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Access options for transcatheter aortic valve implantation

Introduction Transcatheter aortic valve implantation (TAVI) is now the standard treatment for older adults with symptomatic severe stenosis of a trileaflet aortic valve regardless of surgical risk who do not warrant a mechanical valve. A key component in case planning for TAVI involves selecting the appropriate access for delivery of the transcatheter aortic valve (TAV). Although there are numerous access options for TAVI ( Fig. 7.1…

Characteristics and selection of transcatheter aortic valve prostheses

Key features of transcatheter valves In transcatheter aortic valve implantation (TAVI), the selection of the best suited transcatheter aortic valve (TAV) for each individual patient remains a challenge. The ideal bioprosthetic transcatheter valve would have all of the following features: Easy deliverability and placement in the aortic valve position Wide sizing range fitting all annular sizes, even when calcified or asymmetric Secure anchoring mechanism regardless of…

Diagnosis and management of concurrent cardiac disease: Coronary disease, dilated ascending aorta, and mitral and tricuspid valve disease

Coronary artery disease Prevalence and clinical impact In randomized clinical trials, more than two-thirds of intermediate- and high-risk transcatheter aortic valve implantation (TAVI) candidates have coronary artery disease (CAD). , The impact of CAD on long-term outcomes after TAVI is unclear and the optimal treatment strategy remains controversial. Two recent meta-analyses showed discordant results regarding the influence of CAD on outcome in patients undergoing TAVI (…

Preprocedural imaging

Introduction The importance of precise preprocedural multimodality imaging with echocardiography and cardiac multislice computed tomography (MSCT) before transcatheter aortic valve implantation (TAVI) cannot be overemphasized. Both echocardiography and MSCT imaging are the foundations of quality outcomes in TAVI and are key tools for patient selection. Participation of sonographers, technicians, radiologists, and the imaging cardiologist within a multidisciplinary heart team is vital in acquiring key information to…

Patient selection

Introduction The following prerequisites are essential before patient selection in transcatheter aortic valve intervention (TAVI): 1. An accurate diagnosis of severe aortic stenosis (AS) 2. An indication for aortic valve intervention (i.e., severe symptomatic AS) 3. A constellation of clinical, anatomic, or other patient factors likely to favor the transcatheter approach (see Chapter 1 ) This chapter outlines an approach to comprehensive risk stratification and patient…

Transcatheter aortic valve implantation program development to support patient-centered care

TAVI center structure General principles An effective system for the evaluation and management of patients with severe aortic stenosis (AS) requires a multilevel, graduated approach to identify patients with disease and refer them for therapy in a timely and efficient manner. The key guiding principle for a transcatheter aortic valve implantation (TAVI) center is to adopt a multidisciplinary and patient-centered approach that integrates the care of…

Aortic valve intervention: Indications, timing, and choice of transcatheter aortic valve implantation versus surgical aortic valve replacement

Indications for aortic valve intervention Aortic stenosis (AS) is the most common heart valve disease that is associated with increased cardiovascular mortality and requires intervention. The prevalence increases with age, and currently 1 in 20 people age 75 and older have moderate or severe AS. As there are no medical therapies that have been shown to attenuate progression of stenosis, aortic valve intervention (transcatheter aortic valve…

Volume and Outcome

Key Points An inverse relationship between experience and outcome for higher-risk procedures has been repeatedly demonstrated over the past 30 years. In the case of percutaneous coronary angioplasty, the minimum volume thresholds involve low numbers of fewer than four cases per week for hospitals and one case per week for physicians. The volume standards affect relatively few patients (4% of all patients undergo percutaneous coronary intervention…

Quality of Care in Interventional Cardiology

Key Points Owing to increasing state and federal regulations, direct patient access to publicly available information about the quality of care, as well as pressures from payers for cost-efficiency, the delivery of care in the cardiac catheterization laboratory is being examined closely. Efforts to improve the quality of medical care in the United States started more than 150 years ago, and new initiatives such as public…

Medical Economics in Interventional Cardiology

Key Points There are three forms of full economic evaluations that do not assume equivalence of health outcome: cost-effectiveness analysis (CEA), cost-utility analysis (CUA), and cost-benefit analysis (CBA). Both CEA and CUA are widely used to decide whether a medical intervention is economically attractive, whereas CBA is used much less. CEA and CUA assess the incremental costs for a therapy or strategy to produce an incremental…

Optical Coherence Tomography

Key Points Optical coherence tomography (OCT) is an innovative catheter-based imaging technology that uses light and fiberoptic technology to obtain unique details of the vessels on a microscopic scale. OCT provides real-time, full tomographic views of the coronary arteries with accurate measurements. OCT is an efficient method to rapidly map the extension and type of coronary artery disease, guiding precise percutaneous coronary interventions (PCIs) in complex…

The Dynamic Spectrum of Coronary Atheroma: From Atherogenesis to Vulnerable Plaque to Plaque Regression

Key Points Globally cardiovascular disease (CVD) is the leading cause of death, accounting for greater than 17.3 million deaths per year in 2013. The mechanisms involved in acute coronary thrombosis are well established and include of plaque rupture, erosion, and less frequently, calcific nodules. The correlation of coronary angiography, coronary computed tomography angiography and intracoronary imaging with histopathology created the concept of the thin-cap fibroatheroma (TCFA).…

Intravascular Ultrasound

Key Points Intravascular ultrasound (IVUS) was the first clinical imaging method to directly visualize atherosclerosis and other pathologic conditions within the walls of blood vessels. Improvements in core IVUS technology have allowed for higher-resolution images and greater operator convenience. IVUS has provided significant insights into biologically mediated processes of the vasculature, such as the extent of plaque burden, vascular remodeling, and restenosis. IVUS is a practically…

Qualitative and Quantitative Coronary Angiography

Key Points An enhanced understanding of coronary lesion complexity remains a valuable tool for estimating early and late procedural risk after percutaneous coronary intervention (PCI). Aggregate scores that consider the vessel patency and underlying lesion morphology provide the most relevant information for estimating outcome. The SYNTAX trial score, a quantitative assessment of the extent of coronary artery disease, has proven a valuable tool for identifying appropriate…

Interventional Heart Failure

Key Points Despite current guideline-directed drug and electrophysiologic device therapies, many heart failure patients remain highly symptomatic, and outcomes remain poor. New therapies are needed to improve patients’ clinical status and outcomes. Several causes of heart failure are amenable to interventional device-based therapies, an observation that led to emergence of the field of interventional heart failure. Interventional heart failure targets include primary or secondary valve disease,…

Percutaneous Treatment of Paravalvular Leak

Key Points Paravalvular regurgitation (leak) affects 5% to 17% of all surgically implanted prosthetic heart valves. Echocardiography is pivotal in the evaluation of both mitral and aortic paravalvular leaks. Surgical repair is effective but has significantly higher complications rates compared with a percutaneous approach. Percutaneous paravalvular leak closure is feasible and safe with long-term outcomes comparable to a surgical approach. Resolution of symptoms and hemolysis as…

Stem Cell Therapy for Ischemic Heart Disease

Key Points Advances in reperfusion therapy have led to the development of a large population of patients with chronic heart failure. Modulation of cardiac tissue is the next great frontier to lessen symptoms of heart failure and improve patient outcomes. In general, the field has failed to demonstrate robust results in large scale studies. The time for small studies with multiple subgroups is past. Improvements in…

Transcatheter Therapies for Congenital Heart Disease

Key Points Catheter-based therapies are available for a wide variety of congenital structural cardiovascular defects. Balloon dilation provides relief of obstruction for patients with congenital pulmonary or aortic valve stenosis. This therapy may not be adequate if the valve is hypoplastic or calcified. Congenital pulmonary artery stenosis can be effectively relieved with balloon-expandable stents; late stent redilation may be necessary in a growing child. Coarctation of…

Percutaneous Balloon Pericardiotomy for Patients With Pericardial Effusion and Tamponade

Key Points Pericardiocentesis is a catheter-based procedure in which fluid is aspirated from the pericardium. It is indicated in patients with cardiac tamponade, for large pericardial effusions (usually >2 cm), for moderate effusions (10 to 20 mm) in symptomatic patients, or if the fluid is needed for diagnostic purposes; it is also used to drain purulent, tubercular, or neoplastic effusions in patients who are resistant to…

Hypertrophic Cardiomyopathy

Key Points Hypertrophic cardiomyopathy is a disease process that varies broadly in its clinical presentation and has been associated with many different genetic mutations. Obstructive disease is present in a subset of patients, where the severity of obstruction varies depending on loading conditions and adrenergic state in the individual patient. Imaging with echocardiography and magnetic resonance imaging are primarily used to make the diagnosis. Medical management…