Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3737_Библиотеки_им_академика_М_И_Перельмана
.pdf
Acknowledgments
https://t.me/med1917
This textbook would not have been possible without the expertise and effort
of many people. We appreciate Pam Douglas who introduced these editors,
igniting the creative energies to commence this work. We are indebted to our
esteemed contributors who have provided in these pages the culmination of
many years of experience in the art of multimodality imaging for structural
heart disease interventions. We are also grateful to the Duke Cardiac
Diagnostic Unit sonographers who assisted in image acquisition and editing,
enhancing the value of this resource for the heart team including Ashlee
Davis, Danny Rivera, Andrew Monteagudo, Rachel O’brien, Batina Kight,
Carter Davis, and Jayne Leypoldt.
Finally, we would like to recognize friends at Springer Nature, for their
unwavering morale and technical support throughout the project, Grant
Weston, Hemalatha Gunasekaran, and Emily Wong.
xiii
Contents
https://t.me/med1917
Part I Cardiac Imaging and Percutaneous Therapeutic
Intervention in Valvular Heart Diseases
Transcatheter Aortic Valve Replacement . . . . . . . . . . . . . . . . . . . . . . . 3
Kavishka Sewnarain, Zain Ally, and Jonathon A. Leipsic
Multimodality Imaging of Mitral Valve Diseases: TEER,
Valve in Valve, and Beyond . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Taimur Safder, Gloria Ayuba, and Vera H. Rigolin
Multimodality Imaging of Tricuspid Valve Disease
at the Dawn of Transcatheter Intervention . . . . . . . . . . . . . . . . . . . . . 119
Susheel Kodali and Vratika Agarwal
Multimodality Imaging of Right Ventricular Outflow
Tract Disease in Adults with Congenital Heart Disease . . . . . . . . . . . 137
Toi Spates and Richard A. Krasuski
Pre- and Intraprocedural Imaging Considerations in Paravalvular
Leak Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Adriana Postolache, Simona Sperlongano, Mathieu Lempereur,
Raluca Dulgheru, François Damas, Nils Demarneffe,
and Patrizio Lancellotti
Part II Percutaneous Therapeutic Intervention in Non-valvular,
Non-congenital Structural Heart Diseases
Left Atrial Appendage Closure Periprocedural Imaging . . . . . . . . . . 177
Mesfer Alfadhel and Jacqueline Saw
Alcohol Septal Ablation in the Management of Hypertrophic
Obstructive Cardiomyopathy (HOCM) . . . . . . . . . . . . . . . . . . . . . . . . 195
Daniel B. Loriaux, Andrew Wang, and Todd L. Kiefer
Percutaneous Closure of Post- myocardial Infarction
Ventricular Septal Rupture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Jessica Raviv and Barry Love
xv
xvi
https://t.me/med1917
Part III Interventions in Heart Failure
Interatrial Shunt Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Taimur Safder, Sanjiv Shah, and Akhil Narang
Part IV Percutaneous Therapeutic Intervention in Adult
Congenital Heart Diseases
Patent Foramen Ovale and Atrial Septal Defect . . . . . . . . . . . . . . . . . 263
Aken Desai, Edward Gill, and John Carroll
Percutaneous Ventricular Septal Defect Closure . . . . . . . . . . . . . . . . . 283
Kamel Shibbani, Karim A. Diab, Damien Kenny,
and Ziyad M. Hijazi
Coronary Cameral Fistula Closure . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Anita Sadeghpour, Ata Firouzi, and Zahra Hosseini
Transcatheter Closure of Ruptured Sinus of Valsalva . . . . . . . . . . . . . 309
Y. Hejazi, Z. M. Hijazi, and A. Sadeghpour
Transcatheter Approach to Coarctation of Aorta
and Isolated Interrupted Aortic Arch in Adults . . . . . . . . . . . . . . . . . . 327
Ata Firouzi, Anita Sadeghpour, and Zahra Hosseini
Contents
Percutaneous Closure of Patent Ductus Arteriosus . . . . . . . . . . . . . . . 343
Lourdes Prieto and Daniel Duarte
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 357
Part I
https://t.me/med1917
Cardiac Imaging and Percutaneous
Therapeutic Intervention in Valvular Heart
Diseases
Transcatheter Aortic Valve
https://t.me/med1917
Replacement
KavishkaSewnarain, ZainAlly,
andJonathonA.Leipsic
Abstract
Aortic stenosis (AS) is the second most common form of valvular heart disease in the
western world with bicuspid aortic valve being
the second most common congenital cardiac
anomaly, after patent foramen ovale. Isolated
aortic regurgitation (AR) is less common than
symptomatic AS.Imaging plays a signicant
role in diagnosis, procedural planning and
intraprocedural management in these patients.
Management can be either conservative or
include valve replacement with either transcatheter or surgical options for symptomatic
patients with severe disease. This chapter
explores the indications and important imaging features in diagnosis, pre-procedural planning and management. The heart team
discussion highlights the multifactorial
approach optimizing device choice, aortic root
features, chosen access route and the prediction and prevention of complications as well
as Food and Drug Administration approval of
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 50740- 3_1.
Transcatheter Aortic Valve Replacement
(TAVR) in low-risk patients and Valve in Valve
procedures. There is a resurgence in balloon
valvuloplasty which is indicated as a bridge to
more denitive TAVR and Surgical Aortic
Valve Replacement (SAVR) and is now also
increasingly utilised in valve orice dilatation
pre and post Transcatheter heart Valve (THV)
deployment. Post procedural patient followup and imaging is discussed and is aimed at
conrmation of procedural success as well as
identication of procedural complications and
guidance of further clinical decision making.
Keywords
Aortic stenosis · Acquired aortic valve
disease · Bicuspid aortic valve · Aortic
regurgitation · Transcatheter aortic valve
replacement · Transcatheter heart valve ·
Hypoattenuating leaet thickening (HALT) ·
Paravalvular regurgitation · Coronary
obstruction · Valve in valve · Balloon
valvuloplasty · Echocardiography · Cardiac
imaging · Elevated gradients
K. Sewnarain · Z. Ally · J. A. Leipsic (*)
Department of Radiology, Advanced Cardiovascular
Imaging, St. Paul’s Hospital, University of British
Columbia, Vancouver, BC, Canada
e-mail: jleipsic@providencehealth.bc.ca
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. M. Kelsey et al. (eds.), Cardiac Imaging in Structural Heart Disease Interventions,
https://doi.org/10.1007/978-3-031-50740-3_1
3
4
https://t.me/med1917
Test your learning and check your under-
standing of this book’s contents: use the
“Springer Nature Flashcards” app to
access questions.
To use the app, please follow the instruc-
tions below:
1. Go to https://ashcards.springernat-
ure.com/login
2. Create a user account by entering
your e-mail address and assigning a
password.
3. Use the following link to access your
SN Flashcards set: ▶ https://sn.pub/
ambACS
If the link is missing or does not work,
please send an e-mail with the subject
“SN Flashcards” and the book title to
customerservice@springernature.com.
K. Sewnarain et al.
Aortic Stenosis
Case Study
A 75-year-old male patient with a history
of prior percutaneous coronary intervention (PCI) and coronary artery bypass
graft (CABG) presented with chest pain
and progressive dyspnea on exertion. He
experiences palpitations and dizziness but
no syncopal episodes. On physical examination, auscultation revealed a Grade 2/6
systolic ejection murmur at the base radiating to the neck and cardiac apex. Distal
pulses were feeble but palpable. ECG did
not show an old infarct nor other
abnormalities.
Background andDenitions
Learning Objectives
1. Describe how to diagnose aortic stenosis and
use imaging to guide management choices.
2. Describe how to identify bicuspid aortic valve
disease and the indications for valve
replacement.
3. Describe how to identify aortic regurgitation
and recognize the indications for valve
replacement.
4. Describe the strengths and weaknesses of
available preprocedural imaging modalities
and their interpretation in aortic valve
disease.
5. Describe how to assess potential TAVR complications through imaging.
6. Describe the role of imaging in balloon valvuloplasty and valve in valve procedures.
Aortic Stenosis Denition
andClassication
Aortic stenosis (AS) is the second most common
cause of valvular heart disease in the western
world with the primary pathogenesis shifting
from rheumatic to degenerative valve disease in
modern times [1]. Patients at higher risk for AS
include those with congenital (bicuspid, unicuspid) heart valve variants [2] and comorbidities
resulting in abnormal calcium metabolism [3].
Patient risk prole and histopathological leaflet ndings in AS are similar to that of coronary
atherosclerotic disease, with an inammatory
component, commonly progressing to leaet calcication and immobility [1]. This results in
insidious deterioration in left ventricular outow
with subsequent myocardial hypertrophy, systolic and potentially diastolic dysfunction with
Transcatheter Aortic Valve Replacement
https://t.me/med1917
5
resultant heart failure [3]. There is a latent period
with symptoms generally only becoming signicant with the onset of severe stenosis [3]. Classic
symptoms include angina, heart failure or syncope but the elderly may only present with exercise intolerance [1, 3]. Classic clinical signs
include a parvus-tardus carotid pulse, a holo/mid/
late systolic murmur maximal at the second intercostal space radiating to the carotid vessels and
less often to the apex [3].
Imaging plays a central role in the diagnosis,
severity grading, procedural planning, and follow
up of the patient with AS.The mainstay of imaging in AS is echocardiography (Transthoracic
echocardiography (TTE) or Transesophageal
echocardiography (TEE)), cardiac catheterization and computed tomography (CT), supplemented by Magnetic Resonance Imaging (MRI)
in specic scenarios. Intraprocedural imaging is
accomplished with uoroscopy with or without
echocardiography.
Management options are divided into watchful waiting, medical treatment and valve replacement, either via percutaneous or surgical
intervention [3]. Watchful waiting is an option in
patients with severe stenosis who are truly
asymptomatic, with care paid to ensure that
symptoms are not erroneously attributed to
“aging” [3]. Since onset of symptoms may be
sudden, close monitoring is essential with
6–12months serial echocardiograms [4]. Patients
with a velocity of >5 m/s or an increase of
>0.3m/s/year have a strong predilection to valve
replacement within 2years [3] and as a result in
patients with very severe AS (dened as an aortic
velocity of ≥5m/s and low surgical risk), AVR is
reasonable [4]. Severe AS should be actively
excluded in patients with suspected moderate stenosis and low ow low gradient [3]. Follow up
echocardiograms should be performed every
12–24months in moderate stenosis, 3–5years in
mild stenosis or at the onset of new symptoms or
clinical ndings [3].
Diagnosis andPre-procedural
Evaluation
Echocardiography
Transthoracic echocardiography (TTE) plays an
essential role in the non-invasive diagnosis of AS
by dening valve morphology and sclerosis and
assessing the severity of stenosis and its impact
on left ventricular function and remodeling [5].
Severity can be graded as mild, moderate or
severe and additionally categorized as having
reduced or preserved function with normal or low
cardiac outow [5].
Given the patient’s history of coronary artery
disease, presenting symptoms, and physical exam
ndings, diagnoses of progressive coronary
artery disease, as well as aortic stenosis were
considered. Based on this differential diagnosis,
the rst step of further diagnostic testing was to
obtain a transthoracic echocardiogram, primarily
to assess biventricular function and also to evaluate the aortic valve. The echocardiogram revealed
severely thickened aortic valve leaets with
severely restricted leaet motion (Videos 1 and
2). After assessment of the aortic spectral Doppler
from multiple echo windows and with multiple
sonographers when available [6], the aortic valve
Vmax was 3.7 m/s with a mean gradient of
30 mmHg (Fig. 1) [6]. The aortic valve area
(AVA) was calculated from the continuity equation at 1.0cm2 with an AVA index of 0.5cm2/m2.
The stroke volume was calculated at 86mL with
an indexed value of 43mL/m2. There was moderate posterior mitral annular calcication and mild
central mitral regurgitation. The LVEF was estimated at 60% with the ratio of left ventricular
wall thickness to cavity dimension suggestive of
left ventricular concentric remodeling (Video 3).
This patient’s echocardiographic values demonstrate discrepancy between the observed gradients (which would be classied as moderate) and
the calculated AVA and indexed AVA, which
would be classied as severe). This AVA–gradi-
6
ab
https://t.me/med1917
K. Sewnarain et al.
c
Fig. 1 2D trans thoracic echocardiogram of the aortic
valve (a) Parasternal long axis zoomed 2D view with a
LVOT diameter of 24.6mm (measured inner edge to inner
edge) and thickened coronary leaets. (b) Parasternal
short axis demonstrating tricuspid aortic valve with thick-
ent discordance is a clinically common scenario
and the rst step is to conrm the accuracy of the
echo measurements and calculations, especially
the LVOT diameter. The LVOT diameter should
be measured in a zoomed image of the LVOT
taken from the parasternal long axis view during
mid systole from the inner edge to the inner edge.
Errors in the measurement are squared as part of
the calculation of the AVA, the indexed AVA, and
the stroke volume index are the most common
d
ened leaets. (c) Pulsed wave doppler of the LVOT with a
VTI of 18.1cm. (d) Continuous wave doppler across the
aortic valve with a VTI of 82cm. The mean transvalvular
valve gradient was 29mmHg and the peak transvalvular
gradient was 51mmHg. AVA was calculated at 1cm
Once the accuracy of the echo measurements
is conrmed, further imaging will be needed to
conrm the diagnosis of severe AS (Fig.2) In this
case, given that the patient had a normal EF and a
normal stroke volume index, to conrm the presumptive diagnosis of normal ow, low-gradient
AS, the patient underwent non-contrast and contrast multi-detector CT, both for the purposes of
obtaining an aortic valve calcium score [8] as
well as potential procedural planning.
source of inaccuracy in AS grading. To conrm
the accuracy of the LVOT diameter measurement, the observed value can be compared against
the predicted LVOT diameter, calculated as
(5.7×body surface area)+12.1 where discrepancies of >2mm suggest inaccurate LVOT diameter
measurement [7].
Computed Tomography
CT may be used to determine the aortic valve calcium score when there is discordance between
echocardiographic ndings (i.e. low ow, low
gradient and normal ow, low gradient) [9] and
aortic valve area in patients with clinical evi-
2
Transcatheter Aortic Valve Replacement
https://t.me/med1917
7
Fig. 2 Algorithm for assessing AS severity in different
ow-gradient scenerios. AS aortic stenosis; AU agatston
units; AV aortic valve; AVA aortic valve area; AVA
jected aortic valve area; DSE dobutamine stress echocardiography; LV left ventricular; LVEF left ventricular
ejection fraction; LVOT left ventricular outow tract;
LVOTD left ventricular outow tract diameter; MDCT
multidetector computed tomography; MG mean transval-
proj
vular gradient; SV stroke volume; SV
indexed stroke vol-
i
ume; ΔSV change in stroke volume; 3D 3-dimensional.
Reprinted from JACC Case Reports, Vol 4/3, Iria Silva,
pro-
Erwan Salaun, Nancy Côté, Philippe Pibarot, Conrmation
of Aortic Stenosis Severity in Case of Discordance
Between Aortic Valve Area and Gradient, 170–177,
Copyright 2022, with permission from Elsevier
8
ab
cd
https://t.me/med1917
K. Sewnarain et al.
dence of severe stenosis [10]. CT leaet calcium
score does not account for pathological leaets
with brotic rather than calcic thickening [10]
and should be considered especially when evaluating female patients. The presence of a low aortic valve calcium score and echocardiographic
signicant AS should not preclude TAVR with
balloon expandable (BE) devices as these have
demonstrated high device success and lower
paravalvular regurgitation (PVR) rates in comparison to patients with high valve calcium scores
[9]. CT based threshold are gender specic, with
stenosis classied as severe when >1300AU in
women and >2000AU (arbitrary value) in males
[10].
The patient’s aortic valve was tricuspid and
symmetrically calcied with no adverse root features. The calcium score was >2000 Agatston
units, consistent with severe AS.Additionally, the
systolic annular area was 383mm2, with a perimeter of 69mm and diameter of 22mm. There was
no annular or LVOT calcication. The distance
of the left main and right coronary ostia to the
annular plane was measured at 13 mm and
18mm respectively. The average dimension of the
Sinus of Valsalva (SoV) (calculated by averaging
the distances measured from cusp to commissure), was 32mm and the STJ was measured at
27 mm (Fig. 3). Predicted CT derived uoroscopic projections were cusp overlap view of
Fig. 3 Post contrast pre TAVR CT imaging. (a) Annular
area of 383mm
taken in the derived annular plane in the systolic phase of
the cardiac cycle. (b) Left main coronary height of
13.8mm and (c) right coronary height of 17mm from the
annular plane suggests low risk for coronary obstruction.
2
and perimeter of 70mm. Measurement
(d) The sinuses of Valsalva measured from cusp to commissure and the three measurements averaged to give a
SOV average dimensions of 32mm. This suggests a capacious SOV signifying a low risk for coronary artery
obstruction
Соседние файлы в папке Библиотека им академика М.И. Перельмана