SHA24/031004

Dr. Ghormallah Al zahrani Feb 14 , 2013

For Routine Valve assessment For Complications :  Cardiac

Aortic regurgitation Myocardial ischemia Cardiac tamponade Conduction abnormalities  Non cardiac

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Valve assessment 1) Hemodynamic 2) Valvular and paravalvular regurgitation Secondary effects 1) Effect of implantation on the disease processes.

2) Detection of long-term complications such as device migration, thrombus formation, ventricular perforation, mitral valve impingement, and endocarditis

Echocardiography is the imaging modality of choice

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MDCT and CMR • Playing larger roles in the evaluation of structural integrity, sphericity, position, aortic regurgitant volume, and post-procedural complications • Afford excellent anatomic detail.

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Evaluation of Myocardial Function  LV mass regression  Improvement in (EF):

A recent comparison of SAVR with TAVR in patients with low EF showed a greater increase in EF in the TAVR group  Improved diastolic function Other Valves Hemodynamic  Mitral regurgitation

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Clavel, M. A. et al.. J. Am. Coll. Cardiol. 53, 1883–1891 (2009).

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PSCC experience

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AV assessment  Gradient , EOA  Both the SAPIEN and CoreValve have excellent flow characteristics with mean gradients of 10 to 15 mm Hg  The 3-year results from a BA valve suggest that  small increase in mean transvalvular gradient (3.8%/year)  small reduction in valve area (0.06 cm2 /year) might occur over time.

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PSCC experience

Clavel, M. A. et al.. J. Am. Coll. Cardiol. 53, 1883–1891 (2009).

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Prosthesis-patient mismatch (P-PM)    

Severe P-PM is defined by an EOA ≤0.65 cm2/m2.

Determines morbidity, LV mass reg, and mortality after SAVR. Occur in 20% to 70% of patients after open aortic valve replacement Less of a problem after TAVR ( more with Core valve )

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Clavel, M. A. et al.. J. Am. Coll. Cardiol. 53, 1883–1891 (2009).

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Paravalvular, Transvalvular, and Total AR  Most commonly mild .  In 1 registry ; significant AR is more with the self-expanding valve.

 Predictors of AR ; Sizing and calcium ( degree and asymmetry )  Trans Valvular AR is Usually due to  Valvular damage during the implantation procedure,  Too large prosthesis for a small annulus resulting in valve deformation,  Severe calcification of the native valve leading to deformation of the frame of the THV 19

 Paravalvular AR, in contrast to transvalvular AR, is usually caused by  incomplete prosthesis apposition to the native annulus due to remaining material of the native valve or ridges of calcium,  too small a prosthesis for a large annulus,  too-low implantation of the valve leading to paravalvular leakage through uncovered portions of the prosthesis.

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Circumference = 6″ AR = 0.1+0.35 = 0.45″ Ratio = 8% Severity = Mild (< 10%)

Circumference = 6″ AR = 0.5+0.5 = 1.0″ Ratio = 17% Severity = Moderate (10 – 20%) (Trans AR also present) Circumference = 6″ AR = 0.6+1.1 = 1.7″ Ratio = 28% Severity = Severe (> 20%) Images courtesy of Pamela Douglas, MD, FASE

p < 0.0001

N = 277

N = 226

p < 0.0001

N = 230

N = 172

p < 0.0001

N = 216

N = 155

p < 0.0001

N = 145

N = 112

p < 0.0001

N = 279

N = 228

p < 0.0001

N = 231

N = 173

p < 0.0001

N = 217

N = 156

p < 0.0001

N = 145

N = 113

None - Trace

p (log rank) < 0.001

Mild

50.7%

Mortality

Moderate Severe

35.3%

33.4%

26.2% 26.3% 12.7%

Months Post Procedure Numbers at Risk None-Tr

135

125

115

101

68

31

11

Mild

165

139

121

111

71

33

16

Mod-Sev

34

25

22

19

15

6

2

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Echo the modality of choice Valve assessment ;  Success  AV gradient and AR , acute and long term

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Effect on LV EF & mass Effect on MR Complications; Cardiac and Non cardiac Echo is the modality of choice CT & MRI ,ay be useful in some cases

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