1、经皮主动脉瓣植入经皮主动脉瓣植入TAVITAVIQUIZ Street Avenue2经皮主动脉瓣植入经皮主动脉瓣植入TAVIStreet3经皮主动脉瓣植入经皮主动脉瓣植入TAVIAvenue4经皮主动脉瓣植入经皮主动脉瓣植入TAVIHospital of UA5经皮主动脉瓣植入经皮主动脉瓣植入TAVIHospital of UA6经皮主动脉瓣植入经皮主动脉瓣植入TAVIHospital of UA7经皮主动脉瓣植入经皮主动脉瓣植入TAVIHospital of UA8经皮主动脉瓣植入经皮主动脉瓣植入TAVISummarize of TAVI Transcatheter aortic valv
2、e implantation(TAVI)It was introduced as an alternative treatment in patients with severe aortic valve stenosis(AS)Cribier A,Eltchaninoff H,Bash A,Circulation 2002;106:30063008.9经皮主动脉瓣植入经皮主动脉瓣植入TAVIFirst Case of TAVI In 2002,Cribier et al demonstrated for the first time the feasibility of a percutan
3、eous valve implantation in a patient with AS Providing a promising less invasive alternative treatment for valvular heart diseaseCribier A,Eltchaninoff H,Bash A,Circulation 2002;106:30063008.10经皮主动脉瓣植入经皮主动脉瓣植入TAVI two different TAVI devices are widely used the balloon-expandable Edwards SAPIEN Trans
4、catheter Heart Valve the self-expanding Medtronic CoreValve Both received CE Mark approval for European commercial sale in 2007 Edwards SAPIEN valve received FDA pre-market approval in the USA in November 2011Two different TAVI devices11经皮主动脉瓣植入经皮主动脉瓣植入TAVIEdwards balloonexpandable delivery systems1
5、2经皮主动脉瓣植入经皮主动脉瓣植入TAVICoreValve ReValving System(a)schemata and(b)following deployment with aortography13经皮主动脉瓣植入经皮主动脉瓣植入TAVIPatients Selection Feasible in most patients with severe aortic stenosis Generally utilized in patients not suitable for surgical AVR,who are likely to derive functional and su
6、rvival benefit Two risk scores are used to calculate the risk of cardiac surgery14经皮主动脉瓣植入经皮主动脉瓣植入TAVI“High-risk”surgical patients Having a Society of Thoracic Surgeons Predicted Risk of Mortality(STS-PROM)at 30 days of greater than 10%Logistic EuroSCORE of greater than 20%Limited Do not account for
7、 several pertinent clinical risk factors,such as previous CABG,porcelain aorta,previous chest radiotherapy,severe lung disease,and liver cirrhosisTwo risk scores15经皮主动脉瓣植入经皮主动脉瓣植入TAVITwo risk scores16经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessments of TAVI To assess the aortic annulus dimensions and geometry,access
8、site,and approach Transthoracic echocardiography Coronary angiography Aortic angiography MDCT17经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessment of arterial access The evaluation is fundamental in the assessment of the TAVI patient in minimizing potential major vascular complications Arterial dimensions The presence o
9、r absence of atheroma,Calcification Tortuosity18经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessment of arterial access Arterial access is assessed with the combination of invasive angiography and contrast-enhanced CT Iliofemoral assessment with(a)angiography and(b)MDCT19经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessment of aortic root Usin
10、g invasive angiography and contrast MDCT evaluate root and valvular calcification left main height from the left coronary cusp insertion(due to risk of coronary obstruction)technical issues related to each valve type and delivery systemEuropean Heart Journal(2014)35,2627263820经皮主动脉瓣植入经皮主动脉瓣植入TAVIAss
11、essment of aortic root(1)aortic annulus diameter,(2)sinus of Valsalva width(3)ascending aorta width,(4)sinus of Valsalva height21经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessment of aortic root22经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessments Left and right heart catheterizations are also performed assess the presence of pulmonary hy
12、pertension coronary ischemia and the need for revascularization prior to TAVI23经皮主动脉瓣植入经皮主动脉瓣植入TAVIRequirements of TAVI TAVI should be performed in regional centers of excellence with a dedicated heart valve program and high procedural volumes The procedure may be undertaken in a cardiac catheteriza
13、tion laboratory with modifications or in a hybrid operating room equipped with high-quality fluoroscopic imaging24经皮主动脉瓣植入经皮主动脉瓣植入TAVIRequirements of TAVI The facilities need to be large enough to accommodate sophisticated X-ray imaging integrated with echocardiography,cardiopulmonary bypass and int
14、ra-aortic balloon pump machines,and anesthesia equipment,with surgical sterility standards mandatory25经皮主动脉瓣植入经皮主动脉瓣植入TAVITechniques of TAVI TAVI is most often performed utilizing the transfemoral retrograde approach Alternative access approaches usually reserved for patients with concomitant severe
15、 peripheral arterial disease26经皮主动脉瓣植入经皮主动脉瓣植入TAVITransfemoral Approach The common femoral artery,at the level of the femoral head,is the primary access site for the transfemoral approach owing to its relatively large size and compressibility The side with the largest and least diseased,tortuous,or
16、calcified iliofemoral arteryas assessed by a screening angiogramand/or multidetector computed tomographic(CT)angiographyis selected for placement of the sheath27经皮主动脉瓣植入经皮主动脉瓣植入TAVITransfemoral Approach The TAVI procedure may be performed under local or general anesthesia Following balloon valvulopl
17、asty,the valve prosthesis is passed across the aortic valve and positioned under fluoroscopic and transesophageal echocardiographic(TEE)guidance29经皮主动脉瓣植入经皮主动脉瓣植入TAVITransfemoral Approach Balloon-expandable valves are deployed under rapid ventricular pacing at a rate of 160220 bpm to minimize cardia
18、c output and therefore minimize unintentional motion of the valve during balloon dilatation30经皮主动脉瓣植入经皮主动脉瓣植入TAVI31经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical Approach The transapical approach was first described in 2006 with balloon-expandable valves A sheath is placed surgically in the left ventricular apex,a
19、ccessed through a small left anterolateral minithoracotomy32经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical Approach Following balloon valvuloplasty,the valve prosthesis and balloon catheter are passed over a wire into the left ventricle and positioned within the aortic annulus under fluoroscopic and transesophagea
20、l echocardiographic guidance33经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical Approach This approach may be considered if the iliofemoral arterial system is of sufficiently small diameter,calcified,or tortuous and not technically suitable for delivery of the device Also taken into consideration is the angulation of
21、 the aorta and arch34经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical Approach In particular,a transverse or extremely unfolded ascending aorta may increase the diffi culty of delivery and positioning of the balloon-expandable devices It has been suggested that with advances in device technology and a reduction in d
22、elivery system profiles for the transarterial approach,alternative access approaches will be limited to less than 30%of TAVR procedures 35经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical Approach Contraindications to the transapical approach previous left ventricular surgery using a patch calcified pericardium sever
23、e respiratory disease36经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical Approach37经皮主动脉瓣植入经皮主动脉瓣植入TAVIOthers Axillary/Subclavian Approach Transaortic Approach38经皮主动脉瓣植入经皮主动脉瓣植入TAVIComplications of TAVI Procedural Complications Vascular Complications Stroke and Neurological Events Coronary Occlusion Valve Malposition
24、 and Embolization Renal Impairment Conduction Disturbance39经皮主动脉瓣植入经皮主动脉瓣植入TAVIComplications of TAVI Prosthesis-Related Complications ProsthesisPatient Mismatch Paravalvular and Valvular Regurgitation Prosthetic Valve Thrombosis and Endocarditis 40经皮主动脉瓣植入经皮主动脉瓣植入TAVIQuestion41经皮主动脉瓣植入经皮主动脉瓣植入TAVI42经皮主动脉瓣植入经皮主动脉瓣植入TAVI
