Aula 7 Flashcards
Defina estenose aórtica.
Estenose aórtica é o aperto provocado pela impossibilidade dos folhetos valvulares abrirem normalmente.
Quais são as causas da estenose aórtica (4)?
- Degeneração da Válvula Ao (tricúspide > 60 anos)
- Bicúspidia da Válcula Ao (30-50 anos)
- Febre Reumática (30-60 anos)
- Estenose Ao congénita (0-30 anos)
Há uma prevalência maior de doença valvular com o ____________ da idade.
avanço
À medida que a estenose aórtica aumenta em severidade, a velocidade na válvula aórtica _____________ (para compensar pela obstrução), o gradiente de pressão médio da válvula aórtica ______________ e a área _____________.
aumenta; aumenta; diminui
Na estenose aórtica grave sintomática, sem acompanhamento, 50% dos doentes sobrevive ______ anos após início da AS. 20% sobrevive passados ______ anos.
2; 5
Distinguish stenosis from regurgitation/insufficiency.
Stenosis: the valve does not open properly, the forward flow is restricted.
Regurgitation/Insufficiency: the valve fails to close properly, backward flow is not prevented when the heart pumps.
Senile calcific stenosis is caused by a decline in ____________ _______ and presents a marked increase in _________________ __________ of valvular heart diseases in patients > 65 years.
rheumatic fever; degenerative forms
The mechanism of stenosis is similar to atherosclerosis. True or False?
True
What are the common points of senile calcific aortic stenosis and atherosclerosis?
- Mainly solid calcium deposits within the valve cusps
- Similar risk factors to Coronary Artery Disease (CAD)
- High coincidence of CAD and AS in same individual
- 6th, 7th, and 8th decades of life
A smaller velocity quotient indicates a more severely ______________ valve, as more blood flow is directed through a smaller opening, causing a greater __________ in velocities.
narrowed; disparities
In patients with normal cardiac ejection output and normal transvalvular flow, o gradiente de pressão médio e a velocidade máxima de fluxo são > _____ mmHg e >_____ m/s, respectively.
40; 4.0
What are the classic symptoms of AS?
- Dyspnea (shortness of breath)
- Angina (chest pain or discomfort caused by reduced blood flow to the heart muscle);
- Syncope (fainting - reduced blood flow to the brain);
- Heart failure (the heart can’t pump blood efficiently).
On average, people that experience HF, syncope and angina, with AS live for ______, _______ and _______ years, respectively.
2; 3; 5
The survival rate for patients with severe AS increases for those who undergo Aortic Valve Replacement (which, however, decreases with time passed since it appeared). True or False?
True
SAVR requires _________________ bypass and sternotomy. The calcific native valve is ______ ______ and a new (_____________ or bioprosthetic) valve is _______ in place.
Treatment options are limited in patients with ______________ anatomy, severly ______________ aortic arch and a high risk assessment including ________________ __________________.
cardiopulmonary; cut out; mechanical; sewn; abnormal; calcified; prohibitive comorbitidies
What are the main reasons behind the declinal for surgery (33% of patients > 75 with severe AS)?
Age and comorbidities.
Mortality for untreated symptomatic severe AS is up to 50-60% at 2 years in high risk patients. True or False?
True
Inoperable and high risk patients are difficult to treat and had no good option. True or False?
True
Of the patients treated surgically, none are at high risk of morbidity/mortality from the procedure. True or False?
False
Can all patients be treated with TAVI (Transcatheter Aortic Valve Implantation)?
No. It depends on the anatomy of the patient (size of the native aortic valve, of the femoral and sublavia arteries; calcification in the peripheral arteries; angulations and tortuosity, etc).
What are the 4 main characteristics of the CoreValve?
- Nitinol self-expanding frame
- Porcine pericardial tissue
- Supra annular valve design
- Recapturable and repositionable
Nitinol (nickel-titanium) is sensitive to _______________ and super ____________. Returns to its original size and shape once exposed to internal body temperature, so the frame self anchors by way of __________ __________. It is _____________________, highly resistant to _______________ and has proven fatigue performance.
temperature; elastic; radial force; biocompatible; corrosion
What are the CoreValve characteristics in terms of superelasticity (1), shape retention (3) and performance (4) of the frame selection?
Superelasticity: compact designs and small delivery systems.
Shape retention: self-anchoring; controlled retraction for precise delivery and placement; maintain valve shape.
Performance: resistant to corrosion; highly biocompatible; conformable to patient anatomy; fatigue performance.
The porcine pericardium was designed for valve performance and low delivery profile. The porcine pericardium’s thickness is about half that of bovine. Thinner tissue prevents __________ damage during __________, ___________, _____________, and _________________,
allowing for low-profile delivery across all valve sizes.
The __________ _________ ___________ (UTS) and suture pull out stresses for porcine and bovine pericardium are not statistically different and peak physiologic stresses are significantly less than both UTS values.
tissue; loading; crimping; tracking; deployment; ultimate tensile strength
Supra-annular valve function provides unsurpassed ________________. Lowest _____________ ______________ with integrated InLine Sheath. External tissue wrap increases ______________ _____________ _________.
hemodynamics; delivery profile; surface contact area
What are the objectives (8) of the Evolut Platform Transfemoral Procedure?
- Cusp Overlap CT Planning
- Vascular Access
- Crossing the Valve
- Fluoro Load Inspection
- Balloon Aortic Valvuloplasty
- TAVR Deployment
- Post Implant Assessment and Vascular Closure
- Procedure Video
Centering marker on each cusp is critical for CT determination of overlap imaging projections. This is done with a high-quality gated CT with ____________, free from ________________ artifacts and slice ___________________. For this the basal annular plane needs to be set by placing markers at ___________ point in the __________ of each cusp.
In a long axis view, determine cusp ____________ projection by moving along ___________ until _____ and ______ overlap. If imaging projection is unattainable due to patient body habitus and/or equipment limitations, move along S-curve to a near cusp overlap view.
Views which do not maintain alignment of ________ introduce error in perception of TAV _______ at the ________ and ________. This error results in TAV appearing _________ than actual depth. An approximate error of 1 mm in depth is introduced for each 10º movement in the LAO or Caudal directions.
contrast; movement; misregistration; lowest; centre; overlap; S-curve; RCC; LCC; cusps; depth; NCC; LCC; higher
The 18/22 Fr Introducer Sheath is recommended for highly calcified and/or ____________ vessels, has a __________ delivery profile but does not require __________ exchanges.
The InLine Sheath has a __________ delivery profile but requires a ________Fr sheath for exchanges.
tortuous; larger; sheath; smaller; 14/18
To deal with coagulation, an ________________ is admnistered according to hospital protocol. If ___________ is admnistered, the activated clotting time (ACT) needs to be checked after initial ________ and rechecked every 30 minutes to maintain an ACT >= ________ seconds.
Anticoagulant may be administered at any time _________ to this point but avoid __________ beyond this point.
anticoagulant; heparin; bolus; 250; prior; delaying
Ordene os seguintes passos.
A) Position a reference pigtail catheter in the noncoronary cusp via the contralateral access site.
B) Cross the native valve with a 0.035” straight tip guidewire through an angiographic catheter.
C) Once in the left ventricle, advance the angiographic catheter and exchange the straight-tip guidewire for an exchange-length J-tip guidewire.
D) Exchange the angiographic catheter for a 6-Fr pigtail catheter and remove the wire to record the aortic pressure gradient.
E) To reduce contrast use, delay aortic root shot to confirm pigtail placement until after the Evolut system is across the native valve.
A - E - B - C - D
Patient anatomy does not have to be considered when selecting a guidewire. True or False?
False. A more supportive guidewire may be preferred in the presence of tortuous anatomy or horizontal aortic root.
Removal the pigtail catheter has to occur while the __________ position in the left ventricle is precisely maintained (_________ the apex and pointing away from ____________ wall)
guidewire; above; ventricle
What are other 2 things that guidewire management includes apart from its positioning?
- Maintain strict fluoroscopic surveillance of the guidewire in the left ventricle.
- The position of the prosthesis can be adjusted by a combination of pushing the wire and pulling the catheter.
Prior to performing ______ ____________ or inserting the device into the patient, perform a fluoroscopic (cine mode) ________ ____________ to confirm proper loading.
Ensure to use the following imaging settings:
* Cine mode
* AP image projection
* High Magnification
To complete the load inspection:
* Position the capsule flat on an area that will not __________ _____________ of the device.
* Slowly rotate the capsule 360° and inspect the valve for
any indications of a misload.
pre dilation; load inspection; impede clarity
If a misload is detected, ______ _______ attempt to reload the _________________. Discard the entire system and replace
the valve, catheter, loading system, loading tray, and saline with new ___________ components.
do not; bioprosthesis; sterile
If inflow crown overlap ends before the 4th node, the load is ____________.
good
What are the conditions that indicate a misload?
- Inflow crown overlap ends after the 4th node.
- Shadow indicating bent outflow strut.
- Curved capsule.
- Outflow struts not parallel to the paddle attachment.
- Adequate pre-dilatation can help reduce the potential need for _______ ___________ and may mitigate the occurrence of ____________.
- Pre-dilatation may also be useful to prepare the valve for crossing by the delivery catheter system and implantation of the transcatheter valve.
Pre-dilatation is specifically recommended prior to implantation in the following situations:
- Moderate / severe calcification
- Bicuspid anatomy
- Size 34mm valve
- Utilize an adequate size balloon for effective pre dilatation, avoid __________ _______________.
post dilation; inflow; under dilation
Ordene os passos de uma Balloon Aortic Vavuloplasty (BAV).
A) Deflate balloon and stop pacing.
B) Ensure that pressure rebounds and retrieve balloon from patient.
C) Begin rapid pacing and inflate balloon after pressure has dropped.
C - A - B
What are the main 4 commissure alignment phases?
- Inserting delivery system with flush port oriented at 3 o’clock (allow catheter handle to rotate freely while advancing). Insertion of device in this orientation promotes alignment between the hat marker in capsule and outer curve of the aorta.
- Confirm or realign 3 o’ clock flush port orientation prior to crossing aortic arch in the descending aorta.
- Verify hat marker position on outer curve (facing it) when nearing annulus in LAO view. If an inner curve hat marker position is observed, adjust orientation by rotating the handle (up to a ¼ turn).
- Visualize TAV commissure location in cusp overlap view.
While advancing system to ascending aorta, if excess resistance is noticed or a _______ occurs between the nose cone and capsule, DO NOT ________ passage as this may cause injury to the patient and/or damage to the delivery system.
Inner curve hat marker position may occur infrequently due to arch anatomy. If needed, adjust alignment by ________________ the system to the _____________ aorta and rotating the flush port to ____ o’clock before readvancing.
gap; force; withdrawing; descending; 2
To confirm proper pigtail placement at bottom of the NCC for accurate assessment of valve depth, contrast is injected. True or False?
True
How can we avoid extreme parallax in catheter marker band?
By adjusting to a near overlap view or by repositioning wire to ensure appropriate placement in non-right commissure.
The target depth (___ mm) should be approached from __________ to minimise interaction with ____________ system.
3; above; conduction
Consider pacing to help _________ valve stability.
- Begin pacing when marker band is at __rd node.
- Pace at a rate sufficient to achieve desired ___________ in
systolic pressure and in consideration of individual
patient factors. - Rapidly deploy from annular contact until just prior to the
point of no ____________ as _______________ bioprosthesis
temporarily obstructs cardiac output. - Discontinue pacing immediately ____________ reaching the point of no recapture.
- Consider discontinuation of pacing by decreasing the rate
in a stepwise manner.
increase; 3; decrease; recapture; unexpanded; before
While in a cusp overlap view, commissure alignment is indicated by visualizing ___ TAV marker isolated on the _________ side of image (in a cusp overlap view this position corresponds with alignment to the native left/right commissure.
1; right
NCC depth should be assessed only in cusp overlap view, because in _______ view it may appear _______________.
LAO; shallower
If depth adjustment is needed, the valve may be recaptured and repositioned. True or False?
True
To confirm TAV performance, prothetics regurgitation and TAV frame (for infolding) should be assessed, and ____________ ____________ confirmed.
coronary perfusion
Infolding is more likely to occur in the presence of complex anatomies (bicuspid nature, severe calcification). True or False?
True
Pre-dilation is strongly recommended to minimise risk of ___________. If pre-dilatation does not prevent infolding:
- Reassess valve ________ in the presence of complex anatomies.
– Consider a slightly ________ depth of implantation of the second valve to provide additional space for frame ______________.
infolding; sizing; lower; expansion
Target deployment depth is __ mm. Consider recapturing if the implant depth is ≤ 1 mm or > 5 mm.
- ≤ 1 mm depth may contribute to an increased risk of prosthetic valve ___________ during valve release, DCS retrieval, or post-implant ____________.
- > 5 mm depth may contribute to increased risk of conduction ________________, which may require a permanent ______________.
dislodgement; dilation; disturbances; pacemaker
To recapture the valve, rotate the deployment knob in the _____________ direction of the arrows on the handle until the valve can be repositioned and _______________.
opposite; redeployed
The valve can be partially or fully recaptured up to three times at any point before the “Point of No Recapture”, allowing for a total of _________ deployments attempts before the valve must be deployed or retrieved.
- First two recaptures can be used to _____________ and ________________ the valve.
- After the third recapture, the valve must be a completely recaptured and ______________ from patient.
three; reposition; redeploy; retrieved
How can unintended valve movement be mitigated prior to release?
The guidewire should be retracted from ventricle wall and slight forward pressure can be applied to the delivery system.
After dealing with unintended valve movement, the pigtail should be _____________ from ________.
removed; NCC
Very slowly deploy as ___________ _________ leaves capsule and __________ release.
- Use ¼ turns and pauses to _____________ any potential movement upon release.
- This final phase of deployment should generally be completed over 30 seconds.
outflow region; paddles; minimise
How can valve function be evaluated after implantation?
Using angiography, echocardiography and hemodynamics.
If valve function or sealing is impaired due to excessive calcification, bicuspid nature, incomplete expansion, or infolding, a post-implant balloon dilatation (PID) of the bioprosthesis may improve valve function and sealing. True or False?
True
Shallow deployment depth, infolded valve, insufficient pacing rate, and extended inflation times can increase the risk of dislodgement. True or False?
True
