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Handbook of Structural
Heart Interventions
Handbook of Structural Heart Interventions
EDITORS
CHARANJIT S. RIHAL, MD, FACC
CLAIRE E. RAPHAEL, MBBS, PhD, MA
Assistant Professor Department of Cardiovascular Medicine Mayo Clinic Rochester Minnesota
Elsevier Philadelphia, PA
Elsevier
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1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899
HANDBOOK OF STRUCTURAL HEART INTERVENTIONS ISBN: 9780323672788
Copyright © 2021 by Elsevier Inc. All rights reserved.
No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/
permissions.
This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verication of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
Library of Congress Control Number: 2020942732
Content Strategist:
Robin Carter
Content Development Specialist: Content Development Manager: Publishing Services Manager: Project Manager: Design Direction:
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
Srividhya Vidhyashankar
Renee Duenow
Deepthi Unni
Angie Breckon
Meghan Andress
I dedicate this handbook, first and foremost, to my family
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who have tolerated and supported my passion for
innovation and cardiology, to my wonderful colleagues
(including many trainees over the years) without whom
these procedures would not have been possible, and most
of all to our patients who trust us with their health and
lives. It is a privilege to look after you.
—Charanjit Rihal, MD, FACC
To my parents, Sue and Nabil, for their endless support
and for teaching me the importance of hard work and
perseverance.
—Claire E. Raphael, MBBS, PhD, MA
L I S T O F C O N T R I B U T O R S
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Mohammed Al-Hijji, MD
Assistant Professor of Medicine Interventional and Structural Cardiologist Cardiovascular Diseases The Heart Hospital-Hamad Medical
Cooperation
Doha, Qatar
Mohamad Alkhouli, MD
Professor of Medicine Department of Cardiovascular Disease Mayo Clinic College of Medicine Rochester, Minnesota
Oluseun Alli, MD, MHA, FACC
Interventional Cardiologist Department of Cardiology Novant Heart and Vascular Institute Charlotte, North Carolina
Israel Barbash, MD
Associate Professor of Cardiology Director Cath Lab Services Tel Aviv University Sheba Medical Center Israel
Allison K. Cabalka, MD
Professor of Pediatrics Mayo Clinic College of Medicine Rochester, Minnesota
Alexander C. Egbe, MD, MPH, FACC
Cardiologist Department of Cardiovascular Medicine Mayo Clinic Rochester, Minnesota
Mackram F. Eleid, MD
Department of Cardiovascular Medicine Mayo Clinic School of Medicine Rochester, Minnesota
Kashish Goel, MD
Assistant Professor of Medicine Cardiovascular Diseases Vanderbilt University Nashville, Tennessee
Donald J. Hagler, MD, FSACI, FACC, FACP
Professor of Pediatrics and Medicine Department of Cardiovascular Diseases Division of Pediatric Cardiology Mayo Clinic College of Medicine Rochester, Minnesota
Abdallah El Sabbagh, MD
Assistant Professor Department of Cardiovascular Diseases Mayo Clinic Jacksonville, Florida
Kevin L. Greason, MD
Department of Cardiovascular Surgery Mayo Clinic Rochester, Minnesota
Mayra Guerrero, MD
Department of Cardiovascular Medicine Mayo Clinic Rochester, Minnesota
Rajiv Gulati, MD, PhD
Professor of Medicine Department of Cardiology Mayo Clinic Rochester, Minnesota
David R. Holmes Jr., MD
Professor of Medicine Department of Cardiovascular Medicine Mayo Clinic College of Medicine Rochester, Minnesota
Timothy Andrew Joseph, MD
Department of Cardiovascular Disease Mayo Clinic School of Medicine Rochester, Minnesota
Joseph F. Maalouf, MD, FACC, FAHA, FASE
Professor of Medicine Director Interventional Echocardiography Consultant Department of Cardiovascular Medicine Mayo Clinic Rochester, Minnesota
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LIST OF CONTRIBUTORS vii
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Elad Maor, MD, PhD
Associate Professor of Cardiology Tel Aviv University Sheba Medical Center Israel
Rick Nishimura, MD
Professor of Medicine Department of Cardiology Mayo Clinic Rochester, Minnesota
Sidakpal Panaich, MD
Assistant Professor Interventional Cardiology University of Iowa Iowa City, Iowa
Peter Pollak, MD
Consultant Department of Cardiovascular Diseases Mayo Clinic Jacksonville, Florida
Claire E. Raphael, MBBS, PhD, MA
Assistant Professor Department of Cardiovascular Medicine Mayo Clinic Rochester Minnesota
Gautam Reddy, MD
Division of Cardiovascular Diseases Huntsville Hospital Heart Center Huntsville, Alabama
Yogesh N.V. Reddy, MBBS, MSc
Senior Associate Consultant Department of Cardiovascular Diseases Mayo Clinic Rochester, Minnesota
Guy S. Reeder, MD
Professor Department of Cardiovascular Medicine Mayo Clinic Rochester, Minnesota
Charanjit Rihal, MD, FACC
Chair Professor of Medicine Department of Medicine Division of Cardiovascular Diseases Mayo Clinic Rochester, Minnesota
Gurpreet S. Sandhu, MD, PhD
Chair Department of Cardiovascular Medicine Division of Interventional Cardiology Mayo Clinic Rochester, Minnesota
Yader Sandoval, MD
Division of Cardiovascular Diseases Mayo Clinic Rochester, Minnesota
Saurabh Sanon, MD
Division of Cardiology Florida Atlantic University and Tenet Health Boca Raton, Florida
Mohammad Sarraf, MD
Director of Structural Heat Program Division of Cardiovascular Diseases University of Alabama at Birmingham Birmingham, Alabama
Monisha Sudarshan, MD, MPH
Thoracic Surgeon Department of Thoracic and Cardiovascular
Surgery Cleveland Clinic Cleveland, Ohio
Nathaniel Taggart, MD
Associate Professor Pediatric Cardiology Mayo Clinic Rochester, Minnesota
Jeremy J. Thaden, MD
Assistant Professor of Medicine Co-Chair for Clinical Practice and Quality Division of Cardiac Ultrasound Consultant Department of Cardiovascular Medicine Mayo Clinic Rochester, Minnesota
Thomas M. Waterbury, MD
Department of Cardiovascular Diseases Mayo Clinic Rochester, Minnesota
Robert Jay Widmer, MD, PhD
Department of Cardiovascular Medicine Mayo Clinic College of Medicine Rochester, Minnesota
P R E F A C E
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The history of cardiac catheterization is a rich and colorful tale with numerous innovators, pioneers, and Nobel laureates making contributions. Werner Forssmann in 1929 took an x-ray image of a urinary catheter inserted from his own brachial vein into his right atrium, an innova­tion that led to both a Nobel Prize and the end of his cardiology career. Andre Cournand and Dickinson Richards Jr. from the Columbia Service at Bellevue Hospital built on Forssmann’s discovery and shared in the Nobel Prize, establishing the use of cardiac catheterization to measure pressure and saturation and the use of contrast media to image the cardiac chambers. Mason Sones at Cleveland Clinic inadvertently performed the first selective coronary angiogram in 1958 on a young man with severe rheumatic heart disease, recognized its potential, and eventually lead to the era of coronary revascularization. At the Mayo Clinic, Earl H. Wood used the physiologic techniques he developed to study why pilots lose consciousness at high G-forces and adapted them for invasive evaluation of congenital heart lesions and other cardiac shunts. His techniques were integral to successful cardiopulmonary bypass, allowing open heart surgery.
Mitral balloon valvuloplasty, developed by Kanji Inoue, a Japanese surgeon, circa 1982, and balloon aortic valvuloplasty, first performed by Alain Cribier in 1986, were early structural pro­cedures that showed the promise of treating large macrostructures with novel therapies. Sigwart, working on a percutaneous treatment for left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, demonstrated that the degree of obstruction could be effectively reduced by inflation of a balloon in a septal perforator in 1982. It took over 10 years and a move to the United Kingdom for him to gain ethical approval for a larger series of patients to produce small, highly targeted myocardial infarctions in the basal septum through the injection of alcohol.
Although coronary balloon angioplasty and stents were the dominant procedures in cardiac catheterization laboratories for over 20 years, the 2000s saw massive innovation and investment in structural interventional procedures and devices, spurred on by the development of transcuta­neous heart valves. Henning Andersen was training as an interventional cardiologist when he developed the first transcatheter delivery device, crimping a porcine valve into a stent frame in 1990, which became the foundation for the first Sapien valve. Percutaneous Valve Technologies, the company founded by Alain Cribier, acquired the patent, and the first-in-human transcatheter aortic valve replacement (TAVR) was performed by Dr. Cribier a few years later in 2002. The approval of percutaneous mitral edge-to-edge clipping technology gave rise to a new era in treat­ing mitral valve disease. Since then the pace of discovery, invention, and development of promis­ing new technologies and techniques to meet unmet patient needs has only accelerated.
In this handbook, we describe the common and less common structural procedures. Although structural procedures share many commonalities with coronary interventional procedures, they are also fundamentally different in approach, training, and execution. Structural interventions require unique technical and cognitive skills of the interventional cardiologist (and, increasingly, surgeons) interested in minimally invasive cardiac procedures. We describe how structural proce­dures may be visualized as component “building blocks,” which can be utilized to develop new procedures and therapies. The future is bright.
viii
C O N T E N T S
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SE C T ION 1. Building Blocks of Structural Intervention1
1. Building Blocks of Structural Intervention: An Approach for Procedural 
Training  2
Claire E. Raphael Chanranjit Rihal
2. Access and Pitfalls  12
Yader Sandoval Rajiv Gulati
3. Imaging for SHD Interventions  22
Jeremy J. Thaden Joseph F. Maalouf
4. Hemodynamics for the Structural Interventionalist  43
Yogesh N.V. Reddy Rick A. Nishimura
5. Techniques of Transseptal Puncture  57
Mohamad Alkhouli David R. Holmes Jr.
SE C T ION 2. Aortic Valve Interventions 71
6. Balloon Aortic Valvuloplasty  72
Claire E. Raphael David R. Holmes Jr.
7. Transcatheter Aortic Valve Implantation: Work up and Indications for 
Intervention  81
Claire E. Raphael Abdallah El Sabbagh Charanjit Rihal
8.  Balloon Expandable Transcatheter Aortic Valve Replacement  88
Oluseun Alli Rajiv Gulati
9. Transcatheter Aortic Valve Replacement Using Self-Expanding Valve  95
Abdallah El Sabbagh Gurpreet Sandhu
10. Transfemoral TAVR Complications  108
Oluseun Alli Gurpreet Sandhu
11.  TAVR Alternate Access Sites  114
Monisha Sudarshan Claire E. Raphael Mayra Guerrero Kevin L. Greason
12.  Aortic Valve-in-Valve TAVR  129
Elad Maor Israel M. Barbash
13.  Aortic Paravalvular Leak Closure  138
Mohamad Alkhouli Saurabh Sanon Mohammed Al-Hijji Mackram F. Eleid
SE C T ION 3. Mitral Valve Interventions 147
14.  Percutaneous Balloon Mitral Valvuloplasty  148
Mohamad Alkhouli Mohammad Sarraf
15.  Percutaneous Edge-to-Edge Mitral Valve Repair Using the MitraClip
Sidakpal Panaich Guy Reeder
16. Percutaneous Mitral Valve-In-Valve and Valve-In-Ring  175
Timothy A. Joseph Mackram F. Eleid
®
  160
ix