经皮主动脉瓣植入TAVI培训ppt课件

经经皮主皮主动动脉瓣植入脉瓣植入TAVITAVI经经皮主皮主动动脉瓣植入脉瓣植入TAVI1QUIZStreetAvenue2经皮主动脉瓣植入经皮主动脉瓣植入TAVIQUIZStreet2经经皮主皮主动动脉瓣植入脉瓣植入TAVI2Street3经皮主动脉瓣植入经皮主动脉瓣植入TAVIStreet3经经皮主皮主动动脉瓣植入脉瓣植入TAVI3Avenue4经皮主动脉瓣植入经皮主动脉瓣植入TAVIAvenue4经经皮主皮主动动脉瓣植入脉瓣植入TAVI4Hospital of UA5经皮主动脉瓣植入经皮主动脉瓣植入TAVIHospital of UA5经经皮主皮主动动脉瓣植入脉瓣植入TAVI5Hospital of UA6经皮主动脉瓣植入经皮主动脉瓣植入TAVIHospital of UA6经经皮主皮主动动脉瓣植入脉瓣植入TAVI6Hospital of UA7经皮主动脉瓣植入经皮主动脉瓣植入TAVIHospital of UA7经经皮主皮主动动脉瓣植入脉瓣植入TAVI7Hospital of UA8经皮主动脉瓣植入经皮主动脉瓣植入TAVIHospital of UA8经经皮主皮主动动脉瓣植入脉瓣植入TAVI8Summarize of TAVITranscatheteraorticvalveimplantation(TAVI)Itwasintroducedasanalternativetreatmentinpatientswithsevereaorticvalvestenosis(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TAVISummarize of TAVITranscatheter9First Case of TAVIIn2002,CribieretaldemonstratedforthefirsttimethefeasibilityofapercutaneousvalveimplantationinapatientwithASProvidingapromisinglessinvasivealternativetreatmentforvalvularheartdiseaseCribier 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TAVIFirst Case of TAVIIn 2002,Cri10twodifferentTAVIdevicesarewidelyusedtheballoon-expandableEdwardsSAPIENTranscatheterHeartValvetheself-expandingMedtronicCoreValveBothreceivedCEMarkapprovalforEuropeancommercialsalein2007EdwardsSAPIENvalvereceivedFDApre-marketapprovalintheUSAinNovember2011Two different TAVI devices11经皮主动脉瓣植入经皮主动脉瓣植入TAVItwo different TAVI devices are11Edwards balloonexpandable delivery systems12经皮主动脉瓣植入经皮主动脉瓣植入TAVIEdwards balloonexpandable deli12CoreValve 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TAVICoreValve ReValving System(a13Patients SelectionFeasibleinmostpatientswithsevereaorticstenosisGenerallyutilizedinpatientsnotsuitableforsurgicalAVR,whoarelikelytoderivefunctionalandsurvivalbenefitTworiskscoresareusedtocalculatetheriskofcardiacsurgery14经皮主动脉瓣植入经皮主动脉瓣植入TAVIPatients SelectionFeasible in 14“High-risk”surgicalpatientsHavingaSocietyofThoracicSurgeonsPredictedRiskofMortality(STS-PROM)at30daysofgreaterthan10%LogisticEuroSCOREofgreaterthan20%LimitedDonotaccountforseveralpertinentclinicalriskfactors,suchaspreviousCABG,porcelainaorta,previouschestradiotherapy,severelungdisease,andlivercirrhosisTwo risk scores15经皮主动脉瓣植入经皮主动脉瓣植入TAVI“High-risk”surgical patients 15Tworiskscores16经皮主动脉瓣植入经皮主动脉瓣植入TAVITwo risk scores16经经皮主皮主动动脉瓣植入脉瓣植入TAVI16Assessments of TAVIToassesstheaorticannulusdimensionsandgeometry,accesssite,andapproachTransthoracicechocardiographyCoronaryangiographyAorticangiographyMDCT17经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessments of TAVITo assess t17Assessment of arterial accessTheevaluationisfundamentalintheassessmentoftheTAVIpatientinminimizingpotentialmajorvascularcomplicationsArterialdimensionsThepresenceorabsenceofatheroma,CalcificationTortuosity18经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessment of arterial accessT18Assessment of arterial accessArterialaccessisassessedwiththecombinationofinvasiveangiographyandcontrast-enhancedCTIliofemoralassessmentwith(a)angiographyand(b)MDCT19经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessment of arterial accessA19Assessment of aortic rootUsinginvasiveangiographyandcontrastMDCTevaluaterootandvalvularcalcificationleftmainheightfromtheleftcoronarycuspinsertion(duetoriskofcoronaryobstruction)technicalissuesrelatedtoeachvalvetypeanddeliverysystemEuropean Heart Journal(2014)35,2627263820经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessment of aortic rootUsing20Assessmentofaorticroot(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 root(1)21Assessment of aortic root22经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessment of aortic root22经经皮主皮主22AssessmentsLeftandrightheartcatheterizationsarealsoperformedassessthepresenceofpulmonaryhypertensioncoronaryischemiaandtheneedforrevascularizationpriortoTAVI23经皮主动脉瓣植入经皮主动脉瓣植入TAVIAssessmentsLeft and right hear23Requirements of TAVITAVIshouldbeperformedinregionalcentersofexcellencewithadedicatedheartvalveprogramandhighproceduralvolumesTheproceduremaybeundertakeninacardiaccatheterizationlaboratorywithmodificationsorinahybridoperatingroomequippedwithhigh-qualityfluoroscopicimaging24经皮主动脉瓣植入经皮主动脉瓣植入TAVIRequirements of TAVITAVI shoul24Requirements of TAVIThefacilitiesneedtobelargeenoughtoaccommodatesophisticatedX-rayimagingintegratedwithechocardiography,cardiopulmonarybypassandintra-aorticballoonpumpmachines,andanesthesiaequipment,withsurgicalsterilitystandardsmandatory25经皮主动脉瓣植入经皮主动脉瓣植入TAVIRequirements of TAVIThe facili25Techniques of TAVITAVIismostoftenperformedutilizingthetransfemoralretrogradeapproachAlternativeaccessapproachesusuallyreservedforpatientswithconcomitantsevereperipheralarterialdisease26经皮主动脉瓣植入经皮主动脉瓣植入TAVITechniques of TAVITAVI is most26Transfemoral ApproachThecommonfemoralartery,atthelevelofthefemoralhead,istheprimaryaccesssiteforthetransfemoralapproachowingtoitsrelativelylargesizeandcompressibilityThesidewiththelargestandleastdiseased,tortuous,orcalcifiediliofemoralarteryasassessedbyascreeningangiogramand/ormultidetectorcomputedtomographic(CT)angiographyisselectedforplacementofthesheath27经皮主动脉瓣植入经皮主动脉瓣植入TAVITransfemoral ApproachThe commo27经经皮主皮主动动脉瓣植入脉瓣植入TAVI培培训训ppt课课件件28Transfemoral ApproachTheTAVIproceduremaybeperformedunderlocalorgeneralanesthesiaFollowingballoonvalvuloplasty,thevalveprosthesisispassedacrosstheaorticvalveandpositionedunderfluoroscopicandtransesophagealechocardiographic(TEE)guidance29经皮主动脉瓣植入经皮主动脉瓣植入TAVITransfemoral ApproachThe TAVI 29Transfemoral ApproachBalloon-expandablevalvesaredeployedunderrapidventricularpacingatarateof160220bpmtominimizecardiacoutputandthereforeminimizeunintentionalmotionofthevalveduringballoondilatation30经皮主动脉瓣植入经皮主动脉瓣植入TAVITransfemoral ApproachBalloon-e3031经皮主动脉瓣植入经皮主动脉瓣植入TAVI31经经皮主皮主动动脉瓣植入脉瓣植入TAVI31Transapical ApproachThetransapicalapproachwasfirstdescribedin2006withballoon-expandablevalvesAsheathisplacedsurgicallyintheleftventricularapex,accessedthroughasmallleftanterolateralminithoracotomy32经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical ApproachThe transa32Transapical ApproachFollowingballoonvalvuloplasty,thevalveprosthesisandballooncatheterarepassedoverawireintotheleftventricleandpositionedwithintheaorticannulusunderfluoroscopicandtransesophagealechocardiographicguidance33经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical ApproachFollowing 33Transapical ApproachThisapproachmaybeconsiderediftheiliofemoralarterialsystemisofsufficientlysmalldiameter,calcified,ortortuousandnottechnicallysuitablefordeliveryofthedeviceAlsotakenintoconsiderationistheangulationoftheaortaandarch34经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical ApproachThis appro34Transapical ApproachInparticular,atransverseorextremelyunfoldedascendingaortamayincreasethedifficultyofdeliveryandpositioningoftheballoon-expandabledevicesIthasbeensuggestedthatwithadvancesindevicetechnologyandareductionindeliverysystemprofilesforthetransarterialapproach,alternativeaccessapproacheswillbelimitedtolessthan30%ofTAVRprocedures35经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical ApproachIn particu35Transapical ApproachContraindicationstothetransapicalapproachpreviousleftventricularsurgeryusingapatchcalcifiedpericardiumsevererespiratorydisease36经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical ApproachContraindi36Transapical Approach37经皮主动脉瓣植入经皮主动脉瓣植入TAVITransapical Approach37经经皮主皮主动动脉瓣植入脉瓣植入37OthersAxillary/SubclavianApproachTransaorticApproach38经皮主动脉瓣植入经皮主动脉瓣植入TAVIOthersAxillary/Subclavian Appr38Complications of TAVIProceduralComplicationsVascularComplicationsStrokeandNeurologicalEventsCoronaryOcclusionValveMalpositionandEmbolizationRenalImpairmentConductionDisturbance39经皮主动脉瓣植入经皮主动脉瓣植入TAVIComplications of TAVIProcedura39Complications of TAVIProsthesis-RelatedComplicationsProsthesisPatientMismatchParavalvularandValvularRegurgitationProstheticValveThrombosisandEndocarditis40经皮主动脉瓣植入经皮主动脉瓣植入TAVIComplications of TAVIProsthesi40Question41经皮主动脉瓣植入经皮主动脉瓣植入TAVIQuestion41经经皮主皮主动动脉瓣植入脉瓣植入TAVI41THANKS 42经皮主动脉瓣植入经皮主动脉瓣植入TAVITHANKS 42经经皮主皮主动动脉瓣植入脉瓣植入TAVI42