Structural Heart Interventions

Question 1

TAVR Devices

Answer 1

•Edwards Sapien 3

• most commonly used
• balloon expandable
• bovine pericardial tissue
• 20, 23, 26, 29 mm sizes
• deployed via 14 or 16 Fr eSheath
• minimum artery dimensions of 5.5 or 6 mm

•Medtronic Evolut R

• successor of Medtronic Core Valve (associated w/ higher rate of heart block)
• self expanding frame allows capture and repositioning
• porcine pericardial tissue
• Supra-annular valve design = larger EOAs (can use larger EOA w/ smaller annulus to decrease patient-prosthesis mismatch)
• 23, 26, 29, 34 mm sizes

Question 2

MitraClip

Answer 2

•available in two sizes — XTR , NTR
•transvenous access
•percutaneous valve repair device that allows for creation of tissue bridge similar to Alfieri stitch that restores adequate coaptation
•predicted post-clip MVA > 2 cm^2
•eligibility criteria (Everest trials):
 - coaptation length > 2 mm
 - coaptation depth < 11 mm
 - flail gap < 10 mm
 - flail width < 15 mm
•steps: venous access —> trans-septal puncture —> steerable guide into LA —> clip delivery system into LA —> clip above MV —> clip into LV —> grasp leaflets —> detach

Question 3

LAA occlusion

Answer 3

•Watchman

• percutaneous LAA occlusion device deployed transvenous by trans septal puncture
• most frequent major complication = tamponade

•Lariat

Question 4

Trans-septal Puncture

Answer 4

MitraClip —> posterior , mid-superior
Watchman —> posterior , mid-inferior
Lariat —> posterior , mid-superior
PVI —> anterior , mid
PVAD —> mid , mid
TMVR —> posterior , mid-superior
PVL —> posterior , superior-mid (depends on leak location)

• biplane —> simultaneous visualization of superior-inferior and anterior-posterior axes
• superior-inferior: ME bicaval view
• anterior-posterior: ME AV SAX

Question 5

MitraClip Imaging

Answer 5

1. Exam after induction
•3D en face MV w/wo CFD
•MV inflow CW — mean gradient
•MVA — 2D/3D planimetry, PHT
•evaluate for effusion
•evaluate PV flows
•complete exam
2. Procedural guidance
•trans-septal puncture — ME bicaval
•advancement of steerable catheter and clip delivery system
•deploying clip
•prior to release: residual MR, iatrogenic MS, clip stability
3. Post-clip exam
•evaluate residual MR severity
 - CFD jets
 - PV flow
 - MV PW inflow — goal mean gradient < 5 mmHg
 - vena contract — challenging w/ mult jets
 - hemodynamics
•MV inflow gradients — MS severity
•clip stability
•evaluate for effusion
•complete exam

Question 6

MitraClip Criteria

Answer 6

Optimal:
•A2-P2 pathology
•no leaflet calcification
•MVA > 4 cm^2
•posterior leaflet length > 10 mm
•tenting height < 11 mm
•flail width < 15 mm
•flail gap < 10 mm

Conditional:
•A1-P1 or A3-P3 pathology
•mild calcification outside gripping area
•MVA > 3 cm^2
•posterior leaflet length 7 - 10 mm
•tenting height > 11 mm
•leaflet restriction in systole (IIIb)
•flail width > 15 mm w/ option for mult clips

Technically Challenging:
•perforation/cleft
•severe calcifications
•MVA < 3 cm^2
•mean gradient > 5 mmHg
•posterior leaflet length < 7 mm
•Class IIIa
•Barlow’s with multi segment flail

Question 7

Watchman Procedure

Answer 7

•procedure steps: venous access —> transseptal —> system into LA —> pigtail into LAA —> device into LAA —> confirm —> deploy —> release / remove
•Imaging steps:
Initial exam
1. LAA morphology: chicken wing (lowest risk for thrombus), cauliflower, windsock, cactus
2. Evaluate for clot
3. Measurements at 0, 45, 90, 135º
 - LCX —> 1-2cm below Coumadin ridge
 - midpoint annular line to deepest part of LAA
 - largest diameter used for sizing
 - goal for device compression 8-20%
4. Evaluate for effusion
5. Complete exam
Procedural guidance:
1. Trans-septal puncture — posterior , mid-inf
2. Guide wire into LUPV
3. Access LAA
4. Deploy device
 - compression 8 - 20%
 - measure shoulder 0, 45, 90, 130º
 - min residual flow around device
 - tug test
Post-deployment exam:
1. Device stability
2. Residual flow around device
3. Evaluate for effusion
4. Evaluate interatrial shunt
5. Complete exam
6. 3D — structure and residual flow

Question 8

Transcatheter MV replacement

Answer 8

•confirm MV pathology
•trans-septal puncture: posterior, mid-sup
•steer device through annulus
•advance delivery system
•deploy valve
•evaluate post deployment
 - residual MS / MR
 - PVLs
 - LVOTO — CFD / CWD

Question 9

Paravalvular leak closure

Answer 9

•depends on location and nature of leak
•TAVR — often managed w/ repeat ballooning
•surgical — deploy occlusion device
•Imaging role:
 - localization of PVL
 - grading severity (3D VC , % circumference)
 - guide wire across leak
 - deployment septal occluder
 - confirm resolution