Catheter Interventions for Structural Heart Disease

Contents

Preface: Catheter Intervention in Structural Heart Disease ix

Ray V.Matthews

Aortic Stenosis: Role of Balloon Aortic Valvuloplasty 327

Usman Baber, Annapoorna S. Kini, Pedro R.Moreno, and Samin K. Sharma

Calcific aortic stenosis (AS) is the most frequent expression of aortic valve disease intheWestern world, with an increasing prevalence as the population ages. Almost 4%of all adults 75 years of age or older have moderate or severe AS. Many patients donot undergo surgery because of prohibitive comorbidities or other high-risk features.Balloon aortic valvuloplasty (BAV) remains an option for temporary palliation andsymptomatic relief in such patients. In addition, BAV continues to serve an importantrole as a bridge to either surgical or transcatheter aortic valve replacement in certainpatients with AS requiring temporary hemodynamic stabilization.

Transcatheter Aortic Valve Replacement Using the Edwards SAPIEN TranscatheterHeart Valves 337

Pei-Hsiu HuangandAndrewC. Eisenhauer

Transcatheter aortic valve replacement has a place in the therapy for valvular aorticstenosis in a selected population of patients with increased risk for standard aorticvalve replacement. The SAPIEN family of balloon-expandable transcatheter heartvalves is the prototype that initiated this therapy and has undergone rapid develop-ment and evolution. The SAPIEN system has taught cardiologists and cardiac sur-geons much about the nature of aortic stenosis and the potential for less invasivetherapy. This article will review the SAPIEN transcatheter heart valves and the clin-ical experience.

Transcatheter Aortic Valve Replacement with CoreValve 351

Ray V.Matthews andDavidM. Shavelle

The treatment of aortic stenosis in high-risk surgical patients is now possible bytranscatheter aortic valve replacement. The CoreValve is a new transcatheter valvewith a unique design expanding its application in patients with aortic stenosis. TheCoreValve is just completing clinical trial in the United States and not yet availablefor commercial use in the United States but is widely used in Europe.

Transcatheter Left Atrial Appendage Occlusion 363

CreightonW. Don, Cindy J. Fuller, andMark Reisman

Occlusion of the left atrial appendage (LAA) may reduce the risk of stroke in patientswith atrial fibrillation (AF). Trials comparing LAA occlusion to warfarin anticoagulationin patients with nonvalvular AF showed a reduction in hemorrhagic stroke, althoughan increase in safety events due to procedural complications. Long-term follow-upsuggests possible superiority of LAA occlusion due to fewer strokes and bleedingevents. The superior dosing and safety profiles of the novel oral anticoagulants raisethe accepted threshold for safety and efficacy of LAA occlusion procedures, and un-derscore the need for randomized studies comparing LAA occlusion with thesenewer anticoagulants.

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Atrial Septal Defect Closure 385

Andres F. Vasquez and JohnM. Lasala

Congenital heart disease accounted for 0.3% of US hospital admissions in 2007,with 48% related to atrial septal defects (ASDs). More than one-fourth of adultcongenital heart defects are ASDs, 75% of which are ostium secundum ASDs.The progressive impact of volume overload of the right cardiac chambers can behalted by ASD closure. This review focuses on percutaneous ASD closure.

Patent Foramen Ovale 401

Philip B. Dattilo,Michael S. Kim, and John D. Carroll

Patent foramen ovale (PFO) is a common developmental anomaly that allows for thepassage of blood and other substances from the venous to the arterial circulation.The study of PFO closure has been challenging due to widely available off-label clo-sures performed outside the clinical trial setting. To date, no study has demonstratedbenefit of closure using intention-to-treat analyses. Secondary and subpopulationanalyses suggest that there is benefit to closure in patients with atrial septal aneu-rysms and/or substantial degrees of right-to-left shunting. This article reviews the his-tory, associated technologies, and current data regarding PFO closure.

Patent Ductus Arteriosus 417

Mehra Anilkumar

Patent ductus arteriosus in adults is usually an isolated lesion with a small to mod-erate degree of shunt, as a larger shunt becomes symptomatic earlier in childhood.The classic murmur of patent ductus arteriosus may be the first clue to its presence,or it may be detected accidently by transthoracic echocardiography, computedtomography, or magnetic resonance angiography for an unrelated condition. Thepercutaneous approach is safe and effective in more than 98% of patients. Sub-acute bacterial endocarditis prophylaxis is not indicated routinely except for6 months following the closure percutaneously or surgically.

Percutaneous Paravalvular Leak Closure 431

Robert Kumar, Vladimir Jelnin, ChadKliger, and Carlos E. Ruiz

Percutaneous paravalvular leak closure is increasingly being performed as an alter-native to reoperation in patients with symptomatic prosthetic paravalvular regurgita-tion. This article reviews the pathogenesis of paravalvular leaks and percutaneoustechniques for closure. Newer multimodality imaging techniques, including 3-dimen-sional (3D) transesophageal echocardiography and 3D/4D computed tomographicangiography, allow improved preprocedural planning and intraprocedural guidance.Specific techniques can be used for challenging patient anatomy and larger para-valvular leaks. Outcomes from experienced centers show acceptable rates of tech-nical and clinical success, with lower procedural morbidity than reoperation.

A Practical Guide to the Use of Echocardiography in Assisting Structural HeartDisease Interventions 441

Ming-Sum Lee and Tasneem Z. Naqvi

Echocardiography plays an integral role in the evaluation and treatment of patientsundergoing percutaneous interventions for structural heart disease. Preprocedure,

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accurate echocardiographic assessment of cardiac anatomy is crucial in determin-ing patient eligibility. During catheterization, echocardiography is used for proce-dural guidance. Postprocedure, echocardiography is used for patient follow-upand determining the effect of device placement on cardiac remodeling. This articleprovides a practical guide for using echocardiography in common interventionalprocedures, including percutaneous atrial septal defect closure, transcatheter aorticvalve replacement, percutaneous repair of prosthetic valve paravalvular leaks, per-cutaneous mitral valve edge-to-edge repair, and percutaneous placement ofappendage occlusion devices.

Anesthesia for Structural Heart Interventions 455

StevenHaddy

Surgeries in general and cardiac procedures in particular are increasingly performedusing catheter-based or minimally invasive techniques, often with sedation or gen-eral anesthesia. These new approaches require close cooperation and communica-tion between the cardiologist and anesthesiologist to ensure patient safety.Anesthesia-related respiratory complications arising in the catheterization labora-tory are more frequent and more severe than are seen in the operating room. Theprincipals of safe anesthetic practice as they apply to procedures performed outsidethe operating room and suggestions to improve safety and outcome are reviewed inthis article.

Role of Cross-Sectional Imaging for Structural Heart Disease Interventions 467

Joao L. Cavalcante and Paul SchoenhagenVideo of three-dimensional multi-planar reconstruction/reformatting of the aorticvalve with cine loop assessing leaflet motion and aortic valve opening; and a videoof dynamic intraprocedural CT angiography with fluoroscopy fusion/overlayallowing best angle assessment for prosthesis deployment accompany this article

With the aging population, significant valvular heart disease is increasingly identifiedin patients too frail to undergo surgery. Transcatheter therapies for structural heartdisease represent an alternative therapeutic approach for these patients. Duringthese procedures, direct visualization of the surgical field is replaced by image guid-ance for intraprocedural decision making. Advances in percutaneous devices anddelivery systems, coupled with enhancements in 3-dimensional imaging with multi-planar reformatting, have allowed these procedures to be performed safely and withexcellent results. This article describes the role of cross-sectional imaging fordetailed assessment and preprocedural planning of aortic, mitral, and pulmonicvalve interventions.

Index 479