經(jīng)皮主動脈瓣植入TAVI培訓(xùn)課件

1、經(jīng)皮主動脈瓣植入TAVI經(jīng)皮主動脈瓣植入TAVIQUIZStreetAvenue2經(jīng)皮主動脈瓣植入TAVIQUIZStreet2經(jīng)皮主動脈瓣植入TAVIStreet3經(jīng)皮主動脈瓣植入TAVIStreet3經(jīng)皮主動脈瓣植入TAVIAvenue4經(jīng)皮主動脈瓣植入TAVIAvenue4經(jīng)皮主動脈瓣植入TAVIHospital of UA5經(jīng)皮主動脈瓣植入TAVIHospital of UA5經(jīng)皮主動脈瓣植入TAVIHospital of UA6經(jīng)皮主動脈瓣植入TAVIHospital of UA6經(jīng)皮主動脈瓣植入TAVIHospital of UA7經(jīng)皮主動脈瓣植入TAVIHospital of U

2、A7經(jīng)皮主動脈瓣植入TAVIHospital of UA8經(jīng)皮主動脈瓣植入TAVIHospital of UA8經(jīng)皮主動脈瓣植入TAVISummarize of TAVITranscatheter aortic valve 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經(jīng)皮主動脈瓣植入

3、TAVISummarize of TAVITranscatheterFirst Case of TAVIIn 2002, Cribier et al demonstrated for the first time the feasibility of a percutaneous valve implantation in a patient with ASProviding a promising less invasive alternative treatment for valvular heart diseaseCribier A, Eltchaninoff H, Bash A, C

4、irculation 2002;106:30063008.10經(jīng)皮主動脈瓣植入TAVIFirst Case of TAVIIn 2002, Critwo different TAVI devices are widely used the balloon-expandable Edwards SAPIEN Transcatheter Heart Valvethe self-expanding Medtronic CoreValveBoth received CE Mark approval for European commercial sale in 2007Edwards SAPIEN v

5、alve received FDA pre-market approval in the USA in November 2011Two different TAVI devices11經(jīng)皮主動脈瓣植入TAVItwo different TAVI devices areEdwards balloonexpandable delivery systems12經(jīng)皮主動脈瓣植入TAVIEdwards balloonexpandable deliCoreValve ReValving System ( a ) schemata and ( b ) following deployment with a

6、ortography13經(jīng)皮主動脈瓣植入TAVICoreValve ReValving System ( aPatients SelectionFeasible in most patients with severe aortic stenosisGenerally utilized in patients not suitable for surgical AVR, who are likely to derive functional and survival benefitTwo risk scores are used to calculate the risk of cardiac

7、 surgery14經(jīng)皮主動脈瓣植入TAVIPatients SelectionFeasible in “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 % LimitedDo not account for several pertinent clinical risk factors, such

8、 as previous CABG, porcelain aorta, previous chest radiotherapy, severe lung disease, and liver cirrhosisTwo risk scores15經(jīng)皮主動脈瓣植入TAVI“High-risk” surgical patients Two risk scores16經(jīng)皮主動脈瓣植入TAVITwo risk scores16經(jīng)皮主動脈瓣植入TAVIAssessments of TAVITo assess the aortic annulus dimensions and geometry, acces

9、s site, and approach Transthoracic echocardiographyCoronary angiographyAortic angiographyMDCT17經(jīng)皮主動脈瓣植入TAVIAssessments of TAVITo assess tAssessment of arterial accessThe evaluation is fundamental in the assessment of the TAVI patient in minimizing potential major vascular complicationsArterial dimen

10、sions The presence or absence of atheroma, CalcificationTortuosity18經(jīng)皮主動脈瓣植入TAVIAssessment of arterial accessTAssessment of arterial accessArterial access is assessed with the combination of invasive angiography and contrast-enhanced CT Iliofemoral assessment with ( a ) angiography and ( b ) MDCT19經(jīng)

11、皮主動脈瓣植入TAVIAssessment of arterial accessAAssessment of aortic rootUsing invasive angiography and contrast MDCT evaluate root and valvular calcificationleft main height from the left coronary cusp insertion (due to risk of coronary obstruction)technical issues related to each valve type and delivery

12、systemEuropean Heart Journal (2014) 35, 2627263820經(jīng)皮主動脈瓣植入TAVIAssessment of aortic rootUsingAssessment of aortic root( 1 ) aortic annulus diameter, ( 2 ) sinus of Valsalva width( 3 ) ascending aorta width, ( 4 ) sinus of Valsalva height21經(jīng)皮主動脈瓣植入TAVIAssessment of aortic root( 1 )Assessment of aortic

13、 root22經(jīng)皮主動脈瓣植入TAVIAssessment of aortic root22經(jīng)皮主AssessmentsLeft and right heart catheterizations are also performed assess the presence of pulmonary hypertension coronary ischemia and the need for revascularization prior to TAVI23經(jīng)皮主動脈瓣植入TAVIAssessmentsLeft and right hearRequirements of TAVITAVI sh

14、ould 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 catheterization laboratory with modifications or in a hybrid operating room equipped with high-quality fluoroscopic imaging24經(jīng)皮主動脈瓣植入TAVIR

15、equirements of TAVITAVI shoulRequirements of TAVIThe facilities need to be large enough to accommodate sophisticated X-ray imaging integrated with echocardiography, cardiopulmonary bypass and intra-aortic balloon pump machines, and anesthesia equipment, with surgical sterility standards mandatory25經(jīng)

16、皮主動脈瓣植入TAVIRequirements of TAVIThe faciliTechniques of TAVITAVI is most often performed utilizing the transfemoral retrograde approachAlternative access approaches usually reserved for patients with concomitant severe peripheral arterial disease26經(jīng)皮主動脈瓣植入TAVITechniques of TAVITAVI is mostTransfemora

17、l ApproachThe 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 compressibilityThe side with the largest and least diseased, tortuous, or calcified iliofemoral arteryas assessed by a screening angio

18、gramand/or multidetector computed tomographic (CT) angiographyis selected for placement of the sheath27經(jīng)皮主動脈瓣植入TAVITransfemoral ApproachThe commo經(jīng)皮主動脈瓣植入TAVI培訓(xùn)課件Transfemoral ApproachThe TAVI procedure may be performed under local or general anesthesiaFollowing balloon valvuloplasty, the valve prosth

19、esis is passed across the aortic valve and positioned under fluoroscopic and transesophageal echocardiographic (TEE) guidance29經(jīng)皮主動脈瓣植入TAVITransfemoral ApproachThe TAVI Transfemoral ApproachBalloon-expandable valves are deployed under rapid ventricular pacing at a rate of 160220 bpm to minimize card

20、iac output and therefore minimize unintentional motion of the valve during balloon dilatation30經(jīng)皮主動脈瓣植入TAVITransfemoral ApproachBalloon-e31經(jīng)皮主動脈瓣植入TAVI31經(jīng)皮主動脈瓣植入TAVITransapical ApproachThe transapical approach was first described in 2006 with balloon-expandable valves A sheath is placed surgically i

21、n the left ventricular apex, accessed through a small left anterolateral minithoracotomy32經(jīng)皮主動脈瓣植入TAVITransapical ApproachThe transaTransapical ApproachFollowing balloon valvuloplasty, the valve prosthesis and balloon catheter are passed over a wire into the left ventricle and positioned within the

22、aortic annulus under fluoroscopic and transesophageal echocardiographic guidance33經(jīng)皮主動脈瓣植入TAVITransapical ApproachFollowing Transapical ApproachThis approach may be considered if the iliofemoral arterial system is of sufficiently small diameter, calcified, or tortuous and not technically suitable fo

23、r delivery of the deviceAlso taken into consideration is the angulation of the aorta and arch34經(jīng)皮主動脈瓣植入TAVITransapical ApproachThis approTransapical ApproachIn particular, a transverse or extremely unfolded ascending aorta may increase the diffi culty of delivery and positioning of the balloon-expan

24、dable devicesIt has been suggested that with advances in device technology and a reduction in delivery system profiles for the transarterial approach, alternative access approaches will be limited to less than 30 % of TAVR procedures 35經(jīng)皮主動脈瓣植入TAVITransapical ApproachIn particuTransapical ApproachContraindications to the transapical approach previous left ven