Trans Catheter Treatment of Structural Heart Diseases

Tel Aviv Sourasky Medical Center

Lev Mendelevich MD

Echocardiography in Trans Catheter

Treatment of Aortic Stenosis

Aortic Valve Stenosis

Normal Aortic Valve Stenotic Aortic Valve

Types of Aortic Stenosis

Normal Aortic Valve

A normal aortic valve. Both parts were recorded during diastole. A: The long-axis view demonstrates the appearance of a typical normal aortic valve in the closed position. B: The same valve is demonstrated from the short-axis view. Note that, because of shadowing and lateral resolution, the coaptation line between left and noncoronary cusps is not visualized.

Normal Aortic Valve

A normal aortic valve during diastole in the closed position (A) and during systole in the open position (B). Ao, aorta; LA, left atrium; LV, left ventricle; RV, right ventricle.

Valvular Aortic Stenosis – 2 D-Echo

The cusps become thickened and restricted;

Their position is no longer parallel to the aortic walls;

The edges of the cusps point to toward the center of aorta;

No estimation of severity usually by 2 D-echo, but if one of the cusps moves normally – critical aortic stenosis is excluded;

Planimetry is possible on TEE and sometimes on TTE.

A patient with mild aortic stenosis. LA, left atrium; LV, left ventricle; RV, right ventricle.

A transesophageal echocardiogram demonstrates the method of direct planimetry of the aortic valve orifice. By carefully adjusting the level of the short-axis plane, the orifice can be visualized in most patients. In this example, severe stenosis was confirmed. AVA, aortic valve area;

Aortic Stenosis – Two-dimensional Echo

Aortic Stenosis Pressure Gradients

1. Peak instantaneous pressure gradient – ΔP (in mm Hg) = 4V²

V – maximal jet velocity (m/s).

2. Mean pressure gradient :

a. Planimetry of the Doppler envelope – VTI of AV velocity;

b. Another method by formula –

ΔPmean = ΔPmax/1.45 + 2 mm Hg

Continuous

wave Doppler

Pressure gradient = 4 x V² = 4 x 5.4² = 117mmHg

Calculation of Aortic Pressure Gradient

Schematic Diagram of Continuity Equation

Guidelines for Grading Severity of Aortic

Valve Stenosis

Aortic valve area >1.5cm² (>0.9cm²/m²) – mild 1.0 -1.5cm² (0.6 – 0.9 cm²/m²) - moderate <1.0 (<0.6 cm²/m²) - severe Peak pressure gradient < 25mmHg - mild 25-64mmHg - moderate > 64mmHg - severe Peak jet velocity on CW Doppler < 2.5m/sec – mild 2.5-4.0 m/sec – moderate > 4.0m/sec -severe

Echocardiographic Images of Aortic sclerosis (A, B) and Severe Aortic Stenosis (C, D)

Elevated Pressure Gradient - Differential Diagnosis

Sub aortic membrane

Elevated Pressure Gradient - Differential Diagnosis

Hypertrophic obstructive cardiomyopathy

Valvular Heart Disease Disease Burden

Nkomo, et al.

Lancet 2006

Prevalence of moderate-severe aortic/mitral valve disease, n=11,091

<45 45-54 55-64 65-74 >74

MR 7.1%

MS 0.2% S 0.2%

AR 1.7%

AS 4.6%

MR 7.1%

AS 4.6%

AR 1.7%

Operative Mortality for Aortic Valve Surgery

3 to 4 % for AVR

5.5 to 6.8 % for AVR + CABG

7 to 10 % in low volume centers

If > 65 yrs old – 8.8%;

13% in low volume centers

6% in high volume centers

Aortic Valve Replacement

Trans Catheter Aortic Valve Implantation

Echocardiography in Trans Catheter Treatment of Mitral Regurgitation

Mitral Valve

Valves Anatomy

Superior view of the heart showing heart valve anatomy

Normal Mitral Valve Anatomy and Opening

Mitral Valve Annulus

Mitral Valve Chordae

Mitral Valve Commissures

Mitral Valve Leaflets

Coaptation Zone

On the atrial surface of the leaflets

exist two zones, one peripheral

smooth or body zone and one

central rough or coaptation zone.

The gently curved coaptation line

between the two leaflets evident

from an atrial view , separates these

two areas.

The rough zone represents the

coaptation surface of the valve.

The coaptation zone is critical to

valve competency, and the depth

and length of coaptation is viewed

as an important assessment of

mitral valve function.

Papillary Muscles

Mitral Regurgiatation

•

Carpentier Classification

Carpentier’s functional classification

Type I, normal leaflet motion;

Type II, increased leaflet motion (leaflet prolapse);

Type IIIa restricted leaflet motion during diastole and systole;

Type IIIb restricted leaflet motion predominantly during systole

Degenerative Mitral Valve Disease

Degenerative mitral valve disease A, Barlow’s disease B, fibroelastic deficiency

Mitral regurgitation

Severe MR – Continuous Wave Doppler

Mild MR Severe MR

MR- Mitral Inflow Pulsed Doppler

Mild MR Severe MR

Pulmonary Vein Flow

Normal Severe MR

Mitral Regurgitation - Quantification

Proximal isovelocity surface area (PISA)

Vena contracta

Mitral Regurgitation - Quantification

Flow convergence (PISA) Vena contracta

Proximal Isovelocity Surface Area (PISA)

MR - Effective Regurgitant Orifice (ERO)

Mitral Regurgitation Severity

When to Consider Surgery

Vena Contracta

Mild MR Severe MR

Operative Mortality for Mitral Valve Surgery

4 to 5 % for MV replacement

2% for MV repair

• If > 80 yrs old +CABG +LV dysfunction or renal failure – 15%

Trans Catheter Mitral Valve Repair By MitraClip

MitraClipTM

קליף פתוח

קליף סגור

Echocardiography in Trans Catheter

Treatment of Mitral Stenosis

Severity of Mitral Stenosis

MVA (cm2) Mean (mm Hg)

Mild 1.6 - 2.0 < 5

Moderate 1.1 - 1.5 6-10

Severe 1.0 10

Mitral Stenosis - Feasibility of Valvuloplasty

Valve pliable:

-Commissural calcification

- Wilkins/Abascal Score <8

Valve mobility 1-4

Valve Thickening 1-4

Valve Calcification 1-4

Sub-valvular thickening 1-4

MR <2+

No thrombus in LAA

MS Score Index

Mobility

Leaflet thickening

Subvalvular thickening

Calcification

MS Score Index Mobility

Grade 1 Highly mobile valve with leaflet tips only restricted

Grade 2 Leaflet mid and base portions have normal mobility

Grade 3 Valve continues to move forward in diastole, mainly

from the base

Grade 4 No or minimal forward movement from the leaflets

in diastole

MS Score Index Leaflet Thickening

Grade 1 Leaflets near normal in thickness(4 to 5mm)

Grade 2 Mid-leaflets normal, marked thickening of

margins (5 to 8mm)

Grade 3 Thickening extending through the entire leaflet

(5 to 8mm)

Grade 4 Marked thickening of all leaflet tissue (>8mm)

MS Score Index Subvalvular thickening

Grade 1 Minimal thickening just below mitral leaflets

Grade 2 Thickening of chordal structures extending up to

one-third of the chordal length

Grade 3 Thickening extending to the distal third of chords

Grade 4 Extensive thickening and shorting of all chordal

structures extending down to the papillary muscles

MS Score Index Calcification

Grade 1 A single area of increased echo brightness

Grade 2 Scattered areas of brightness confined to leaflet

margins

Grade 3 Brightness extending into the mid-portion of the

leaflets

Grade 4 Extensive brightness throughout much of the

leaflet tissue

MS Score Index Determining Echo Score

Add the grades from the four

categories.

Patients who score < 8

are more favorable

candidates for balloon

valvuloplasty

Wilkins' Score and Increase in Valve Area

(NHLBI Register Circulation 1992; 85: 448-61)

Inoue Balloon Metallic

Commissurotome