s urgical t reatment for v alvular h eart d isease 1 susan raaymakers, mpas, pa-c, rdcs (ae)(pe)...
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SURGICAL TREATMENT FOR VALVULAR HEART DISEASE
1Susan Raaymakers, MPAS, PA-C, RDCS (AE)Susan Raaymakers, MPAS, PA-C, RDCS (AE)
(PE)(PE)Grand Valley State University, Grand Rapids, Grand Valley State University, Grand Rapids,
[email protected]@gvsu.edu
BACKGROUND Review
Rheumatic heart dz originates as throat infection from streptococcal infection Article in January 2009 JASE
Rheumatic heart disease was the leading cause of death 100 years ago in people aged 5-20 years in the United States Incidence just above 0% in developed countries
Chronic rheumatic heart disease is estimated to exist in 5-30 million children and young adults; 90,000 patients die from this disease each year. The mortality rate from this disease remains 1-10%
Occurs generally in children 5-15 years old but may present in adult 2
http://www.emedicine.com/ped/topic2007.htm
INITIAL SURGICAL TREATMENTS
First successful attempt at surgical treatment Incising the left atrial appendage, placing finger
through the incision into the left atrium, feeling the stenotic mitral and relieving the obstruction by simple finger pressure.
3
INITIAL SURGICAL TREATMENTS In the early days of cardiovascular surgery,
procedures were done on the beating heart
1950’s cardiac and pulmonary bypass machines were developed This development made it possible to keep the patient
alive while stopping the heart for surgical repair Ability to stop the heart allowed examination of valve
pathology and repair Stimulated surgeons’ collaboration with mechanical
engineers in developing prosthetic valves
4
Erector set heart pump, 1950 Using a toy Erector set, William Sewell Jr. and William W. L. Glenn, Yale University medical students, built this section of a heart pump,
which Sewell successfully used in experimental bypass surgery on dogs. Acquired in 1959 from
Sewell's mother, this heart pump is one of many invention prototypes in the Smithsonian
collections
INDICATIONS FOR SURGICAL REPAIR/REPLACEMENT OF VALVES
5
FIRST GENERATION OF SYNTHETIC VALVES Era of valve surgery proceeded the development
of echocardiography by only a few years. 1960s One of the earliest applications of echocardiography was the
evaluation of prosthetic valves.
The first generation of synthetic valves retained in a cage Free-floating balls (mechanical ball and cage) or Disc occluders (caged disk)
6
INDICATIONS
Valvular stenosis Valvular regurgitation Native valve endocarditis Aortic dissection with severe aortic
regurgitation
7
VALVULAR REPLACEMENT8
9
THREE TYPES OF PROSTHETIC HEART VALVES
10
THREE TYPES OF PROSTHETIC HEART VALVES
MechanicalBioprostheticHomograft
11
MECHANICAL VALVES
All mechanical valves haveA Sewing ring
Moving component Cage, strut or frame.
Made from a compressed carbon material •Hard enough and yet free of significant friction to provide long term durability •Providing relative freedom from wear, breakage or excessive clotting.
MECHANICAL VALVESTYPES Ball and Cage Caged Disc Tilting Disc Bileaflet Valved Conduit
13
MECHANICAL VALVEBALL AND CAGE
14
MECHANICAL VALVESBALL AND CAGEStarr-Edwards (used in the first
clinically successful valve replacement)Was most Common
Smeloff-Cutter Braunwald-Cutter Magovern-Surgitool Magovern-Cromie Harken DeBakey-Surgitool Hufnagel
15
MECHANICAL BALL AND CAGE
16Hufnagel
1952
Starr-Edwards in Mitral Position – introduced 1961
To open, the ball moves forward into the cage, allowing blood flow around the entire circumference. To occlude, the ball is driven back into the sewing ring to prevent backflow.
Smeloff-Cutter
STARR-EDWARDS VALVE IN MITRAL POSITION
17
•poppit
•moving forward and backward in the cage.
•Diastole,
•poppet moves forward allowing blood to flow around the occluder.
•These valves are highly echogenic, and small thrombi or vegetations can be easily hidden or overlooked.
14.5 Feigenbaum
FLOW PROFILEBALL AND CAGE Open position
Blood flows across sewing ring and around the ball occluder on all sides In Colorflow, observed as bilateral horns.
Closed positionSmall amount of regurgitation: circumferentially
around the ball as it seats in the sewing ring
18
M-MODE STARR-EDWARDS FROM APEX
19
SHORT-COMINGS OF BALL AND CAGE
1. Bulky in design and did not fit well into a small ventricle or aorta
2. Small internal orifice, making them relatively stenotic
3. Stimulated thrombus formation, which precipitated thromboembolic events, necessitating long-term anti-coagulation therapy 20
MECHANICAL VALVECAGED DISC
21
MECHANICAL VALVE - CAGED DISCNO LONGER IN USE Beall-Surgitool
Was the most common Kay-Shiley Kay-Suzuki Cooley-Cutter Cross-Jones
22
MECHANICAL VALVE - CAGED DISC
23Beall-Surgitool
Movable disc (discoid)
Disc elevated by very slight pressure to demonstrate closure
Cooley-Cutter
MECHANICAL VALVE - CAGED DISC
Advantage over ball and cage Caged disc occupied less area
Disadvantage Similar to ball and cage
Tissue overgrowth Chipping of the disc due to constant impact Mechanical problems
24
MECHANICAL VALVESINGLE TILTING DISC
25
MECHANICAL VALVE SINGLE TILTING DISC Most common
Medtronic-HallBjörk-Shiley
No longer available in U.S. due to the problem of strut fracture
Other tilting discsLillehei-KasterHall-KasterWada-CutterOmniscience Omnicarbon
26Van der Spuy "toilet seat" valveBlood tended to clot at the spring pivot of this valve.
http://www.hhmi.org/biointeractive/museum/exhibit98/content/h12info.html
MECHANICAL VALVE SINGLE TILTING DISC
27Björk-Shiley (1971 First Successful Tilting Disk)
Medtronic-Hall Pivoting Disc Valve
•Single disk prosthesis •Round sewing ring and a circular disk fixed eccentrically to the ring via a hinge.
• Disk moves through an arc of less than 90º allows:•Antegrade flow in the open position •Seating within the sewing ring to prevent backflow in the closed position.
FLOW PROFILE – SINGLE TILTING DISK
Open positionTwo orifices of unequal size (major vs. minor)
Asymmetric flow profile as blood accelerates along the tiled surface of the open disk
Subtle variations dependent on shape of disk (concave vs. convex) and sewing ring design
Closed positionSmall central jet of regurgitation occurs around
the central hole 28
COMPLICATIONS OF SINGLE TILTING DISCS Björk-Shiley had issues with strut fractures
619 of the 80,000 convexo-concave valves implanted fractured with patient death in 2/3 of cases
FDA removed from market in 1986 Perhaps the most infamous recall case on record
Hinge is eccentrically positioned within the sewing ring and the disk opens less than 90 degrees. Major and minor orifices are created and some
stagnation of flow occurs behind the disk. 29
BJORK-SHILEY
30
SINGLE TILTING DISCS Advantage
Low profile, can be inserted into aortic and mitral positions
Disadvantage High degree of leakage around central strut Region of stagnation behind disc
Thrombus formation Tissue overgrowth
31
MECHANICAL VALVEBILEAFLET
32
MECHANICAL VALVE - BILEAFLET St. Jude
Most frequently used mechanic valve Three orifices, which promote central flow Least stenotic mechanical prosthetic valve
Carbomedics Duromedics (Hemex) Gott-Daggett
33
Non-dynamic
MECHANICAL VALVE - BILEAFLET
34St. Judehyperlink Carbomedics
• Opening angle is generally more vertical (approx 80º) than single disk prosthesis • Results in three distinct orifices:
• Two larger ones on either side and a smaller central rectangular-shaped orifice.
ST. JUDE MITRAL PROSTHESIS
35
BI-LEAFLET MECHANIC VALVE
Colorflow profile Single large flow pattern or Two major jets on sides and one minor in middle.
36
FLOW PROFILE - BILEAFLET
Complex fluid dynamics
Open positionTwo large lateral valve orifices with a small
narrow central “slitlike” orificeThree peak velocities corresponding to
three orifices Highest velocity in middle orifice Local gradients are often substantially higher than
overall valvular pressure
Closed positionTwo crisscross jets of regurgitation are seen
in plane parallel to the leaflet opening plane
37
OVERALL COMPLICATIONS OF MECHANICAL VALVES
38
COMPLICATIONS OF MECHANICAL VALVES
Thrombus Indefinite anti-coagulation Stenosis
Thrombosis Pannus ingrowth
Fibrotic tissue which grows around a newly implanted prosthetic heart valve.
Vigorous growth of this healing tissue can freeze or obstruct a replacement valve.
May be related, in part, to the design or materials of the prosthesis, or to the degree of anticoagulation
Dehiscensce Infective endocarditis Hemolysis
39
COMPLICATIONS OF MECHANICAL VALVESCONTINUED Mechanical failure
Ball/disc/cage variance/strut fracture
Heart-valve mismatch
Left ventricular outflow tract obstruction
Valve bed abnormalityPseudoaneurysm, valve ring abscess,
fistula, hematoma
RegurgitationCentral, perivalvular
40
BIOPROSTHETIC VALVESConstructed from either human or animal tissue.
41
BIOPROSTHETICVALVES Heterograft (xenograft)
Transfer from animal to humanLongest replaced approximately 10 yearsTypically replaced at 5 years
Auto-graft Transfer from self to self
Homograft (allograft)Transfer from one human to another
Last approximately 5 years 42
HETEROGRAFTTransfer from Animal to Human43
HETEROGRAFT (XENOGRAFT)PORCINE VALVES
Limited availability of heterograft prompted the use of porcine valves procured from slaughterhouses
Pig’s aortic valve is placed on stents, attached to a sewing ring and glutaraldehyde stabilized
Most common: Hancock I and II Carpentier-Edwards Intact (aortic)
44
Hancock Porcine – Valve Closed
NORMAL FUNCTIONING PORCINE AORTIC PROSTHESIS
45
•Leaflet opening during systole resembles that of a normal native valve.
•Overall appearance is similar that bioprosthesis
•Occasionally mistaken for native when historical information is not available.
• Careful observation yields an echogenic sewing ring and struts.
NORMAL FUNCTIONING PORCINE MITRAL PROSTHESIS
46
HETEROGRAFT (XENOGRAFT)STENTLESS PORCINE VALVE
47
A low-pressure glutaraldehyde fixed intact porcine valve supported by Dacron cloth
Advantage: No stents allows larger valve to be implanted
Two approved valves: Toronto SPV Freestyle Valve
Toronto SPV
STENTLESS AORTIC VALVE Stentless Aortic Valve
48
SAME PATIENT - PSAX
49
HETEROGRAFT (XENOGRAFT)BOVINE PERICARDIUM
Bovine (cow) pericardium fashioned into a trileaflet valve Mounted on stents and a
sewing ring
Most common brands: Carpentier-Edwards Ionescu-
Shiley (Withdrawn from United States Market)
Mitroflow 50
Carpentier Edwards – Valve Closed
AUTOGRAFTTransfer from Self to Self51
AUTOGRAFTROSS PROCEDURE
52
Excision of the aortic valve Placement of the pulmonary valve annulus and
trunk into the aortic position Reimplantation of the coronary arteries.
Pulmonary side, a homograft conduit is placed between the right
ventricle and pulmonary artery
HOMOGRAFTTransfer from One Human to Another53
HOMOGRAFT (ALLOGRAFT)
Rarely used to replace a MV or TV
Aortic Homograft Harvested from human cadavers shortly
after death, (cryopreseved) May be sown into the aortic annulus without
stents. Customized by the surgeon in the operating
room at the time of implantation.
May be difficult to identify by echocardiography Aortic root may appear thicker than normal Valve failure is usually due to valvular
regurgitation 54
ADVANTAGE OF BIOPROSTHETIC VALVES May avoid anticoagulation Lower pressure gradients Central flow dynamics Failure usually occurs slowly Valve of choice in the tricuspid/pulmonic
position Stentless valve may be hemodynamically
superior to stented heterograft Increased effect orifice area Lower gradients Greater regression of ventricular
hypertrophy55
COMPLICATIONS OF BIOPROSTHETIC VALVES Calcification/degeneration Infective endocarditis
Vegetation, valve ring abscess, fistula Dehiscence (all valve replacements)
Sewing ring around prosthesis becomes unsecured to surrounding structures
Inherently stenotic Tissue preserved and fixed with within
a prolypropylene mount attached to a Dacron sewing ringLess pliable than native valve tissue. 56
COMPLICATIONS OF BIOPROSTHETIC VALVES – CONTINUED
StenosisDegeneration, thrombotic
Sewing ring may be too small relative to the flow
In young patients, what was normal as a child is now too small as an adult
Effective orifice area is significantly smaller than the area of the sewing ring Valve assembly (i.e. occluder mechanism) occupies
some of the central space57
COMPLICATIONS OF BIOPROSTHETIC VALVES - CONTINUED Deterioration of tissue valve
Occurs at an accelerated rate Younger patients Patients with end-stage renal disease on hemodialysis.
Older patients, especially in those with a risk of falling, Tissue valve may be the most appropriate choice.
Tissue valves are less durable than mechanical valves with a reported failure rate of 25% at 10 years 42% at 12 years 60% at 15 years The failure rate is higher in young patients (less than 35
years of age) and in chronic renal failure patients58
VALVED CONDUITS59
VALVED CONDUITS Used in congenital heart surgery and
ascending aortic repairs When a new passageway for blood flow
and a valve are needed
May be biologic (i.e. homograph) or artificial (i.e. Gore-Tex or Dacron) material
May incorporate either tissue or a mechanical valves
Fluid dynamics similar to those for a valve implanted in the native annulus 60
CARPENTIER-EDWARDS BIOPROSTHETIC VALVED CONDUIT
61
OTHER CONDUITS
62
EVALUATION OF PROSTHETIC VALVES BY TRANSTHORACIC ECHOCARDIOGRAPHY
63
EVALUATION OF PROSTHETIC VALVES BY TRANSTHORACIC ECHOCARDIOGRAPHY
Confirm stability of the sewing ring Determine the specific type of prosthesis Confirm the opening and closing motion of
the occluding mechanism Can be difficult but with careful interrogation the
rapid motion of the leading edge of the disk or ball generally can be recorded.
Evaluate for gross structural abnormalities such as vegetations and thrombi
64
TEE EVALUATION OF PROSTHETIC VALVES
65
EVALUATION BY TEE GENERAL QUESTIONS THAT SHOULD BE ANSWERED
Is there valve dehiscence?
Is there evidence of torn/flail leaflets, ball/disc variance?
Are there mass lesions? Vegetations, thrombi, pannus
Is there valve ring abscess / pseudoaneurysm/ fistula?
How much volume/leakage volume/ pathological valvular regurgitation / paravalvular leak is present?
Is there valvular stenosis?66
TEE EVALUATION OF PROSTHETIC VALVES Helpful in patients who are too unstable to
undergo cardiac catheterizations
Surface study is inadequate for diagnosis
Regurgitation jets appear larger as compared to transthoracic
67
Non dynamic
PRESSURE RECOVERY68
PRESSURE RECOVERY Downstream pressure after
an obstruction Will be lower than the upstream
pressure before
After flow passes through orifice Pressure recovers toward its original
value Rate and magnitude: variable
depending on valvular geometry
Difference between cardiac catheterization and echocardiography pressure gradients 69
ROUTINE EVALUATION OF PROSTHETIC VALVES
70
ROUTINE EVALUATION OF PROSTHETIC VALVESChamber dimension and functionValve type and movementPeak flow velocityMaximum and mean pressure
gradientsPressure half time
Generally overestimates valve area in presence of mitral prosthesis
71
ROUTINE EVALUATION OF PROSTHETIC VALVES
Effective orifice area by continuity equation Pulmonary artery pressures Diastolic filling profile Color flow jet length, duration and area,
pulmonary vein (mitral regurgitation) Color flow jet or descending thoracic aorta flow
(aortic regurgitation)
72
GENERAL M-MODE/ 2-D/ CARDIAC DOPPLER FINDINGS POST-PROSTHETIC VALVE SURGERY
73
POST-PROSTHETIC VALVE SURGERY
7414.23 Feigenbaum
GENERAL M-MODE/ 2-D/ CARDIAC DOPPLER FINDINGS POST-PROSTHETIC VALVE SURGERYAortic Stenosis Left ventricular systolic/diastolic function
Should improve is decreased preoperatively Left ventricular hypertrophy
Should regress Peak/mean gradient
Will be reduced compared to pre-op but a residual peak and mean gradient will be present due to aortic valve replacement
If mitral regurgitation was present before surgery, May be decreased in severity post-op
Left ventricular intracavitary systolic gradients May predict a poor prognosis 75
GENERAL M-MODE/ 2-D/ CARDIAC DOPPLER FINDINGS POST-PROSTHETIC VALVE SURGERY
Aortic Regurgitation Left ventricular dimensions
Should decrease with an improvement of ventricular systolic function
Peak/mean gradients Will be increased for prosthetic heart valve compared
to native aortic valve
76
GENERAL M-MODE/ 2-D/ CARDIAC DOPPLER FINDINGS POST-PROSTHETIC VALVE SURGERY
Mitral Stenosis May be a slight increase in
Left ventricular dimensions
Left atrial dimension May decrease slightly but usually will not normalize
Left atrial appendage May be obliterated at surgery
Valve leaflets, chordae tendineae, papillary muscles May be left intact
Peak/mean gradients Will be reduced compared to pre-op
Mitral valve area Larger than pre-op
Pulmonary artery pressures May decrease 77
GENERAL M-MODE/ 2-D/ CARDIAC DOPPLER FINDINGS POST-PROSTHETIC VALVE SURGERY
Mitral Regurgitation LV dimension
Should decrease with an improvement in systolic function
LA dimension Should decrease but will not normalize
Valve leaflets, chordae tendineae, papillary muscles
May be left intact
Decreased compared to pre-op with mitral valve replacement Transmitral peak velocity, peak pressure gradient, mean
pressure gradient
Pulmonary artery pressures may decrease
78
NORMAL OR PHYSIOLOGICAL REGURGITATION
79
NORMAL OR PHYSIOLOGIC REGURGITATION
Regurgitation occurs in Virtually all types of mechanical prostheses Seating regurgitation or "closure backflow"
appears only briefly Due to retrograde volume displacement as the valve
leaflets close.
Divided into two types Closure backflow Leakage
80
COMPLICATIONS81
AORTIC ROOT ABSCESS
Echo-free space is seen posterior to the aortic root and associated perivalvular regurgitation.
82
14.27 Feigenbaum
14.27b Feigenbaum
PERIVALVULAR LEAK
83
Example of stentless aortic prosthetic valve Mild degree of
perivalvular regurgitation is seen.
14.28a Feigenbaum
OBSTRUCTION
The most common cause of prosthesis obstruction is the presence of a thrombus.
84
THROMBUS ECHOCARDIOGRAM
Large thrombus Left atrial aspect of
the mitral prosthesis
8514.37 Feigenbaum
VEGETATION Prosthetic valve
Most common site for attachment of a vegetation is the sewing ring.
Large vegetation can be seen in the left atrium Attached to the sewing
ring of a St. Jude mitral prosthesis.
86
14.46 Feigenbaum
RING ABSCESS
87
14.51b Feigenbaum
14.51c Feigenbaum
DEHISCENCE
Dehiscence of porcine mitral prosthesis Excessive motion of the prosthetic valve was evident.
Abnormally high peak flow velocity (2.8 cm/sec) Increased gradient
(14 mm Hg) 88
14.52 Feigenbaum
VALVED CONDUITS89
VALVED CONDUITS Part of repair of some forms of
complex congenital heart disease
Not all conduits contain valves and those that do may use either bioprosthetics or mechanical prostheses.
Conduit itself often has a characteristic echocardiographic appearance due to the conduit material and the ribbed design 90
REPAIR
Adult patients with aortic valve pathology are seldom candidates for valve repair.
Valve replacement is usually necessary for significant aortic stenosis or regurgitation.
91
MITRAL VALVE REPAIR92
MITRAL VALVE REPAIR
Repairing rather than replacing Several advantages and is being performed with
increasing frequency.
Mitral and tricuspid valve pathologies should be considered for valve repair Operative mortality associated with repair of these
valves is lower than that associated with their replacement.
93
MITRAL VALVE REPAIR
Selection of repair vs. replace is dependent uponEtiology, morphology and severity as
well as the status of the left ventricle.
Replacement for :severe scarring and deformation by a disease process such as advanced rheumatic heart disease advanced lupus another inflammatory process
94
MITRAL VALVE REPAIR SUCCESS RATE IN PATIENTS WITH MYXOMATOUS DEGENERATION AND MITRAL VALVE PROLAPSE
Posterior leaflet prolapse Carries a greater likelihood of successful
repair Than anterior or bi-leaflet prolapse
95
http://www.escardio.org/communities/EAE/CasePortal/Pages/Case159.aspx
96
SOME DEGREE OF REGURGITATION MAY REMAIN AFTER REPAIR
97
Stable mitral ring in mitral position Well preserved leaflet
excursion
14.59 Feigenbaum
14.60a Feigenbaum
FUTURE OF VALVULAR REPLACEMENT?
98
99
SAFETY AND EFFICACY STUDY OF THE MEDTRONIC COREVALVE® SYSTEM IN THE TREATMENT OF SYMPTOMATIC SEVERE AORTIC STENOSIS IN HIGH RISK AND VERY HIGH RISK SUBJECTS WHO NEED AORTIC VALVE REPLACEMENT
100
Clinical Trial for transcatheter aortic valve implantation (TAVI)
>1,300 patients Subjects have one of two options:
1. Open heart surgical aortic valve replacement2. Transcatheter aortic valve implantation (only
available through the clinical trial)
CLINICAL TRIAL FOR TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI)
101
45 Sites Across the US. Trial Locations in Michigan
Detroit Medical Center Spectrum Health Hospitals University of Michigan Health Systems
COREVALVES
102
Inclusion criteriaPredicted risk of operative mortality ≥15%Senile degenerative aortic valve stenosis
Mean > 40 mmHg/left velocity >4.0 m/sec AND
Initial AVA ≤0.8 cm2 (or AVA index ≤0.5 cm2/m2)
Symptomatic; NYHC Functional Class II or greaterSubject informed of the nature of the trial, agrees and has provided written informed consent as approved by IRB of the respective clinical siteSubject and treating physician agree that the subject will return for all post-procedure follow-up visits
COREVALVES
103
Exclusion CriteriaEvidence of an acute myocardial infarction ≤ 30 days before the index procedure.Any percutaneous coronary or peripheral interventional procedure performed within 30 days prior to the index procedure.Blood dyscrasias as defined: leukopenia (WBC < 1000mm3), thrombocytopenia (platelet count <50,000 cells/mm3), history of bleeding diathesis or coagulopathy, or hypercoagulable states.Untreated clinically significant coronary artery disease requiring revascularization.Cardiogenic shock manifested by low cardiac output, vasopressor dependence, or mechanical hemodynamic support.Need for emergency surgery for any reason.Severe ventricular dysfunction with left ventricular ejection fraction (LVEF) < 20% as measured by resting echocardiogram.Recent (within 6 months) cerebrovascular accident (CVA) or transient ischemic attack (TIA).
COREVALVES
104
Exclusion CriteriaEnd stage renal disease requiring chronic dialysis or creatinine clearance < 20 cc/min.Active Gastrointestinal (GI) bleeding within the past 3 months.A known hypersensitivity or contraindication to any of the following which cannot be adequately pre-medicated:
aspirin Heparin (HIT/HITTS) and bivalirudin (only for Extreme Risk
patients) nitinol (titanium or nickel alloy) ticlopidine and clopidogrel contrast media
COREVALVES
105
Exclusion CriteriaOngoing sepsis, including active endocarditis.Subject refuses a blood transfusion.Life expectancy < 12 months due to associated non-cardiac co-morbid conditions.Other medical, social, or psychological conditions that in the opinion of an Investigator precludes the subject from appropriate consent.Severe dementia (resulting in either inability to provide informed consent for the trial/procedure, prevents independent lifestyle outside of a chronic care facility, or will fundamentally complicate rehabilitation from the procedure or compliance with follow-up visits).Currently participating in an investigational drug or another device trial.Symptomatic carotid or vertebral artery disease.Additional Exclusion for High Risk Surgical only: Subject has been offered surgical aortic valve replacement but declined.Anatomical
COREVALVES (TAVI)
106
Exclusion CriteriaNative aortic annulus size < 20 mm or > 29 mm per the baseline diagnostic imaging.Pre-existing prosthetic heart valve any position.Mixed aortic valve disease (aortic stenosis and aortic regurgitation with predominant aortic regurgitation (3-4+).Moderate to severe (3-4+) or severe (4+) mitral or severe (4+) tricuspid regurgitation.Moderate to severe mitral stenosis.Hypertrophic obstructive cardiomyopathy.Echocardiographic evidence of intracardiac mass, thrombus or vegetation.Severe basal septal hypertrophy with an outflow gradient.Aortic root angulation (angle between plane of aortic valve annulus and horizontal plane/vertebrae) > 70° (for femoral and left subclavian/axillary access) and > 30° (for right subclavian/axillary access).
COREVALVES
107
Ascending aorta diameter > 43 mm unless the aortic annulus is 20-23 mm in which case the ascending aorta diameter > 40 mm.
Congenital bicuspid or unicuspid valve verified by echocardiography.
Sinus of valsalva anatomy that would prevent adequate coronary perfusion.
Vascular Transarterial access not able to accommodate an
18Fr sheath.
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[Cited: February 20, 2012.] http://www.medtronic.com/corevalve/ous/system.htm.
Feigenbaum H, Armstrong W. (2004). Echocardiography. (6th Edition). Indianapolis. Lippincott Williams & Wilkins.
Goldstein S., Harry M., Carney D., Dempsey A., Ehler D., Geiser E., Gillam L., Kraft C., Rigling R., McCallister B., Sisk E., Waggoner A., Witt S., Gresser C.. (2005). Outline of Sonographer Core Curriculum in Echocardiography.
Kardon, Eric. Prosthetic Heart Valves. Medscape Reference. [Online] February 08, 2010. [Cited: February 20, 2012.] http://emedicine.medscape.com/article/780702-overview.
Otto C. (2004). Textbook of Clinical Echocardiography. (3rd Edition). Elsevier & Saunders.
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