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1、 TAVIXIONGRAN2014-11-25QUIZStreetAvenueStreetAvenueHospital of UAHospital of UAHospital of UAHospital of UASummarize of TAVITranscatheteraorticvalveimplantation(TAVI)Itwasintroducedasanalternativetreatmentinpatientswithsevereaorticvalvestenosis(AS)CribierA,EltchaninoffH,BashA,Circulation2002;106:300
2、63008.First Case of TAVIIn2002,CribieretaldemonstratedforthefirsttimethefeasibilityofapercutaneousvalveimplantationinapatientwithASProvidingapromisinglessinvasivealternativetreatmentforvalvularheartdiseaseCribierA,EltchaninoffH,BashA,Circulation2002;106:30063008.twodifferentTAVIdevicesarewidelyusedt
3、heballoon-expandableEdwardsSAPIENTranscatheterHeartValvetheself-expandingMedtronicCoreValveBothreceivedCEMarkapprovalforEuropeancommercialsalein2007EdwardsSAPIENvalvereceivedFDApre-marketapprovalintheUSAinNovember2011Two different TAVI devicesEdwardsballoonexpandabledeliverysystemsCoreValveReValving
4、System(a)schemataand(b)followingdeploymentwithaortographyPatients SelectionFeasibleinmostpatientswithsevereaorticstenosisGenerallyutilizedinpatientsnotsuitableforsurgicalAVR,whoarelikelytoderivefunctionalandsurvivalbenefitTworiskscoresareusedtocalculatetheriskofcardiacsurgery“High-risk”surgicalpatie
5、ntsHavingaSocietyofThoracicSurgeonsPredictedRiskofMortality(STS-PROM)at30daysofgreaterthan10%LogisticEuroSCOREofgreaterthan20%LimitedDonotaccountforseveralpertinentclinicalriskfactors,suchaspreviousCABG,porcelainaorta,previouschestradiotherapy,severelungdisease,andlivercirrhosisTwo risk scoresTworis
6、kscoresAssessments of TAVIToassesstheaorticannulusdimensionsandgeometry,accesssite,andapproachTransthoracicechocardiographyCoronaryangiographyAorticangiographyMDCTAssessment of arterial accessTheevaluationisfundamentalintheassessmentoftheTAVIpatientinminimizingpotentialmajorvascularcomplicationsArte
7、rialdimensionsThepresenceorabsenceofatheroma,CalcificationTortuosityAssessment of arterial accessArterialaccessisassessedwiththecombinationofinvasiveangiographyandcontrast-enhancedCTIliofemoralassessmentwith(a)angiographyand(b)MDCTAssessment of aortic rootUsinginvasiveangiographyandcontrastMDCTevalu
8、aterootandvalvularcalcificationleftmainheightfromtheleftcoronarycuspinsertion(duetoriskofcoronaryobstruction)technicalissuesrelatedtoeachvalvetypeanddeliverysystemEuropeanHeartJournal(2014)35,26272638Assessmentofaorticroot( 1 ) aortic annulus diameter, ( 2 ) sinus of Valsalva width( 3 ) ascending ao
9、rta width, ( 4 ) sinus of Valsalva heightAssessment of aortic rootAssessmentsLeftandrightheartcatheterizationsarealsoperformedassessthepresenceofpulmonaryhypertensioncoronaryischemiaandtheneedforrevascularizationpriortoTAVIRequirements of TAVITAVIshouldbeperformedinregionalcentersofexcellencewithade
10、dicatedheartvalveprogramandhighproceduralvolumesTheproceduremaybeundertakeninacardiaccatheterizationlaboratorywithmodificationsorinahybridoperatingroomequippedwithhigh-qualityfluoroscopicimagingRequirements of TAVIThefacilitiesneedtobelargeenoughtoaccommodatesophisticatedX-rayimagingintegratedwithec
11、hocardiography,cardiopulmonarybypassandintra-aorticballoonpumpmachines,andanesthesiaequipment,withsurgicalsterilitystandardsmandatoryTechniques of TAVITAVIismostoftenperformedutilizingthetransfemoralretrogradeapproachAlternativeaccessapproachesusuallyreservedforpatientswithconcomitantsevereperiphera
12、larterialdiseaseTransfemoral ApproachThecommonfemoralartery,atthelevelofthefemoralhead,istheprimaryaccesssiteforthetransfemoralapproachowingtoitsrelativelylargesizeandcompressibilityThesidewiththelargestandleastdiseased,tortuous,orcalcifiediliofemoralarteryasassessedbyascreeningangiogramand/ormultid
13、etectorcomputedtomographic(CT)angiographyisselectedforplacementofthesheathTransfemoral ApproachThepotentialsiteofaccessisassessedfirstwithfluoroscopyand/orultrasound,andarterialaccessisgainedbypercutaneouspunctureAlternatively,asurgicalcutdownisutilizedtoaccessthefemoralarteryAsmallerpercutaneousshe
14、athisinsertedintothefemoralarteryonthecontralateralsideforplacementofapigtailcatheterintheascendingaortaforrootangiographyTransfemoral ApproachTheTAVIproceduremaybeperformedunderlocalorgeneralanesthesiaFollowingballoonvalvuloplasty,thevalveprosthesisispassedacrosstheaorticvalveandpositionedunderfluo
15、roscopicandtransesophagealechocardiographic(TEE)guidanceTransfemoral ApproachBalloon-expandablevalvesaredeployedunderrapidventricularpacingatarateof160220bpmtominimizecardiacoutputandthereforeminimizeunintentionalmotionofthevalveduringballoondilatationTransapical ApproachThetransapicalapproachwasfir
16、stdescribedin2006withballoon-expandablevalvesAsheathisplacedsurgicallyintheleftventricularapex,accessedthroughasmallleftanterolateralminithoracotomyTransapical ApproachFollowingballoonvalvuloplasty,thevalveprosthesisandballooncatheterarepassedoverawireintotheleftventricleandpositionedwithintheaortic
17、annulusunderfluoroscopicandtransesophagealechocardiographicguidanceTransapical ApproachThisapproachmaybeconsiderediftheiliofemoralarterialsystemisofsufficientlysmalldiameter,calcified,ortortuousandnottechnicallysuitablefordeliveryofthedeviceAlsotakenintoconsiderationistheangulationoftheaortaandarchT
18、ransapical ApproachInparticular,atransverseorextremelyunfoldedascendingaortamayincreasethedifficultyofdeliveryandpositioningoftheballoon-expandabledevicesIthasbeensuggestedthatwithadvancesindevicetechnologyandareductionindeliverysystemprofilesforthetransarterialapproach,alternativeaccessapproacheswi
19、llbelimitedtolessthan30%ofTAVRproceduresTransapical ApproachContraindicationstothetransapicalapproachpreviousleftventricularsurgeryusingapatchcalcifiedpericardiumsevererespiratorydiseaseTransapical ApproachOthersAxillary/SubclavianApproachTransaorticApproachComplications of TAVIProceduralComplicatio
20、nsVascularComplicationsStrokeandNeurologicalEventsCoronaryOcclusionValveMalpositionandEmbolizationRenalImpairmentConductionDisturbanceComplications of TAVIProsthesis-RelatedComplicationsProsthesisPatientMismatchParavalvularandValvularRegurgitationProstheticValveThrombosisandEndocarditisQuestionTHANKS
