interventional management of valvular disease

7/31/2019 Interventional Management of Valvular Disease

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Interventional Managementof Valvular Heart Disease

Interventional Managementof Valvular Heart Disease


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Current Perspec tive VHD not as c ommon a s CAD, HF in Western Popula tion

Cha nging trends in the pa tient popula tion and etio logy

Better understand ing of pa tho-physiology

Improved d iagnostic mod a lities- ec hoc ard iog raphy

Varied trea tment op tions- c onserva tive surg ic a l tec hniquesand perc utaneous interventions


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Valvular Heart Disease Left sided valve lesions:

Aortic : stenosis / regurg ita tion

Mitra l: stenosis / regurg ita tion

Right sided va lve lesions:

Tric usp id : stenosis / regurg ita tion

Pulmona ry: stenosis / regurg ita tion

Prosthetic heart va lves


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Aortic stenosisAortic stenosis

Aetiology

Aortic stenosis may be congenital or acquired.

Congenital malformations may be tricuspid, bicuspid or

more rarely unicuspid / quadricuspid

Acquired causes include the following:

- Degenerative disease

- Rheumatic disease

- Calcific e.g. end-stage renal failure, Pagets disease

- Miscellaneous e.g. rheumatoid involvement


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Aortic Valve MorphologyAortic Valve Morphology


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Symptoms

Exertiona l dyspnoea or fatigue

Angina

Sync ope

Physical findings Slow rising pulse

Reduc ed systo lic and pulse p ressure

Systo lic thrill over the aortic a rea Ejec tion systolic , c resc endo-dec resc endo murmur

Soft or inaud ib le sec ond heart sound

ECG: LVH, AV nod e conduc tion defec ts


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Echoc ardiography

Thic kened va lves with reduced motion, sometimescalcified

Grad ing of stenosis severity is as fo llows:

- Normal va lve a rea = 3-4cm2

- Mild stenosis = 1.5-3c m2

- Moderate stenosis = 1.0-1.5c m2

- Severe stenosis 1.0cm2

When stenosis is severe, the peak grad ient a c ross theaortic va lve is usua lly > 60mmHg.


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Aortic regurgitationAortic regurgitation

Aetiology

Either due to p rimary d isease of the aortic va lve or wa ll ofthe aortic root or both.

Causes of primary aortic va lve disease inc lude:

- Congenita l eg . b ic usp id aortic va lve- Ac quired : rheumatic va lve d isease, infec tive endoc ard itis,trauma, c onnec tive tissue d isease.

Causes of primary aortic root disease inc lude:

- Degenera tive, c ystic med ia l nec rosis (eg . Marfan s), aorticd issec tion, syphilis, c onnec tive tissue d isease, hypertension.


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Clinical history

Chronic severe ARDyspnoea is the p rinc ipa l symptom

Sync ope is ra re and ang ina is less frequent than in

aortic stenosis.

Ac ute severe AR

LV dec ompensa tion oc c urs read ily with fa tigue,Severe dyspnoea and hypotension.


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Physical findings

Collapsing pulse Wide pulse pressure

Periphera l signs- De Musset s, Corrigan s, Quinkes,

Muller s, Duroziez s Hyperdynamic apex bea t

Early b lowing d iasto lic murmur


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Aortic RegurgitationAortic Regurgitation

ECG: Left axis devia tion, LV hypertrophy.

CXR: Ca rd iomeg a ly, aortic c a lc ific a tion, aortic root d ila ta tion

Echoc ardiography

Colour flow

- wid th of the jet a t its orig in

- extent into the LV

Doppler

- Rate of dec line of aortic reguritant flow

- Diasto lic flow reversa l into the desc end ing aorta


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Mitral stenosisMitra l stenosis

Aetiology

Rheumatic

Congenital

Carc ino id , SLE, rheumatoid a rthritis,

mucopolysaccharidoses. Left a tria l myxoma, ba ll-va lve thrombus, infec tive

end oc ard itis with la rge vegeta tion and c ortria tria tum.


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Natural history

Long latent period of 20 to 40 years

Once significant limiting symptoms occur, 10-year survival

rate is 5-15%.

With severe pulmonary hypertension, mean survival falls to< 3 years.

Mortality from untreated mitral stenosis is due to progressive

heart failure (60-70%), systemic embolism (20-30%) andpulmonary embolism (10%).


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Clinical features

Dyspnoea

Haemoptysis may a lso oc c ur

Angina

Embolic events


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Physical findings

Mitra l fac ies

Tapp ing apex bea t

Right ventric ula r heave, loud P2

Loud first heart sound . Op ening snap.

Rumbling , mid -diasto lic murmur with p resysto licac c entua tion in sinus rhythm.


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Mitra l RegurgitationMitra l Regurgitation

Chronic MR

Ac ute MR

Mitral valve prolapse


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Mitral regurgitationMitral regurgitation

Aetiology

Mitra l reg urg ita tion ma y be c aused by ab norma lities of the va lve lea flets,c hordae tend inae, pap illa ry musc les or mitra l annulus:

Valve leaflets

- myxoma tous degeneration

- rheumatic hea rt d isea se

- infec tive endoc ard itis

Chordae tendinae

- c ong enita l, infec tive end oc ard itis, trauma , rheumatic fever, myxomatous

Papillary musc les

- myoc ard ia l isc haemia , c ongenita l abnorma lities, infiltra tive d isease

Mitral annulus

- d ila tation eg . isc haemic or d ila ted c ard iomyop athy

- ca lc ific a tion due to d eg enera tion, hypertension, d iabetes, rena l failure


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Mitral regurgitationMitra l regurgitation

Clinical features

Symptoms usua lly oc c ur with LV dec ompensation:dyspnoea and fa tigue.

Physic a l find ings inc lude:

- Pulse: sha rp up stroke

- Apex: d isp lac ed , hyperdynamic

- Pansystolic murmur


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Mitral regurgitationMitra l regurgitation

Natural history

The na tura l history of chronic MR depends on the vo lumeof regurg ita tion, the sta te o f the myoc ard ium a nd theunderlying c ause.

Preopera tive LV end -systo lic d iameter is a useful p red ic tor

of postopera tive surviva l in c hronic MR.

The p reopera tive LV end -systo lic d iameter should be 3+ MR, > 3+ AI

HOCM

Crea tinine > 3 mg / d l

Hgb < 9

GI b leed < 3 months

Ca rd iogenic Shock

TIA o r CVA < 6 months

Life expec tanc y < 12 months AAA

Vasc ula r ac c ess

Inc lusion Criteria

Symp tomatic pa tients withsevere AS (AVA10%)

NYHA >2

Op erab le vs. Inoperab le


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Sc reening Ec hoc ard iographySc reening Ec hoc ard iography

Transthorac ic Ec hoc ard iogram

Determine severity o f AS

Confirm annular d imension

Eva luate LVEF

Cha rac terize other va lvular d isea se

Transesophagea l Ec hoc ard iogram

Annulus c onfirmation

Eva lua te severity of MR

Controversy in measurements of TTEand TEE*

Consider DSE to assess c ontrac tile

reserve


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Sc reening Ang iogramSc reening Ang iogram

Aortic angiogram

Identify idea l p rojec tion where a ll aortic lea flets a re in

p lane w ith the image intensifier Identify charac teristic s of the aortic a rc h and

asc end ing aorta that may c omplic a te the p roc edure


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Sc reening AngiogramSc reening Angiogram

Iliac angiogram

Gross marker of periphera l va sc ula r d isease

Rud imentary assessment of a rteria l to rtuosity, ca lc ific a tion, andd iameter to determine pa tient candidac y for la rge shea thinsertion.

EuroIntervention. 2009 Sep;5(4):438-42


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Patient EvaluationPatient Evaluation

CT Angiogram

Arteria l ca lc ific a tion

Arte ria l tortuosity

Minima l lumina l d iameter


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CT Ang iographyCT Angiography

Contrast vs. non-c ontrast

Intra -arteria l c ontrast d ec rease c ontrast volume

required

Automated vs. manual d iameter determination

Large arte ries determina tion is simila r

Smaller, c a lc ified a rteries there is a marked d ifferenc e

Sc reening CTSc reening CT


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Distanc e from c oronary

artery to a ortic annulus

Aortic annulusdimension

LVOT and sino-tubulardimension

S i CT


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Predic tion of angle of inc idenc e to limit radiation andcontrast

Lack of conc ordance in measurements in the sagita lor coronal projec tions with ec hoc ardiography

Messika , J Am Coll Ca rd iol. 2010;55(3):186-94 KurraJACC Card iova sc Inte rv. 2010;3(1):105-13

TAVRTAVR

TransfemoralTransfemoral andand TransapicalTransapical


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TransfemoralTransfemoral andand TransapicalTransapical

Transfemora lTransfemora l Transap ic a lTransap ic a l


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Transfemora l Approac hTransfemora l Approac h

CoreValveCoreValve


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CoreValveCoreValve

Transfemora l Approac h Sap ien Va lveTransfemora lTransfemora l ApproachApproach Sap ienSap ien ValveValve


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pp ppppp pp

RetroFlex 3 introd uc er Shea th Set

Edwards SAPIEN THV

RetroFlex 3 Delivery System

RetroFlex Balloon Catheter

AtrionInflation Device

RetroFlex Dila tor KitCrimper

T f l A hTransfemora l Approac h


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Aortic Ang iogram



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Balloon Aortic

Valvuloplasty



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ValveDeployment

AorticPressure

RV pac ing: 200/ min



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Aortic Ang iogram



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Femora l Ang iogram


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Transap ic a l Approac hTransap ic a l Approac h

Ascendra Transap ic a l Approac hAscendraAscendra Transap ic a lTransap ic a l ApproachApproach


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Edwards SAPIEN THV

Ascendra Introducer Shea th Set

Ascendra Delivery System

Atrion Inflation Device

Ascendra Valvuloplasy Catheter

Crimper



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Direc t left

ventricularpuncture



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AorticValvulopalsty



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Plac ement andvalvedeployment



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Aortogram

3F3F Transap ic a lTransap ic a l Anteg rade Aortic Va lve Imp lantAntegrade Aortic Va lve Imp lant


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3F3 Transap ic a la sap c a Anteg rade Aortic Va lve Imp lantteg ade o t c a e p a t

Thin Film Nanotec hnologyThin Film Nanotec hnology eeNitinolNitinol

MembranePercValveMembranePercValve


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MembranePercValveMembranePercValve

Aortic Va lve Ca lc ific a tion


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Aortic Va lve Ca lc ific a tion

CORAZON perc utaneous


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aortic va lve systemflexible multilumen central catheter(navigable)

soft tip for plac ement into left ventric le anda balloon for oc c luding the LV outflowtractbelow the aortic valve

expandable c entral lumen with temporaryaortic valve enab ling bea ting heart aorticvalve trea tment

aortic isola tion of trea tment area using acompliant bell designed to conform to theshape of aortic va lve cusps

balanc ed solution inflow and aspiration

CORAZON percutaneous aortic va lve system


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Percutaneous Mitra l Valve Therapies


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Perc utaneous Mitra l Repair Technologies


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Perc utaneous Mitra l Repair Technologies

Perc utaneous Transvenous Mitra lReshaping/ Annuloplasty through the Coronary

Sinus Stra ightening, Stent basedReshaping/ Annuloplasty through the Ventric lePerc utaneous/ Transatria l edge to edge

(E2E or Alfieri) repairPlicating Left Atria l/ Ventricular Tissue anchors

Perc utaneous Mitra l E2E RepairPerc utaneous Mitra l E2E Repair


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Balloon Valvuloplastyfor Mitra l & Aortic StenosisBalloonBalloon ValvuloplastyValvuloplastyforfor MitralMitral & Aortic& Aortic StenosisStenosis

Double Balloon Tec hniqueDouble Balloon Tec hnique


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Inoue Balloon Catheter

Inflation Charac teristic sInoue Balloon Catheter

Infla tion Charac teristic s


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Mechanism ofPercutaneous Commissurotomy

Mechanism ofPercutaneous Commissurotomy


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yy

Stepwise Method for PTMCStepwise Method for PTMC


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Feldman et al; Cathet Cardiovasc Diagn 28:199,1993

Balloon vs Open SurgicalCommissurotomy

Balloon vs Open SurgicalCommissurotomy


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yy

* a ll p


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ACC/ AHA Task Force

Balloon Aortic ValvuloplastyBalloon Aortic Valvuloplasty


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Retrograde

Tec hnique not well developed

Rapid pac ing

Antegrade

Indications

Underutilized palliative therapy

Pre-trea tment for valve rep lacement

Rapid RV Pac ing for AorticValvuloplasty

Rapid RV Pac ing for AorticValvuloplasty


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Aortic Valvuloplasty TechniqueAortic Valvuloplasty Technique


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Surviva l After Aortic ValvuloplastySurvival After Aortic Valvuloplasty


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Mean duration of symptom improvement 13+3 monthsAg arwa l, None ; S. Atta nt i, None ; R. Astiani, None; A.S. Kini, None ; S.K. Sha rma

C irc 108 Su IV :674 2003

Common Management Prob lemsAortic Valvulop lasty

Common Management Prob lemsAortic Valvulop lasty


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Bradycardia

- Conduc ting system injury

- Vaga l- Perfora tion

Hypotension- LV depression

- Bleed ing

- Perfora tion- Aortic insuffic ienc y

- Shea th injury


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Transsepta l

WirePassage

for

AntegradeAortic

Valvuloplasty

Transsepta l

WirePassage

for

AntegradeAortic

Valvuloplasty


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BALLOON MITRAL VALVULOPLASTYBALLOON MITRAL VALVULOPLASTY


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The Multi-Track System

Shares the advantages of the traditional doubleballoon tec hnique

It is safer reduc ing the risk of acc identa l balloon

displacement. The procedure is easier to perform and

proc edure times are reduced .

The system is versatile and c an be used in otherindications

BALLOON MITRAL VALVULOPLASTYThe Multi-Trac k System



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BALLOON MITRAL VALVULOPLASTYThe Multi-Track System



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Cardiac Surgery in oc togenarians;Peri-operative outcome and long-term results

Cardiac Surgery in oc togenarians;Peri-operative outcome and long-term results


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University Hospital o f Lieg e

Eur Heart J. 22(14):1235-43, 2001

Outcomes of c ardiac surgery in patients age 80 years:results from the National Cardiovasc ular Network

67,764 patients (4,743 oc togenarians)

Outcomes of c ardiac surgery in patients age 80 years:results from the National Cardiovasc ular Network

67,764 patients (4,743 oc togenarians)


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67,764 pa tients (4,743 oc tog ena rians)J. Am. Coll. Cardiol., Mar 2000; 35: 731 - 738

Major Points: ValvuloplastyMajor Points: Valvuloplasty


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Percutaneous mitral commissurotomy is the therapy of choice formost patients with predominant mitra l stenosis.

Randomized comparisons with surgery show no a dvantages to surgical

commissurotmy.

Asymptomatic patients with mitra l stenosis should be c onsideredfor catheter commissurotomy when the resting PASP is >50mmHgat rest or 60mmHg with exerc ise

Congenita l AS in patients


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Valve Replac ement in High RiskPatients with Severe Aortic Stenosis:

Results From The PARTNER Tria l

Cra ig R. Smith, MDon beha lf o f The PARTNER Tria l Investiga tors

ACC 2011 | New Orlea ns | Ap ril 3, 2011

Conc lusions (1)Conc lusions (1)

Th i d i t f th t i l t


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The p rimary endpoint o f the tria l was met:

In p a tients with aortic stenosis a t high risk for opera tion, TAVRwas non-inferior to AVR for a ll-c ause morta lity a t

1 year (24.2% vs. 26.8%, p=0.001 for non inferiority) Transfemora l TAVR subgroup was a lso non-inferior to

AVR (p=0.002 for non-inferiority)

Death a t 30 days was lower than expec ted in botharms of the tria l:

TAVR morta lity (3.4%) was the lowest reported in any series,desp ite an ea rly genera tion devic e and limited p revious

operator experience AVR morta lity (6.5%) was lower than the expec ted op era tive

mortality (11.8%)

Conc lusions (2)Conc lusions (2)

Both TAVR and AVR were assoc ia ted with importa nt b ut


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Both TAVR and AVR were assoc ia ted with importa nt b utd ifferent peri-p roc edura l hazards:

Major strokes a t 30 days (3.8 vs. 2.1%, p=0.20) and

one yea r (5.1% vs. 2.4%, p=0.07) and major vasc ula rc omplic a tions were more frequent with TAVR(11.0% vs. 3.2%, p


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Symptom improvement (NYHA c lass and 6-min wa lkd ista nc e) favored TAVR a t 30 days and was simila rto AVR a t one yea r

Ec ho find ings ind ic a te:

Small hemodynamic benefit w ith TAVR vs. AVR a t 1 year (meangrad ient p=0.008, AVA p=0.002)

Inc reased para -va lvula r regurg ita tion assoc ia ted with TAVR(p


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I don t ska te where the puc k is.

I ska te, to where the puc k is going .

Wayne Gretzky

NHL All Sta r 81-99


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Thank YouThank YouThank You

interventional management of valvular disease

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