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Valvular heart disease
Published in Ian Mann, Christopher Critoph, Caroline Coats, Peter Collins, The Junior Doctor’s Guide to Cardiology, 2017
Ian Mann, Christopher Critoph, Caroline Coats, Peter Collins
Percutaneous aortic valve replacement is increasing in popularity, and outcomes in tertiary centres are comparable with those achieved by surgery. Current indications are those where surgery is high risk (EuroSCORE > 20%), contraindicated or technically challenging (e.g. thoracic deformity, previous CABG, porcelain aorta).
Assessment of severity and treatment strategy
Published in Neeraj Parakh, Ravi S. Math, Vivek Chaturvedi, Mitral Stenosis, 2018
Combined mitral and aortic stenosis (AS) is relatively uncommon. MS protects the LV from increased wall stress imposed by AS. The low cardiac output in severe MS leads to a state of low-flow, low-gradient AS potentially leading to underestimation of the severity of AS. The history and symptoms in combined significant MS and AS are those of mitral stenosis.72 Combined MS and AS is more common in females. Symptoms occur earlier and palpitations, dyspnea, and peripheral embolism are common. Angina and syncope are infrequent. The clinical signs of MS and AS may easily be discerned or one lesion may mask the other (often findings of AS mask MS).72,73 Findings of MS such as loud S1, OS, and mid-diastolic murmur may be diminished or absent, being dominated by the harsh AS murmur. Likewise, the findings of AS such as late peaking pulse, heaving apex, systolic thrill, and systolic murmur may not be evident. At times, the murmur of AS may become evident only after control of heart failure. The recognition of severe AS in patients of severe MS is important while selecting patients for valvotomy. Sudden relief of MS may place a hemodynamic burden on the unprepared and previously protected LV, leading to heart failure. Urrichio et al. reported three patients who, following successful CMV, developed progressive heart failure and had a fatal outcome over 2 years from unrecognized or uncorrected AS.74 Calculation of aortic valve area either by TTE (continuity equation) or cardiac catheterization is essential to assess the severity of AS in combined severe AS and MS. In combined severe AS and MS, it is essential that both the valves are addressed. Double valve replacement (DVR) appears to be one straightforward solution. While such a scenario is common, it needs to be emphasized that the operative mortality for DVR is substantial (mortality double for DVR). Further, the long-term morbidity and mortality associated with DVR is significantly worse as compared to single valve replacement. Thus, if feasible, mitral valve repair (OMV/PTMC) associated with aortic valve replacement (AVR) appears to be an alternative to DVR. Percutaneous techniques have been used to address combined MS and AS. Simultaneous aortic and mitral balloon valvuloplasty has been performed if the anatomy of both valves is suitable.75 Antegrade, retrograde, and combined antegrade-retrograde techniques have been described with good success rates. It needs to be stressed that the aortic valve in RHD is often calcified and regurgitant, making it unsuitable for balloon valvotomy. In such a case, percutaneous aortic valve replacement has been performed along with PTMC, if the surgical risk is prohibitive. Percutaneous replacement of both the aortic and mitral valves has also been reported when both the valves are severely calcified. When the AS is less than severe, PTMC alone is sufficient. The AS can be followed up until it becomes severe.
Transcatheter aortic valve replacement and cardiac conduction
Published in Expert Review of Cardiovascular Therapy, 2019
Satya Shreenivas, Edward Schloss, Joseph Choo, Ian Sarembock, Scott Lilly, Dean Kereiakes
Conduction abnormalities continue to be the Achilles heel of percutaneous aortic valve replacement. While the patient population is intrinsically high risk to develop conduction abnormalities, specific valve types and procedural techniques predispose to a higher risk for conduction abnormalities post-TAVR. Over the next 5 years, progress will be made on understanding anatomical risk factors for conduction abnormalities, modeling valves and choosing a specific valve type based on individual risk, and finally, developing more durable temporary pacemakers that can facilitate safer, early discharge through ambulatory monitoring and treatment as necessary at home. By understanding the disease process better, tailoring our techniques to account for individual risk, and by developing better temporary pacemaker devices, the care of TAVR patients will improve.
Systematic Transfemoral Transarterial Transcatheter Aortic Valve Replacement in Hostile Vascular Access
Published in Structural Heart, 2019
Cezar S. Staniloae, Hasan Jilaihawi, Nicholas S. Amoroso, Homam Ibrahim, Kazuhiro Hisamoto, Danielle N. Sin, Hanah Lee, Run Du, Zhen-Gang Zhao, Peter J. Neuburger, Mathew R. Williams
Adequate vascular access is critical for successful percutaneous aortic valve replacement. Alternative access pathways were introduced to allow aortic valve replacement in subjects with prohibitive vascular access. In the PARTNER 1 trial, including the continuous access registry, half of TAVR subjects underwent transapical intervention due to “inadequate” vascular access.7 Subsequently, the direct transaortic approach was developed. It is essential to note that larger delivery sheaths were required in PARTNER 1 trial. Due to the significant invasiveness of these two procedures as well as inferior outcomes when compared with the TF approach, “alternatives” were quickly introduced7,8 and trans-subclavian, trans-carotid, and trans-caval procedures have been described.9–11
Therapeutic options for functional mitral regurgitation in chronic heart failure
Published in Expert Review of Medical Devices, 2018
Judith E. Lowry, Stephan Fichtlscherer, Klaus K. Witte
A fully percutaneous mitral valve replacement might provide a possible solution for patients with severe MR especially in the setting of mixed etiologies in people with prohibitive comorbidities. The major challenge over percutaneous aortic valve replacement is the great anatomical complexity and variability of the mitral valve including the subvalvular apparatus, and also the mobility of the mitral valve structure during the cardiac cycle. Due to difficulties of achieving access and positioning of a large valve, most systems to date have been transapical, but in the longer term, the greater morbidity associated with this route over a transfemoral approach is likely to be a limiting factor. A large number of TMVR systems are in clinical and preclinical trials [60], but with an average 30-day mortality of 23% (with half of these occurring periprocedurally) it is clear that a trial comparing sham with a TMVR approach is still far in the future.