TAVR, Mitraclip, Epicardial Flashcards
Risk factors for neurologic injury
age, female sex, prior stroke, systolic htn, diabetes, asc ao atherosclerosis
risk factors for atherosclerosis of asc ao
old age
htn
unstable angina
copd
stroke
pvd
elevated creatinine
What is the standoff in epiaortic images
the space between aorta and probe
bubbles in standoff can present as artifact in aorta!
linear vs phased array
linear does have standoff, but may not see all sides of aorta
phased array has standoff but better able to see all sides
5 views of epiaortic exam
sax prox asc - stj - prox pa
sax mid asc -adjacent to right pa
sax distal asc - r pa to innominate
lax asc ao
lax arch
Grading plaque
grade 1 normal intimal thickening
grade 2 severe thickening without protruding atheroma
grade 3 3-5 mm atheroma
grade 4 >5 mm atheroma
grade 5 anything mobile
changes made due to epiaortic ultrasound
convert to off pump cabg
circulatory arrest
change cannulation, clamp position
repair / replace aorta
use heart string
only use LIMA
Why epiaortic us may not be used
time
risk of contamination
will information change procedure? Make procedure more harmful?
epicardial us exam
when TEE may be contraindicated or unfavorable risk benefit
Images for epicardial exam
av short axis
av long axis
lv basal sax
lv mid sax
lv lax
LV 2 chamber - hard to get
Edwards sapien vs medtronic corevalve
sapien is balloon expandable bovine pericardium.
Medtronic is self expandable nitinol porcine pericardium suprannular valve design and larger EOA
catheter mitral valve procedures
TMVR no current fda approved devices (can use sapiens series)
mitraclip - XTR and NTR
LAA occlusion
watchman - percutaneous via transeptal puncture.
lariat
most common complication of watchman
tamponade/effusion
Area for transeptal puncture
in fossa ovalis, but exact location can vary per type of procedure.
For mitraclip, posterior and mid superior
FOr LAAO watchman posterior and mid inferior
views for transeptal puncture
BIcaval for inferior and superior
AV SAX for anterior and posterior
Mitraclip eligibility criteria low yield
coaptation length >2mm
coaptation depth <11mm
flail gap <10mm
flail width <15mm
inital exam for mitraclip
3d MV
MV inflow gradients
measure MVA
eval for effusion
evaluate pv flows
complete exam
post clip exam
eval residual mr
measure inflow gradient
evaluate for effusion
complete exam
goal for tenting of needle above mitral annulus for mitraclip
4-5 cm
where should wire go after transeptal puncture for mitraclip
into lupv
Checking for residual mr
cfd of jets
pulm vein flow
pwd inflow (mean g <5 mmHg)
vena contracta width and area
resultion of v wave?
reduction in LAP?
Reduction in pa pressures?
optimal features for mitraclip
a2-p2 pathology
no leaflet calcification
mva >4 cm2
post leaflet length >10 mm
tenting height <11 mm
flail width <15 mm
flail gap < 10 mm
imaging exam for LAA watchman
LAA morphology
evaluate for clot
measurements at multiple angles
eval for effusion
complete exam
Types of LAA
chicken wing
windsock
cauliflower
cactus (more prominent indentations than cauliflower)
which morphology of laa has lowest risk of thrombus
chickenwing
where to measure LAA for watchman sizing
region of circumflex to 1-2 cm in from tip of coumadin ridge
pre deployment imaging
look for adequate compression
confirm minimal flow
confirm no protrusion
tug test
challenges for TMVR
LVOT obstruction
calcium
complex anatomy
severity of Paravalvular leak vena contracta and % circ
moderate 10-30%
moderate 0.2-0.7cm2
