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2017-01-30
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1/30/2017 Vumedi January 2017 Challenging Case Paul Sorajja, MD Director, Center for Valve and Structural Heart Disease Minneapolis Heart Institute Abbott Northwestern Hospital Disclosures: none 84 year old woman MV repair in 2005 New DOE for 6 months NYHA III Frail 1 1/30/2017 What next? 2 1/30/2017 3 1/30/2017 4 1/30/2017 TAVR in bicuspid Aortic valve Itsik Ben-Dor ,MD Augusto Pichard ,MD Medstar Washington Hospital Center. Washington, DC Classification of Bicuspid Valves 7% 88% 5% 71% 15% 3% Sievers et at. J Thorac Cardiovasc Surg 2007;133:1226-33. Potential Problems in Bicuspids Often heavily calcified Incomplete valve expansion Paravalvar leak Annulus rupture Coronary obstruction Higer rate of pacemaker Frequently associated with ascending aortic aneurysm Risk of rupture/dissection Oval shaped valve area Risk of paravalvar leak Sizing is difficult Long-term durability of the TAVI valve? For these reasons bicuspid valves had been excluded from all randomized trials 1 1/30/2017 Valve size in bicuspid valves Avoid oversizing Risk of rupture Larger self-expanding valves have less radial force Usually it is safe to undersize Very large annuli may still be suitable for TAVI due to higher degree of calcification Sizing Balloon sizing 29 mm Core Valve Case History • 81 year-old woman with presents with progressive SOB and leg edema • PMH: • Atrial fibrillation s/p retinal embolus on Eliqius • DVT Echo : EF 20-25% STS score: 2.4% AVA 0.5cm2 v2 6.3m/sec, mean gradient 106mmHg Mild to moderate AR BAV (2 months before) – Maxi 22mm AVA 0.25 to 0.52 cm2 Mean gradient 100 to 43mmHg 2 1/30/2017 Echo Date of ECHO 01.27.2016 (post BAV) LVEF ( 20%) * 45% Aortic Valve Area (< 1.0cm2)* 0.7 Mean Aortic Gradient ( 44 40mmHg)* Aortic Valve Area Index (< 0.41 0.6cm2/m2)* Normal size, RV Size and Function borderline reduced systolic function Peak Velocity ( 4.0 m/sec)* 4.2 Estimated Systolic 36 Pulmonary Pressure (mmHg) Other Valvular Findings Mild MR, trace AR; mild TR Native Coronary and Graft Findings LM 30%; LAD 10%; LCX = 10%; RCA=10% Bicuspid valve Which Valve would you choose ? 1.Balloon expandable 2. Self expandable 3 1/30/2017 4 1/30/2017 CT Analysis Annulus by CT Measure Short Annulus Diameter 25.1 mm Long Annulus Diameter 30.0 mm Annular Perimeter 85.3 mm Annular Area 581.1 mm2 Derived diameter (perimeter/area) 27.2/27.2 mm/mm CT Analysis Aortic Root by CT Measure Sinus of Valsalva Diameter 37.7(L)x30.5(R)x33.2(N)mm STJ Diameter 32.5x35.4mm Sinus Height 24.1(L)x21.5(R)x24.0(N)mm Left Coronary Height 13.2mm Right Coronary Height 15.7mm Aorta 39.1x40.3mm Angle 44° Access CIA EIA CFA Right Left 8.7 6.6 6.8 10.4 7.5 7.1 5 1/30/2017 Procedure • Right femoral two perclose • Temporary pacer BAV Maxi 20/4 Procedure 31 mm core valve Procedure 6 1/30/2017 Procedure True balloon 22mm Echo post valve Mild to moderate AR Hospital course • LBBB – EP study –CAVB with infra-his conduction block • Pacemaker day 3 • Echo at 2 days: moderate AR • Home day 5 7 1/30/2017 Post discharge • Shortness of breath with minimal activity • TTE and TEE TEE one month post Echo Variable (TTE) Measure Peak Velocity 2.2 m/se Mean Gradient 11 mmH g c Calculated AVA Severity of AR Severity of MR Ejection Fraction n/a cm2 Severe Mild 55-60 % 2 paravalvular leaks: the larger leak in the non-coronary cusp and the smaller is more anterior. Reversal of flow in the descending and abdominal aorta consistent with severe paravalvular leak. Next step ? • Para valvular closure device • Valve in valve core or Edwards • Surgery 8 1/30/2017 S3 Annulus by CT Measure Short Annulus Diameter Long Annulus Diameter Annular Perimeter Annular Area Oversizing 25.1 mm 30.0 mm 85.3 mm 581.1 mm2 11.9 % Procedure 29mm S3 Edwards Procedure 9 1/30/2017 Procedure No AR Hospital course Day one post procedure mild chest pain Cardiac enzyme – troponin 14 → 35 → 43 stable Hospital course Day one post procedure mild chest pain 10 1/30/2017 Hospital course Discussion with CV surgery for CABG or PCI More than 24 hours post infarct Medical treatment Discharge day 5 after the procedure 11 1/30/2017 Challenges for TAVI in BAV Asymmetric anatomy Annulus-orifice “mismatch” Incorrect valve sizing Incomplete apposition Non-circular & inadequate expansion Migration Paravalvular leak Aggressive post-dilation Impaired valve durability Annular rupture Valve-in-valve Conclusions TAVI in bicuspid valves is feasible but may be technically more difficult. Results are comparable to those tricuspid valves. Paravalvular leaks may be more frequent. Pacemaker may be more frequent. Oversizing of the valve should be avoided. Balloon sizing may be better than CT sizing. Supra-annular sizing better than balloon sizing. Patients with large annulus may still be suitable for TAVI if the valve is bicuspid Better results can be expected with newer valves. CT Analysis (1/6/2017) S3 Annulus by CT Measure Short Annulus Diameter 24.0 mm Long Annulus Diameter 31.0 mm Annular Perimeter Annular Area Oversizing 89.0 mm 621.0 mm2 3% 12 1/30/2017 CT Analysis (1/6/2017) Aortic Root by CT Measure Sinus of Valsalva Diameter (L)35x(R)32x(N)37mm Sinotubular Junction Diameter 31x32mm Sinus Height (L)21x(R)20x(N)25mm Left Coronary Height 19mm Right Coronary Height 15mm Aorta 35x37mm Angle 53° 13 1/30/2017 14 1/30/2017 Preemptive Alcohol Septal Ablation in Prevention of LVOT Obstruction for TMVR Christopher U. Meduri, MD MPH Co-Director Marcus Heart Valve Center Piedmont Heart Institute Atlanta, GA Disclosures Affiliation Company ● Proctor/Speaker/Advisory Board ● Boston Scientific ● Proctor/Speaker/Consultant/Grant ●Medtronic ● Proctor/Grant ● Edwards • Proctor/Consultant ● Mitralign Will be discussing the use of THV for off-label uses Page 2 M.K. • 76 y/o woman with severe PVD, LM disease, severe AS and severe MS with MAC with NYHA III symptoms Page 3 1 1/30/2017 M.K. • 76 y/o woman with severe PVD, LMT disease, severe AS and severe MS with MAC with NYHA III symptoms • Extreme risk because of porcelain aorta Page 4 Baseline Angio Page 5 Coronary Stenting Page 6 2 1/30/2017 TAVR Planning • Normal LV/RV function • Aortic velocity = 4.1 meters/sec • Aortic annulus area = 309 mm2 • Area derived annulus = 19.8 mm • Ileofemorals = 4.0 – 4.5 cm Page 7 Do We Treat Mitral Stenosis? Aorto-Mitral Angle 106 degrees Septal Bulge 1.8cm Page 8 23 mm Sapien XT Page 9 3 1/30/2017 23 mm Sapien XT Page 10 23 mm Sapien XT Page 11 Recurrent Dyspnea 6 months later • 23 Sapien XT gradients = 27/15 mmHg (post procedure = 28/17 mmHg) • No aortic regurgitation Page 12 4 1/30/2017 Re-assessment of Mitral Valve Page 13 Re-assessment of Mitral Valve Page 14 Re-assessment of Mitral Valve Page 15 5 1/30/2017 Severe MAC Page 16 Risk Factors for LVOT Obstruction Page 17 Severely Hypertrophied Basal Septum Page 18 6 1/30/2017 Aorto-Mitral Images Page 19 Proceed? • Very high risk of LVOT obstruction • No potential surgical bailout for patient if worse • Must be confident in result and have ability to remove if needed • Plan for septal ablation and request compassionate use Lotus in MAC from FDA Page 20 Alcohol Septal Ablation LVOT Pre-Ablation LVOT Post-Ablation Page 21 7 1/30/2017 Page 22 Pre Procedure Page 23 Page 24 8 1/30/2017 Page 25 TEE Guidance of Implant Depth Page 26 Page 27 9 1/30/2017 Page 28 No LVOT Gradient Page 29 Post Procedure Page 30 10 1/30/2017 No MR/PVL Page 31 Page 32 Post-Procedure • Extubated on table • Within 6 hours walking laps around CVICU saying, “I feel like a new person” • Discharge POD 2 • Walked 2.5 miles without stopping within 1 week of procedure! Page 33 11 1/30/2017 30 Day Follow-Up CT Page 34 Thank You Christopher.Meduri@piedmont.org Page 35 12
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