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Year 3 Cardiac physiology > CC11: TAVI and Mitra -Clip > Flashcards

CC11: TAVI and Mitra -Clip Flashcards

1
Q

Causes of MR

A

-Rheumatic fever
-HCM/DCM
-Mitral valve prolapse
-MI
-Endocarditis

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2
Q

Symptoms of MR

A

-SOB (pulmonary oedema)
-Arrhythmias/palpitations
-Swollen ankles/feet

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3
Q

Types of MR

A

Degenerative
-Mitral valve itself is dysfunctional (e.g. prolapse)

Functional MR
-Issues outside of the valve cause leakage
-Most common is heart failure LV dilation causing dilation of the mitral annulus and tethering of leaflets

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4
Q

What does this image show?

A

-Valve prolapse
-Valve falls behind annular line and flails

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5
Q

How can MI cause MR?

A

-MI causes papillary muscle necrosis
-Chordae tendon snap

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6
Q

What is pulmonary vein flow reversal?

A

-Blood flows from LA into pulmonary vein

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7
Q

Intervention options for MR

A

Gold standard: surgical intervention
-Valve repair
-Valve replacement
However, patient can be at high surgical risk

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8
Q

Mitraclip procedure

A

-Access: Femoral vein, IVC, RA, puncture IAS, LA
-TOE performed to check LAA for clot, confirm device position and leaflet capture
-Perform gradient checks to confirm not causing stenosis

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9
Q

What does TOE confirm before clip is released?

A

-Clip position is good for reducing MR
-Clip is not causing mitral stenosis
-Ideally MV mean gradient <5mmHg

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10
Q

Does this echo show significant MR?

A

-Mean MV gradient <5
-Not significant MR

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11
Q

What does mitraclip leave behind?

A

-Iatrogenic ASD

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12
Q

What change do you look for in LA pressure after mitraclip?

A

-Reduction in V wave
-No significant increase in mean pressure

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13
Q

Describe features of Triclip?

A

-Femoral vein access
-Delivery system differs from mitral system as different angulation
-No need for septal puncture (right side)
-TOE guided

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14
Q

Complications of mitraclip

A

-Significant residual regurgitation
-Mitral stenosis (mean gradient > 5mmHg)
-Major vascular complication
-Cardiac perforation/tamponade

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15
Q

Causes of mitral stenosis

A

-Rheumatic fever
-Calcium deposits
-Radiation therapy
-Congenital

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16
Q

Symptoms of mitral stenosis

A

-SOB
-Fatigue
-Swollen legs/feet
-Palpitations
-Dizziness/fainting

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17
Q

What is the gold standard treatment for mitral stenosis?

A

Surgical valve replacement

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18
Q

Other methods of treating mitral valve

A

-Mitral valve balloon valvuloplasty
-Mitral valve replacement (TMVR)

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19
Q

What is the lampoon procedure?

A

-Cutting the mitral valve prior to TMVR
-This prevents LVOT obstruction

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20
Q

How to perform trancatheter tricuspid valve replacement (TTVR)?

A

-TOE and angio guided to confirm position
-TOE and RV gram to check for significant leak
-Usually for valve in valve procedures

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21
Q

Who is pulmonary valve replacement done on?

A

-Congenital patients

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22
Q

How does tricuspid valve replacement affect RV function?

A

-RV contraction is mainly longitudinal (up and down)
-Tricuspid valve reduces longitudinal function
-Causes poor RV function

23
Q

What are the causes of aortic stenosis?

A

-Calcium build up on valve
-Congenital
-Rheumatic fever

24
Q

Symptoms of aortic stenosis

A

-Chest pain
-Dizziness
-SOB
-Fatigue
-Palpitations

25
Q

Risk factors for aortic stenosis

A

-Older age
-Congenital
-Diabetes
-High cholesterol
-High blood pressure

26
Q

Diagnosis of aortic stenosis

A

-Heart murmur
-Cardiac cath
-Imaging: Echo, MRI, CT

27
Q

Treatment for aortic stenosis

A

-Surgical aortic valve replacement
-Balloon valvuloplasty
-TAVI

28
Q

Factors to consider when choosing between surgical AVR and TAVI

A

-Patient’s age
-Patient’s choice
-Estimated surgical risk/co-morbidities
-Clinical characteristics
-Anatomical and technical aspects

29
Q

What is the gold standard treatment for aortic stenosis?

A

-Surgical aortic valve replacement

30
Q

How is surgical aortic valve replacement carried out?

A

-Patient on heart/lung bypass machine
-Medical sternotomy
-Stenotic valve removed and replaced with new valve

31
Q

Why would surgical aortic valve replacement be chosen over TAVI?

A

-Poor TAVI access
-Aortic dimensions unsuitable
-Valve morphology unfavourable
-Active or suspected endocarditis
-Other surgical intervention required

32
Q

What are the types of surgical valve?

A

Mechanical
-Very durable
-Needs lifelong anticoagulation due to increased risk of blood clots

Tissue valve
-Can be human or porcine
-Less durable
-Does not require anticoagulation

33
Q

Why is balloon aortic vavuloplasty not used anymore?

A

-Prior to TAVI, BAV was the only alternative to surgical AVR
-However, it poses a significant risk of AR
-Now used as part of TAVI, pre or post valve

34
Q

Why is pacing used in TAVI?

A

-Fast pacing required to lower blood pressure
-This prevents valve being displaced by the LV/aortic pressure
-Pacing normally >180bpm

35
Q

Benefits of TAVI

A

-Less invasive
-Shorter procedure time
-Less/no intensive care time
-Shortened recovery time/hospital stay
-More rapid improvement in QoL

36
Q

What is access for TAVI?

A

-Radial access for pigtail catheter for aortagram
-Valve requires a large access
=> Transfemoral
=> Subclavian
=>Transcaval

37
Q

What is transcaval approach?

A

-Femoral vein into femoral artery

38
Q

Pre TAVI procedures

A

Echocardiogram
-Assess aortic valve, morphology, gradients, valve area, regurgitation
-Assess for other valvular disease
-Assess chamber size and function

CT scan
-Assess aortic valve diameter and area
-Valve calcium score
-Measure coronary height
-Access entire course of aorta and femorals for access evaluation

39
Q

How did TAVI valves develop

A

-New valves have skirts to prevent paravalvular leak

40
Q

What should you do if you’re trying to pace at 180 but not achieving?

A

-Check Safari wire position
-Refractory time with blocked paced beats
-Consider starting slow and ramping up

41
Q

What should you do if you’re pacing at 180bpm but not enough pressure drop?

A

-Pace faster
-However, more risk of triggering VT/VF

42
Q

Why do you do aortagram after valve is implanted?

A

-Check for paravalvular leak
-Check coronaries are not blocked

43
Q

What are self expanding valves?

A

Abbott Navitor
-No need for rapid pacing
-Gradual deployment - valve can be retracted
-Large open cell geometry - minimises obstruction to coronary ostium
-Reduces paravalvular leak

44
Q

What is a complication of TAVI?

A

-Paravalvular leak

45
Q

Causes of paravalvular leak?

A

-Native anatomy - calcification
-Under-expanded valve - could balloon valve
-Undersized valve
-Valve malposition

46
Q

How to identify paravalvular leak?

A

-Angiography
-Intra-procedural TTE
-Haemodynamics (AR)

47
Q

TAVI vs surgical AVR risk

A

-No significant difference in death, stroke, MI

TAVI higher risk of:
-Major vascular complications
-Paravalvular leaks
-Need for permanent pacemaker

Surgical AVR higher risk of:
-Major bleeding
-Tamponade
-Increased risk of post-operative AF

48
Q

Why is there a high pacing risk with aortic valve replacement?

A

-Aortic valve is near AV node/bundle branches

49
Q

What is most common conduction abnormality in TAVI?

A

-LBBB
-AV block
-Self expanding valves more likely to cause conduction disturbances due to exerting higher pressures

50
Q

Why would you not use temporary pacing wire for all patients?

A

-Creates hole that increases risk of cardiac tamponade and vascular complications
-Use Safari guidewire instead unless patient is high risk (RBBB and AV block)
-Patient’s pacemaker can be used

51
Q

Downsides of Safari pacing

A

-Wire is supporting the whole TAVI system, not stable, unreliable threshold
-Pace at max output of temporary pacing box
-If pacing dependent post-procedure, can’t remove TAVI delivery system because pacing clip is on wire

52
Q

What is the Jena valve for AR?

A

-Can be used on a non-calcific aortic valve
-Therefore, can be used for AR
-Clips to native leaflet to secure position

53
Q

Why do echo pre and post TAVI?

A

-Check for effusion
-Check for AR post TAVI
-Anything unexpected (e.g. LV function, RV size, MR)

Year 3 Cardiac physiology (30 decks)

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