsalvaheight整理pptAssessmentofaorticroot整理pptAssessmentsLeftandrightheartcatheterizationsarealsoperformedassessthepresenceofpulmonaryhypertensioncoronaryischemiaandtheneedforrevascularizationpriortoTAVI整理pptRequirementsofTAVITAVIshouldbeperformedinregionalcentersofexcellencewithadedicatedheartvalveprogramandhighproceduralvolumesTheproceduremaybeundertakeninacardiaccatheterizationlaboratorywithmodificationsorinahybridoperatingroomequippedwithhigh-qualityfluoroscopicimaging整理pptRequirementsofTAVIThefacilitiesneedtobelargeenoughtoaccommodatesophisticatedX-rayimagingintegratedwithechocardiography,cardiopulmonarybypassandintra-aorticballoonpumpmachines,andanesthesiaequipment,withsurgicalsterilitystandardsmandatory整理pptTechniquesofTAVITAVIismostoftenperformedutilizingthetransfemoralretrogradeapproachAlternativeaccessapproachesusuallyreservedforpatientswithconcomitantsevereperipheralarterialdisease整理pptTransfemoralApproachThecommonfemoralartery,atthelevelofthefemoralhead,istheprimaryaccesssiteforthetransfemoralapproachowingtoitsrelativelylargesizeandcompressibilityThesidewiththelargestandleastdiseased,tortuous,orcalcifiediliofemoralartery—asassessedbyascreeningangiogramand/ormultidetectorcomputedtomographic(CT)angiography—isselectedforplacementofthesheath整理pptTransfemoralApproachThepotentialsiteofaccessisassessedfirstwithfluoroscopyand/orultrasound,andarterialaccessisgainedbypercutaneouspunctureAlternatively,asurgicalcutdownisutilizedtoaccessthefemoralarteryAsmallerpercutaneoussheathisinsertedintothefemoralarteryonthecontralateralsideforplacementofapigtailcatheterintheascendingaortaforrootangiography整理pptTransfemoralApproachTheTAVIproceduremaybeperformedunderlocalorgeneralanesthesiaFollowingballoonvalvuloplasty,thevalveprosthesisispassedacrosstheaorticvalveandpositionedunderfluoroscopicandtransesophagealechocardiographic(TEE)guidance整理pptTransfemoralApproachBalloon-expandablevalvesaredeployedunderrapidventricularpacingatarateof160–220bpmtominimizecardiacoutputandthereforeminimizeunintentionalmotionofthevalveduringballoondilatation整理ppt整理pptTransapicalApproachThetransapicalapproachwasfirstdescribedin2006withballoon-expandablevalvesAsheathisplacedsurgicallyintheleftventricularapex,accessedthroughasmallleftanterolateralminithoracotomy整理pptTransapicalApproachFollowingballoonvalvuloplasty,thevalveprosthesisandballooncatheterarepassedoverawireintotheleftventricleandpositionedwithintheaorticannulusunderfluoroscopicandtransesophagealechocardiographicguidance整理pptTransapicalApproachThisapproachmaybeconsiderediftheiliofemoralarterialsystemisofsufficientlysmalldiameter,calcified,ortortuousandnottechnicallysuitablefordeliveryofthedeviceAlsotakenintoconsiderationistheangulationoftheaortaandarch整理pptTransapicalApproachInparticular,atransverseorextremelyunfoldedascendingaortamayincreasethedifficultyofdeliveryandpositioningoftheballoon-expandabledevicesIthasbeensuggestedthatwithadvancesindevicetechnologyandareductionindeliverysystemprofilesforthetransarterialapproach,alternativeaccessapproacheswillbel