Structural Heart Interventions Flashcards
1
Q
TAVR Devices
A
•Edwards Sapien 3
- most commonly used
- balloon expandable
- bovine pericardial tissue
- 20, 23, 26, 29 mm sizes
- deployed via 14 or 16 Fr eSheath
- minimum artery dimensions of 5.5 or 6 mm
•Medtronic Evolut R
- successor of Medtronic Core Valve (associated w/ higher rate of heart block)
- self expanding frame allows capture and repositioning
- porcine pericardial tissue
- Supra-annular valve design = larger EOAs (can use larger EOA w/ smaller annulus to decrease patient-prosthesis mismatch)
- 23, 26, 29, 34 mm sizes
2
Q
MitraClip
A
•available in two sizes — XTR , NTR •transvenous access •percutaneous valve repair device that allows for creation of tissue bridge similar to Alfieri stitch that restores adequate coaptation •predicted post-clip MVA > 2 cm^2 •eligibility criteria (Everest trials): - coaptation length > 2 mm - coaptation depth < 11 mm - flail gap < 10 mm - flail width < 15 mm •steps: venous access —> trans-septal puncture —> steerable guide into LA —> clip delivery system into LA —> clip above MV —> clip into LV —> grasp leaflets —> detach
3
Q
LAA occlusion
A
•Watchman
- percutaneous LAA occlusion device deployed transvenous by trans septal puncture
- most frequent major complication = tamponade
•Lariat
4
Q
Trans-septal Puncture
A
MitraClip —> posterior , mid-superior Watchman —> posterior , mid-inferior Lariat —> posterior , mid-superior PVI —> anterior , mid PVAD —> mid , mid TMVR —> posterior , mid-superior PVL —> posterior , superior-mid (depends on leak location)
- biplane —> simultaneous visualization of superior-inferior and anterior-posterior axes
- superior-inferior: ME bicaval view
- anterior-posterior: ME AV SAX
5
Q
MitraClip Imaging
A
1. Exam after induction •3D en face MV w/wo CFD •MV inflow CW — mean gradient •MVA — 2D/3D planimetry, PHT •evaluate for effusion •evaluate PV flows •complete exam 2. Procedural guidance •trans-septal puncture — ME bicaval •advancement of steerable catheter and clip delivery system •deploying clip •prior to release: residual MR, iatrogenic MS, clip stability 3. Post-clip exam •evaluate residual MR severity - CFD jets - PV flow - MV PW inflow — goal mean gradient < 5 mmHg - vena contract — challenging w/ mult jets - hemodynamics •MV inflow gradients — MS severity •clip stability •evaluate for effusion •complete exam
6
Q
MitraClip Criteria
A
Optimal: •A2-P2 pathology •no leaflet calcification •MVA > 4 cm^2 •posterior leaflet length > 10 mm •tenting height < 11 mm •flail width < 15 mm •flail gap < 10 mm
Conditional: •A1-P1 or A3-P3 pathology •mild calcification outside gripping area •MVA > 3 cm^2 •posterior leaflet length 7 - 10 mm •tenting height > 11 mm •leaflet restriction in systole (IIIb) •flail width > 15 mm w/ option for mult clips
Technically Challenging: •perforation/cleft •severe calcifications •MVA < 3 cm^2 •mean gradient > 5 mmHg •posterior leaflet length < 7 mm •Class IIIa •Barlow’s with multi segment flail
7
Q
Watchman Procedure
A
•procedure steps: venous access —> transseptal —> system into LA —> pigtail into LAA —> device into LAA —> confirm —> deploy —> release / remove •Imaging steps: Initial exam 1. LAA morphology: chicken wing (lowest risk for thrombus), cauliflower, windsock, cactus 2. Evaluate for clot 3. Measurements at 0, 45, 90, 135º - LCX —> 1-2cm below Coumadin ridge - midpoint annular line to deepest part of LAA - largest diameter used for sizing - goal for device compression 8-20% 4. Evaluate for effusion 5. Complete exam Procedural guidance: 1. Trans-septal puncture — posterior , mid-inf 2. Guide wire into LUPV 3. Access LAA 4. Deploy device - compression 8 - 20% - measure shoulder 0, 45, 90, 130º - min residual flow around device - tug test Post-deployment exam: 1. Device stability 2. Residual flow around device 3. Evaluate for effusion 4. Evaluate interatrial shunt 5. Complete exam 6. 3D — structure and residual flow
8
Q
Transcatheter MV replacement
A
•confirm MV pathology •trans-septal puncture: posterior, mid-sup •steer device through annulus •advance delivery system •deploy valve •evaluate post deployment - residual MS / MR - PVLs - LVOTO — CFD / CWD
9
Q
Paravalvular leak closure
A
•depends on location and nature of leak •TAVR — often managed w/ repeat ballooning •surgical — deploy occlusion device •Imaging role: - localization of PVL - grading severity (3D VC , % circumference) - guide wire across leak - deployment septal occluder - confirm resolution