David R. Holmes, MD, FACC, Michael J

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Presentation transcript:

2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement David R. Holmes, MD, FACC, Michael J. Mack, MD, FACC, Sanjay Kaul, MBBS, FACC, Arvind Agnihotri, MD, Karen P. Alexander, MD, FACC, Steven R. Bailey, MD, FACC, FSCAI, John H. Calhoon, MD, Blase A. Carabello, MD, FACC, Milind Y. Desai, MBBS, FACC, Fred H. Edwards, MD, FACC, Gary S. Francis, MD, FACC, Timothy J. Gardner, MD, FACC, A. Pieter Kappetein, MD, PhD, Jane A. Linderbaum, MS, CNP, AACC, Chirojit Mukherjee, MD, Debabrata Mukherjee, MD, FACC, Catherine M. Otto, MD, FACC, Carlos E. Ruiz, MD, PhD, FACC, FSCAI, Ralph L. Sacco, MD, MS, FAHA, Donnette Smith, James D. Thomas, MD, FACC The Journal of Thoracic and Cardiovascular Surgery Volume 144, Issue 3, Pages e29-e84 (September 2012) DOI: 10.1016/j.jtcvs.2012.03.001 Copyright © 2012 American Association for Thoracic Surgery, the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Terms and Conditions

Figure 1 Sapien valve. Source: Edwards Lifesciences. The Journal of Thoracic and Cardiovascular Surgery 2012 144, e29-e84DOI: (10.1016/j.jtcvs.2012.03.001) Copyright © 2012 American Association for Thoracic Surgery, the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Terms and Conditions

Figure 2 CoreValve. The Medtronic CoreValve System is currently limited to investigational use in the United States. Source: Medtronic, Inc. The Journal of Thoracic and Cardiovascular Surgery 2012 144, e29-e84DOI: (10.1016/j.jtcvs.2012.03.001) Copyright © 2012 American Association for Thoracic Surgery, the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Terms and Conditions

Figure 3 PARTNER trial design. The Journal of Thoracic and Cardiovascular Surgery 2012 144, e29-e84DOI: (10.1016/j.jtcvs.2012.03.001) Copyright © 2012 American Association for Thoracic Surgery, the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Terms and Conditions

Figure 4 Benefit/risk balance in the PARTNER trial. Data are shown for every 1000 patients treated with TAVR instead of standard treatment in Cohort B (above) or standard AVR in Cohort A (below). The excesses listed are not mutually exclusive, because some patients had more than 1 event. Only data with statistically significant differences at 1 year of follow-up are shown except for deaths* (P = .44) and atrial fibrillation† (P = .07) in Cohort A. AR, Aortic valvular regurgitation; AVR, surgical aortic valve replacement; TAVR, transcatheter aortic valve replacement. The Journal of Thoracic and Cardiovascular Surgery 2012 144, e29-e84DOI: (10.1016/j.jtcvs.2012.03.001) Copyright © 2012 American Association for Thoracic Surgery, the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Terms and Conditions

Figure 5 Reconstructed multidetector computed tomographic images of the abdominal aorta and its pelvic branches demonstrating tortuosity and extensive calcific atherosclerosis. The extent and degree of peripheral arterial disease is essential in determining the feasibility and safety of transfemoral approaches. In some patients with extensive disease, alternative approaches such as direct aortic, subclavian, or transapical procedures should be considered. The Journal of Thoracic and Cardiovascular Surgery 2012 144, e29-e84DOI: (10.1016/j.jtcvs.2012.03.001) Copyright © 2012 American Association for Thoracic Surgery, the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Terms and Conditions

Figure 6 Midesophageal long-axis TEE view showing the proper positioning of a sapien valve (black line*) across the aortic annulus prior to balloon deployment. Note that approximately half the valve is above and below the annulus. Note also the difficulty of imaging due to shadowing from the prosthesis and annular and mitral valve calcification, as well as a prominent reverberation artifact, emphasizing the need for thorough training prior to providing procedural guidance. LA, Left atrium. ∗Visible as black line. The Journal of Thoracic and Cardiovascular Surgery 2012 144, e29-e84DOI: (10.1016/j.jtcvs.2012.03.001) Copyright © 2012 American Association for Thoracic Surgery, the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Terms and Conditions

Figure 7 Mixed AR. Central and paravalvular AR following TAVR deployment in a biplane long- and short-axis TEE view. A1 and A2 are trivial paravalvular leaks, whereas B is a trivial central regurgitation, all of which are negligible. C is a more severe paravalvular leak, which was ameliorated by a second valve inflation. Ao, Aorta; AR, aortic regurgitation; LA, left atrium; LV, left ventricle. The Journal of Thoracic and Cardiovascular Surgery 2012 144, e29-e84DOI: (10.1016/j.jtcvs.2012.03.001) Copyright © 2012 American Association for Thoracic Surgery, the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Terms and Conditions

Figure 8 Severe AR. Long-axis TEE view showing severe AR following TAVR deployment (A), confirmed by flow reversal in the descending aorta (B). Short axis imaging (C and D) demonstrates that this is due to failure of the leaflet in the left coronary position (arrow) to close in diastole, ultimately treated by deploying a second valve inside this one. Ao, Aorta; AR, aortic regurgitation; LA, left atrium; LV, left ventricle. The Journal of Thoracic and Cardiovascular Surgery 2012 144, e29-e84DOI: (10.1016/j.jtcvs.2012.03.001) Copyright © 2012 American Association for Thoracic Surgery, the American College of Cardiology Foundation, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Terms and Conditions