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Handbook of Structural
Heart Interventions


Handbook of
Structural Heart
Interventions
EDITORS
CHARANJIT S. RIHAL, MD, FACC
Professor
Department of Cardiovascular Medicine
Mayo Clinic
Rochester Minnesota
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 verication 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
vi

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 Intervention 1
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
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