1. Echo Essentials for TAVI
Steven A. Goldstein, MD
Director, Noninvasive Cardiology
Washington Hospital Center
Sunday, February 27, 2011

2. financial relationships
DISCLOSURE
I have N O relevant
financial relationships

3. Severe Aortic Stenosis
One of the most lethal of
all cardiovascular diseases

4. Percutaneous/Transapical AVR Team Approach
Interventional cardiologist
Imaging cardiologist
Vascular surgeons
Cardiac surgeons
Anesthesiologists

5. TEE in Cath Lab: Set-up O Nurse Operator Monitors Tech Echo-2
SUCTION
Nurse
Echo-
Operator
cardiographer
Monitors
Tech

6. Percutaneous AV Replacement Role of Pre-Procedure Echo
Determine severity of aortic stenosis
Assess aortic valve morphology
Estimate annular size
Distance from valve to L-main orifice
Discovery of severe aortic atheroma
(may mandate transapical approach)

7. Percutaneous AV Replacement Role of On-Line TEE
Reassess annular diameter  critical for sizing
Monitor deployment of valve
Assess severity and location of AR
Assess leaflet motion of the deployed valve
Measure gradients (transgastric views)
Detect new regional WMAs
Detection of complications
(verify correct positioning)  co-axial alignment
(detect impingement on coronaries)

8. Measurement of aortic annulus
1.8 cm
Measurement of aortic annulus

9. Measurement of aortic annulus
1.8 cm
Measurement of aortic annulus

10. Percutaneous AV Replacement Role of On-Line TEE
Reassess annular diameter  critical for sizing
Monitor deployment of valve
Assess severity and location of AR
Assess leaflet motion of the deployed valve
Measure gradients (transgastric views)
Detect new regional WMAs
Detection of complications
(verify correct positioning)  co-axial alignment
(detect impingement on coronaries)

11. Percutaneous AV Replacement Complications
Vascular complications
Stroke
Dislodgement of aortic atheroma
Thrombus formation of catheters, wires, etc
Valve migration
Myocardial ischemia from coronary obstruction
Damage to mitral valve
AV block

12. Percutaneous AV Replacement Role of On-Line TEE
Additional Miscellaneous Issues
Sigmoid septum
MV structure, function, calcification
LV apical thrombus
Occurrence of thrombi on catheters
Wire not through mitral apparatus

13. Case 1
Case 1

14. 95 year-old man  mentally clear
2 years ago  bowling and yard work
Since then, progressive effort angina and dyspnea
“Burning” and pressure with exertion
Now NYHA class III-IV

18. Vmax = 4.3 m/s  peak instantaneous gradient = 74 mm Hg

22. 23 mm balloon
25 mm balloon 22

25. LAD flow velocity pre transcatheter AV replacement
51 cm/sec 
LAD flow velocity pre transcatheter AV replacement

26. LAD flow velocity post transcatheter AV replacement
63 cm/sec 
LAD flow velocity post transcatheter AV replacement

27. Pre
Post

28. This 95 year-old man has returned to bowling !

29. LA LV
Coaxial
Not coaxial

30. LA LV
distal
proximal

31. Case 2
Case 7

32. Percutaneous Aortic Valve Replacementb. c.
AV placed to avoid impingement on coronary ostia or
to impeded motion of anterior mitral leaflet
Prosthesis deployed by inflating the delivery balloon
Balloon is deflated and rapidly withdrwan

34. Make sure wire does not interfere with mitral apparatus

36. Case 3
Case 7

37. Transapical approach - wire not thru mitral apparatus

38. Balloon valvuloplasty

39. Pre-deployment - valve in good position

40. Deployment of valve

41. Valve deployed - good position

42. Case 4
Case 7

43. Valve deployed - slightly “aortic” (too high)

44. Case 5
Case 7

45. Wire passing through mitral apparatus

46. Wire passing through mitral apparatus

47. Wire withdrawn and re-inserted  now “safe”

48. Potential problem
Now OK

49. Case 6
Case 7

50. Mobile thrombus in descending thoracic aorta

51. Mobile thrombus in aortic arch

52. Case 7
Case 7

53. SK year old lawyer
Severe aortic stenosis
Symptomatic  dyspnea and angina
Successful transcatheter deployment
Post-procedure  R-hemiparesis
of #26 Edwards-Sapien prosthetic
aortic valve

55. The End

56. Different Shapes of Stent Deployment
Zegdi (Paris) J Am Coll Cardiol 2008; 51:579-84

57. Sharp Calcific Excrescenses Crossing the
Stent Frame Protrude Inside the Aortic Lumen
Zegdi (Paris) J Am Coll Cardiol 2008; 51:579-84

58. Influence of Size or Shape of the Orifice
On the Valved Stent Deployment
Zegdi (Paris) J Am Coll Cardiol 2008; 51:579-84

59. Leaflet Distortion in the Presence of Annular Calcification
Close to One Commissure of the Deployed Valved Stent
Zegdi (Paris) J Am Coll Cardiol 2008; 51:579-84

60. Valve Distortion Secondary to the Valved Stent
Deployment Inside a Triangular Orifice
Zegdi (Paris) J Am Coll Cardiol 2008; 51:579-84

61. Stent Shapes after Deployment According to Aortic Valve Pathology
Tricuspid
(n = 19)
Bicuspid
(n = 19)
Circular n (%)
Elliptic n (%)
Triangular n (%) 13 2 4
(68)
(11)
(21) 2 11 1
(14)
(79)
(7)
Zegdi (Paris) J Am Coll Cardiol 2008; 51:579-84

63. Backup Slides

64. Symptomatic Aortic Stenosis
AVR Must Be Performed
100 80
Valve Replacement 60
Survival (%) 40
No surgery 20
Chi2 = 23.5
P<0.001
P<0.05
P<0.001 1 2 3 4 5
Years
Schwartz Circulation 1982;66:

65. Based on estimated population growth projection
Incidence of Aortic Stenosis for Population > 65
Based on estimated population growth projection
data from US census
2.00
1.80
1.60
1.40
1.20
Population (x106)
1.00
0.80
0.60
0.40
0.20
0.00
2000
2010
2020
2030
2040
2050
Year
US Census Bureau. US Interim Projections by Age, Sex, Race,
and Hispanic Origin. In 2004.

66. Aortic Valve Replacement
Increasing need over next 10 years
Aging population
Increase of world population
Under-diagnosed in upcoming countries
(China, India)

67. Transcatheter Percutaneous Aortic Valve Replacement
A driving force for catheter-based
therapies for valvular heart disease
since mid-1980s
Alain Cribier
Rouen, France
Pioneered the development of
Cribier-Edwards heart valve
Performed the first PTAVR in 2002

68. Percutaneous Aortic Valves
CoreValve
Edwards-Sapien
Direct Flow
Lotus
Paniagua
Enable
Perceval
Jena
CoreValve, Inc
Edwards Life Sciences
Direct Flow Medical, Inc
Sadra Medical
Endoluminal Technology Research
ATS
Sorin Group
Jena Valve technology

69. Placement of AoRTic TraNscathetER Valves Trial
PARTNER Trial

70. Severe AS - symptomatic
PARTNER - Algorithm
Severe AS - symptomatic
High Risk Patient
Operable
High Risk
Non-operable
Percutaneous
AVR
Percutaneous
AVR
Surgery
High Risk
Medical
Therapy

71. Percutaneous Aortic Valve Indications
Severe AS from degenerative disease
Symptomatic
Aortic valve area <0.8 cm2 and
Surgical mortality > 20%
Vmax >4.0 m/s or mean gradient > 40 mm Hg

72. Edwards SAPIEN™ THV using the RetroFlex 3™ Transfemoral Delivery System Procedural Steps
Balloon
Valvuloplasty
Aortic Arch
Navigation
Native valve
crossing
Valve
deployment
Final
assesment

73. Edwards SAPIEN™ THV using the Ascendra™ Transapical Delivery System
Direct
access the apex
Balloon
valvuloplasty
Native valve
crossing
Valve
deployment
Final
assesment
Procedure steps

74. Valve before deployment

75. Valve after deployment

78. Transcatheter AV Replacement Rapidly Emerging Field
Improving technology
Improved patient selection
Growing procedural experience

79. Transcatheter AV Replacement Progress with Successive
Device Generations - Core Valve
1st
(25-F)
2nd
(21-F)
3rd
(18-F)
Procedure success rate
Periprocedural mortality
Periprocedural stroke rate
70%
10%
71% 8%
91% 0%
<5%
Grube Circulation Cardiovasc Intervent 2008;1;167-75

80. RetroFlex RetroFlex II
Next-Generation Transfemoral Valve Delivery System
RetroFlex
RetroFlex II
RetroFlex II Offers:
Greatly improved native valve crossability
Smoother tracking
Improved handle functionality
Fewer system components
Continued advancement of the THV Program 80

81. Conclusions Marked hemodynamic and clinical improvement
Careful selection and screening essential
TEE  important role during procedure
Procedural success rate ≈ 90%
At present, only short-term results
improvement
(closely linked to experience)

83. New

84. Case 57

85. DR year-old woman
Longstanding aortic stenosis
Felt not to be surgical candidate due to multiple
Entered PARTNER Trial and randomized to
Transapical due to small femoral arteries
medical problems and small size
receive transcatheter prosthetic aortic valve

86. Valve positioned properly

87. Valve deployed properly

88. Coronary flow pre-procedure
42 cm/sec
Coronary flow pre-procedure

89. 68 cm/sec

90. Case 8
Case 7

91. History
85 year-old man with aortic stenosis, mild CAD, and PVD complained of shortness of breath with minimal exertion.

92. LVOTD=2.0cm
Ao Valve Area = 0.8cm2
V2=4.1m/s
V1=1.1m/s

93. After deployment of 23mm Edwards-Sapien aortic valve

94. Reason……

95. Patient’s blood pressure decreased from 170/69 to 93/32mmHg

96. Decision was made to place 2nd valve inside the 1st valve.

97. Deployment of 2nd valve inside the 1st valve

98. After valve deployment  trace aortic regurgitation

99. “If at first you don’t succeed, try and try again.”
Confucius said……
“If at first you don’t succeed, try and try again.”

100. ECHO

101. Transcatheter AV Repalcement
Edwards-Sapien Valve
Successful deployment
30-day mortality
Major adverse cardiac event rate
87%
7.4%
16.7%
Tops, Kapadia, Tuzcu, Vahanian, Alfieri, Webb, Bax
Current Problems in Cardiology 2008;33A:415-57

102. Aortic Valve Replacement Percutaneous Approach
General anesthesia or awake patients
Avoids surgery
Steep learning curve
Still experimental

103. Edwards-Sapien Valve Balloon expandable Stainless steel stent
Fabric sealing cuff
Bovine pericardial leaflets
Two sizes:
23 mm
26 mm
New height

104. CoreValve Prosthesis Self expanding Nitinol alloy stent
Porcine pericardial leaflets
Pericardial sealing cuff
50 mm long
Waist in the middle part
Two sizes:
26 mm
29 mm