经皮主动脉瓣植入tav.ppt

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1、TAVI,XIONGRAN 2014-11-25,QUIZ,StreetAvenue,Street,Avenue,Hospital of UA,Hospital of UA,Hospital of UA,Hospital of UA,Summarize of TAVI,Transcatheter aortic valve implantation(TAVI)It was introduced as an alternative treatment in patients with severe aortic valve stenosis(AS),Cribier A,Eltchaninoff H

2、,Bash A,Circulation 2002;106:30063008.,First Case of TAVI,In 2002,Cribier et al demonstrated for the first time the feasibility of a percutaneous valve implantation in a patient with ASProviding a promising less invasive alternative treatment for valvular heart disease,Cribier A,Eltchaninoff H,Bash

3、A,Circulation 2002;106:30063008.,two different TAVI devices are widely used the balloon-expandable Edwards SAPIEN Transcatheter Heart Valvethe self-expanding Medtronic CoreValveBoth received CE Mark approval for European commercial sale in 2007Edwards SAPIEN valve received FDA pre-market approval in

4、 the USA in November 2011,Two different TAVI devices,Edwards balloonexpandable delivery systems,CoreValve ReValving System(a)schemata and(b)following deployment with aortography,Patients Selection,Feasible in most patients with severe aortic stenosisGenerally utilized in patients not suitable for su

5、rgical AVR,who are likely to derive functional and survival benefitTwo risk scores are used to calculate the risk of cardiac surgery,“High-risk”surgical patients Having a Society of Thoracic Surgeons Predicted Risk of Mortality(STS-PROM)at 30 days of greater than 10%Logistic EuroSCORE of greater tha

6、n 20%LimitedDo not account for several pertinent clinical risk factors,such as previous CABG,porcelain aorta,previous chest radiotherapy,severe lung disease,and liver cirrhosis,Two risk scores,Two risk scores,Assessments of TAVI,To assess the aortic annulus dimensions and geometry,access site,and ap

7、proach Transthoracic echocardiographyCoronary angiographyAortic angiographyMDCT,Assessment of arterial access,The evaluation is fundamental in the assessment of the TAVI patient in minimizing potential major vascular complicationsArterial dimensions The presence or absence of atheroma,CalcificationT

8、ortuosity,Assessment of arterial access,Arterial access is assessed with the combination of invasive angiography and contrast-enhanced CT,Iliofemoral assessment with(a)angiography and(b)MDCT,Assessment of aortic root,Using invasive angiography and contrast MDCT evaluate root and valvular calcificati

9、onleft main height from the left coronary cusp insertion(due to risk of coronary obstruction)technical issues related to each valve type and delivery system,European Heart Journal(2014)35,26272638,Assessment of aortic root,(1)aortic annulus diameter,(2)sinus of Valsalva width(3)ascending aorta width

10、,(4)sinus of Valsalva height,Assessment of aortic root,Assessments,Left and right heart catheterizations are also performed assess the presence of pulmonary hypertension coronary ischemia and the need for revascularization prior to TAVI,Requirements of TAVI,TAVI should be performed in regional cente

11、rs of excellence with a dedicated heart valve program and high procedural volumes The procedure may be undertaken in a cardiac catheterization laboratory with modifications or in a hybrid operating room equipped with high-quality fluoroscopic imaging,Requirements of TAVI,The facilities need to be la

12、rge enough to accommodate sophisticated X-ray imaging integrated with echocardiography,cardiopulmonary bypass and intra-aortic balloon pump machines,and anesthesia equipment,with surgical sterility standards mandatory,Techniques of TAVI,TAVI is most often performed utilizing the transfemoral retrogr

13、ade approachAlternative access approaches usually reserved for patients with concomitant severe peripheral arterial disease,Transfemoral Approach,The common femoral artery,at the level of the femoral head,is the primary access site for the transfemoral approach owing to its relatively large size and

14、 compressibilityThe side with the largest and least diseased,tortuous,or calcified iliofemoral arteryas assessed by a screening angiogramand/or multidetector computed tomographic(CT)angiographyis selected for placement of the sheath,Transfemoral Approach,The potential site of access is assessed fi r

15、st with fluoroscopy and/or ultrasound,and arterial access is gained by percutaneous punctureAlternatively,a surgical cutdown is utilized to access the femoral arteryA smaller percutaneous sheath is inserted into the femoral artery on the contralateral side for placement of a pigtail catheter in the

16、ascending aorta for root angiography,Transfemoral Approach,The TAVI procedure may be performed under local or general anesthesiaFollowing balloon valvuloplasty,the valve prosthesis is passed across the aortic valve and positioned under fluoroscopic and transesophageal echocardiographic(TEE)guidance,

17、Transfemoral Approach,Balloon-expandable valves are deployed under rapid ventricular pacing at a rate of 160220 bpm to minimize cardiac output and therefore minimize unintentional motion of the valve during balloon dilatation,Transapical Approach,The transapical approach was first described in 2006

18、with balloon-expandable valves A sheath is placed surgically in the left ventricular apex,accessed through a small left anterolateral minithoracotomy,Transapical Approach,Following balloon valvuloplasty,the valve prosthesis and balloon catheter are passed over a wire into the left ventricle and posi

19、tioned within the aortic annulus under fluoroscopic and transesophageal echocardiographic guidance,Transapical Approach,This approach may be considered if the iliofemoral arterial system is of sufficiently small diameter,calcified,or tortuous and not technically suitable for delivery of the deviceAl

20、so taken into consideration is the angulation of the aorta and arch,Transapical Approach,In particular,a transverse or extremely unfolded ascending aorta may increase the diffi culty of delivery and positioning of the balloon-expandable devicesIt has been suggested that with advances in device techn

21、ology and a reduction in delivery system profiles for the transarterial approach,alternative access approaches will be limited to less than 30%of TAVR procedures,Transapical Approach,Contraindications to the transapical approach previous left ventricular surgery using a patchcalcified pericardiumsev

22、ere respiratory disease,Transapical Approach,Others,Axillary/Subclavian ApproachTransaortic Approach,Complications of TAVI,Procedural ComplicationsVascular ComplicationsStroke and Neurological EventsCoronary OcclusionValve Malposition and EmbolizationRenal ImpairmentConduction Disturbance,Complications of TAVI,Prosthesis-Related ComplicationsProsthesisPatient MismatchParavalvular and Valvular RegurgitationProsthetic Valve Thrombosis and Endocarditis,Question,THANKS,