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
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Mild
165
139
121
111
71
33
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Mod-Sev
34
25
22
19
15
6
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Echo the modality of choice Valve assessment ; Success AV gradient and AR , acute and long term
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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