Mastering Structural Heart Disease E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 1542

Veröffentlichungsjahr: 2023

Beschreibung

MASTERING STRUCTURAL HEART DISEASE A COMPREHENSIVE AND IN-DEPTH GUIDE TO MANAGING THE TREATMENT OF STRUCTURAL HEART DISEASE In Mastering Structural Heart Disease, a team of distinguished experts in interventional cardiology deliver a complete and robust explanation of nearly all present-day structural heart disease devices, their appropriate uses, and technical tricks to help ensure treatment success. The text is written in a Socratic, "question-and-answer" format which is designed to help readers absorb and retain knowledge. Online clinical cases and vignettes supplement the material in the book, providing a comprehensive overview of the subject. The authors combine the latest techniques, devices, clinical research trials, future directions, and innovation ideas into a single, practical, and accessible study and practice resource. From transcatheter valvular interventions, interventions for selected adult congenital structural diseases, and a variety of other cardiac disorders that require intervention, readers will find coverage of the treatment of virtually every structural disease they're likely to encounter in practice. They'll also find: * A thorough introduction to structural interventions for the aortic valve, including the natural history, hemodynamic assessment and transcatheter interventions * Comprehensive explorations of structural interventions for the mitral valve, including imaging assessment and procedural planning with dedicated imaging tools prior to mitral valve edge to edge repair and transcatheter mitral valve replacement * Practical discussions of structural interventions for the tricuspid and pulmonic valves, including intraprocedural imaging, devices and techniques * Extensive treatments of structural interventions for the left atrial appendage and management of perivalvular leaks * Complete discussion of the latest devices and techniques for pulmonary embolism interventions, renal denervation and mechanical support for structural interventions Perfect for interventional cardiologists, general cardiologists, and cardiac surgeons, Mastering Structural Heart Disease will also earn a place in the libraries of fellows in training and internists seeking a comprehensive guide to the management of structural heart disease.

Leseprobe

Table of Contents

Cover

Title Page

Copyright

Dedication

Acknowledgements

Cover Design Artist Statement

List of Contributors

Preface

About the Companion Website

Part I: Structural Interventions for the Aortic Valve

1 The Natural History and Hemodynamic Assessment of Aortic Valve Disease

Aortic Stenosis

1. What are the causes of aortic stenosis (AS)?

2. How is AS severity graded?

3. What are the hemodynamic consequences of AS?

4. How are the hemodynamics of AS translated into symptoms?

5. How are the hemodynamics of AS translated into physical exam findings?

6. How is AS diagnosed (imaging and invasive hemodynamics)?

7. What is low-flow AS?

8. What are the indications for medical therapy of AS, and what do those therapies consist of?

9. What are the indications for mechanical therapy of AS, and what do those therapies consist of?

10. What is the prognosis for AS?

Aortic Regurgitation

11. What are the major etiologies of aortic regurgitation (AR)?

12. How is severe AR defined?

Chronic AR

13. What are the hemodynamics of chronic AR?

14. How are chronic AR hemodynamics translated into symptoms?

15. How are chronic AR hemodynamics translated into physical signs?

16. How is AR diagnosed (imaging and invasive hemodynamics)?

17. What are the indications for medical therapy in AR and of what do Those therapies consist?

18. What are the indications for mechanical therapy of AR and of what do Those therapies consist?

19. What is the prognosis following treatment

Severe Acute AR

Bibliography

2 Pathology Insights of Aortic Valve Disease

Introduction

1. What is the normal anatomy of the aortic valve?

2. What are the etiologies of aortic valve diseases?

3. What is the epidemiology of aortic valve disease?

4. What is the pathology of tricuspid calcific aortic stenosis?

5. What is the etiology of bicuspid aortic valve?

6. What is the classification of bicuspid aortic valves?

7. What are the pathologic findings of a bicuspid aortic valve?

8. What are the classification and pathology of the unicuspid aortic valve (UAV)?

9. What are the differences between the pathological findings in tricuspid vs. bicuspid vs. unicuspid aortic valves?

10. What are the risk factors for calcific aortic stenosis?

11. What are the underlying mechanisms of aortic valve calcification?

Conclusion

Bibliography

3 The Top Ten Clinical Trials in Patients Undergoing Transcatheter Aortic Valve Implantation

1. Who invented TAVI, and where were the early studies performed?

2. How was TAVI evaluated in the United States?

Leon, M.B., Smith, C.R., Mack, M. et al. (2010). Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.

N. Engl. J. Med

. 363 (17): 1597–1607.

3. Did PARTNER B affect “clinical equipoise” for randomized trials in non-operable patients?

Popma, J.J., Adams, D.H., Reardon, M.J. et al. (2014). Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery.

J. Am. Coll. Cardiol

. 63 (19): 1972–1981.

4. When did the Heart Team develop, and what has it meant to TAVI decision-making?

Smith, C.R., Leon, M.B., Mack, M.J. et al. (2011). Transcatheter versus surgical aortic-valve replacement in high-risk patients.

N. Engl. J. Med

. 364 (23): 2187–2198.

5. Were the initial concerns about stroke with TAVI justified?

Adams, D.H., Popma, J.J., Reardon, M.J. et al. (2014). Transcatheter aortic-valve replacement with a self-expanding prosthesis.

N. Engl. J. Med

. 370 (19): 1790–1798.

6. What contributed to the differences in one-year mortality between TAVI and surgery patients?

Leon, M.B., Smith, C.R., Mack, M.J. et al. (2016). Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.

N. Engl. J. Med

. 374 (17): 1609–1620.

Reardon, M.J., Van Mieghem, N.M., Popma, J.J. et al. (2017). Surgical or transcatheter aortic-valve replacement in intermediate-risk patients.

N. Engl. J. Med.

376 (14): 1321–1331.

7. What have we learned about the assessment of valve durability?

Feldman, T.E., Reardon, M.J., Rajagopal, V. et al. (2018). Effect of mechanically expanded vs self-expanding transcatheter aortic valve replacement on mortality and major adverse clinical events in high-risk patients with aortic stenosis: the REPRISE III randomized clinical trial.

J. Am. Med. Assoc

. 319 (1): 27–37.

Mack, M.J., Leon, M.B., Thourani, V.H. et al. (2019). Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.

N. Engl. J. Med

. 380 (18): 1695–1705.

Popma, J.J., Deeb, G.M., Yakubov, S.J. et al. (2019). Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.

N. Engl. J. Med

. 380 (18): 1706–1715.

Makkar, R.R., Cheng, W., Waksman, R. et al. (2020). Self-expanding intra-annular versus commercially available transcatheter heart valves in high and extreme risk patients with severe aortic stenosis (PORTICO IDE): a randomised, controlled, non-inferiority trial.

Lancet

396 (10252): 669–683.

8. What did we learn about subclinical leaflet thrombosis from this study?

9. What are other areas of improvement for TAVI?

10. What should be considered for the lifetime management of patients undergoing TAVI?

11. What patient subsets have yet to be studied?

Conclusions

Bibliography

4 Present and Future Generations of Transcatheter Aortic Valves

1. What life-long management is required for patients undergoing TAVR

2. How is TAVR used for low-surgical-risk patients?

3. Describe the hemodynamics after TAVR

4. How durable is TAVR?

5. Describe coronary access after TAVR.

6. Describe pacemaker implantation after TAVR

7. What is the present generation of transcatheter valves?

8. What is the future generation of transcatheter valves?

Conclusions

Bibliography

5 Computed Tomography for Transcatheter Aortic Valve Replacement Planning

Introduction

1. What Is the best way to approach pre-procedural CT assessment, patient preparation, contrast administration, scanning protocol, and data-reconstruction techniques in patients undergoing CT evaluation prior to TAVR?

2. What is the best way to analyze aortic valve calcium extension, scoring, and its clinical significance?

3. What is the best approach for aortic valve annular evaluation and sizing?

4. What is the best way to evaluate the aorta on CT scan prior to TAVR, and what is the evaluation's clinical significance?

5. What are the TAVR access sites, and how are they evaluated on a CT scan?

6. What is the importance of assessing the suitability of carotid embolic protection devices prior to TAVR?

7. What is the best way to evaluate coronary arteries and coronary bypass grafts using CT scan?

8. What is the importance of reporting the CT scan functional assessment, and what is the significance of cardiac and non-cardiac incidental findings?

9. What is the best way to use myocardial extracellular volume (ECV) as a potential screening for cardiac amyloidosis and myocardial fibrosis?

10. What is the best way to perform CT evaluation of valve-in-valve TAVR?

11. What are the CT assessments in patients with bicuspid aortic valve prior to TAVR?

Bibliography

6 Optimal Selection of TAVR Devices

1. What types of transcatheter aortic valve replacement devices are commercially available?

2. Are other TAVR devices under clinical investigation?

3. Is there evidence to claim superiority of one type of TAVR device over the others?

4. Are there situations in which one valve should be considered over another?

5. Does annular size affect the choice of valve?

6. What type of valve should be chosen based on aortic valve calcification?

7. How does the risk of conduction abnormalities influence the choice of the TAVR device?

8. Why are the risk of coronary occlusion and the need to reaccess the coronaries are important?

9. What is the impact of aortic angulation on TAVR outcomes?

10. What about bicuspid aortic valves?

11. Should any other factors be considered for optimal selection of TAVR device?

Clinical Vignette

Bibliography

7 Transcatheter Aortic Valve Replacement

1. What is transcatheter aortic valve replacement (TAVR)?

Patient Evaluation

2. What are the current indications for TAVR?

3. Are there any absolute contraindications to TAVR?

Step-By-Step TAVR Approach

4. What are the pre-procedural approach to and planning for successful TAVR?

5. What are the steps during the TAVR procedure?

Vascular Access

6. What is the approach for vascular access during TAVR?

7. What is the current best practice to establish femoral access safely?

8. For patients with inadequate femoral access, what are the potential options for alternative arterial access for transcatheter valve delivery?

9. What is the approach to axillary/subclavian artery access?

10. What is the approach to carotid artery access?

11. What is the approach for transaortic access for TAVR?

12. What is the approach to transcaval access for TAVR?

13. What is the approach to antegrade, transapical access?

14. What is the approach to antegrade, transseptal access?

15. What are the optimal vascular closure techniques for large-bore vascular access during TAVR?

Balloon-Expandable Transcatheter Aortic Valve Replacement

16. What are the components of the Edwards SAPIEN balloon-expandable valve?

17. What are the essential considerations during balloon-expandable TAVR?

Self-Expanding Transcatheter Aortic Valve Replacement

18. What are the components of the self-expanding valve and catheter system?

19. What are the essential considerations during self-expandable TAVR?

20. Can the Evolut valve be repositioned during deployment?

21. After valve implantation, how is adequate valve position confirmed?

Conclusion

Bibliography

8 Balloon Aortic Valvuloplasty

1. What are the guideline recommended indications for aortic balloon valvuloplasty (BAV)?

2. What are the contra-indications to aortic balloon valvuloplasty?

3. What are the goals of BAV and what defines a successful BAV?

4. What is the incidence of complications in BAV?

5. What are the balloon sizing considerations for BAV?

6. Which types of balloons are available for BAV?

7. What is the technique used to cross stenotic aortic valve?

8. How is the valvuloplasty balloon stabilized across the aortic valve during inflation?

9. What is the role of valvuloplasty in patients undergoing TAVR?

10. What is the role of BAV in patients with low-flow, low-gradient aortic stenosis?

11. What is the role of BAV to reduce cardiac complications of patients requiring non-cardiac surgery?

12. What is the post-procedure care of BAV patients?

13. What are the options for hemodynamically assisted aortic valvuloplasty?

Bibliography

9 Challenging Anatomy Scenarios in TAVR

Aortic Root

1. During

transcatheter aortic valve replacement

(

TAVR

), what are important principles for patients with severe aortic leaflet and annular calcification?

2. What unique risks exist during TAVR when there is minimal aortic leaflet and annular calcium?

3. How does

sinotubular junction

(

STJ

) calcification affect valve deployment?

4. What does “horizontal aorta” refer to during TAVR, and what techniques are required in this situation?

5. How should LVOT calcification affect valve deployment?

6. What is the role of TAVR in patients with bicuspid aortic valve disease?

7. What can be done for patients with a small aortic annulus?

8. How should a valve be correctly sized in an extremely large annulus?

9. What are the options for annular sizing in patients who cannot receive

computer tomography

(

CT

) with contrast?

Coronary Arteries

10. For what patient anatomy should you consider protecting the left main coronary artery?

11. How should you perform TAVR if a patient will likely need a future

percutaneous coronary intervention

(

PCI

)?

Aorta

12. Is it possible to perform a TAVR in a patient with an ascending aortic aneurysm?

13. What techniques allow transfemoral access for patients with a tortuous descending aorta?

14. Does the presence of a bovine arch prevent the placement of a cerebral embolic protection device?

Femoral Arterial Access

15. How can transfemoral TAVR be performed if there is significant iliac artery calcification?

16. How can transfemoral TAVR be performed if there is significant femoral artery calcification?

17. What can be done if there is only one patent iliofemoral artery?

18. If iliofemoral access is not feasible, what are different options for alternate access?

Valve-in-Valve (ViV)

19. When performing ViV TAVR, how do you choose the correct transcatheter valve?

20. What are the relevant considerations when potentially fracturing an existing surgical valve prior to ViV implantation?

21. What can be done if there is a high risk of coronary artery obstruction with ViV TAVR?

Bibliography

10 TAVR for Bicuspid Aortic Valve

Epidemiology

1. What is the prevalence of bicuspid aortic valves?

2. How is BAV identified?

3. How do patients with bicuspid AS undergoing transcatheter aortic valve replacement compare to patients with tricuspid AS?

Bicuspid Valve Morphology

4. Match the illustrated valve morphologies to the correct bicuspid phenotypes according to the conventional Sievers classification and the newly derived CT classification (see figure 10.1).

5. What anatomical characteristics commonly associated with BAVs may complicate TAVR?

Procedural Planning

6. What considerations should be taken into account when choosing a THV type (annular/supra-annular; balloon-expandable/self-expanding)?

7. Can computer simulation complement pre-procedural TAVR planning?

8. What sizing strategies exist for selecting THV size in bicuspid AS?

9. What is recommended for pre-dilatation and post-dilatation?

Outcomes

10. How do outcomes of TAVR in bicuspid AS compare with tricuspid AS?

11. Describe how the different bicuspid phenotypes (see question 4) impact outcome after TAVR.

12. What features of the newer-generation THVs significantly improved the outcome of TAVR?

Bibliography

11 TAVR for Pure Native Valve Aortic Regurgitation

1. How common is aortic regurgitation (AR)?

2. What are the most common causes of NAVR?

3. What are the natural history and prognosis of AR?

4. What are the indications and the best timing for intervention of the aortic valve in AR?

5. What is the recommended therapy for patients with severe NAVR and indication for intervention?

6. What are the challenges of TAVR in pure NAVR?

7. What is the available evidence evaluating TAVR for pure NAVR?

8. What is the preferred type of THV for TAVR in pure NAVR?

9. What are some critical technical considerations?

Bibliography

12 Aortic Valve-in-Valve Interventions

1. Why are aortic valve-in-valve procedures needed?

2. Why are ViV TAVR outcomes better than native valve TAVR?

3. What are the primary limitations of aortic ViV TAVR?

4. Why does the mechanism of bioprosthetic valve failure matter?

5. How do you plan for a ViV procedure?

6. How do you avoid PPM in aortic ViV procedures?

Supra-Annular vs. Intra-Annular Design

Implantation Technique (High vs. Low)

High-Pressure Post-Dilation and Balloon Valve Fracture

7. How do you prevent and treat coronary obstruction?

BASILICA Procedure

Chimney Technique

8. How important is adjunct pharmacology after ViV-TAVI?

Bibliography

13 Prevention and Management of Coronary Artery Obstruction in TAVR

1. What is the incidence of coronary artery obstruction in transcatheter aortic valve replacement (TAVR)?

2. What is the mechanism of coronary artery obstruction in TAVR?

3. Which coronary artery is most commonly obstructed during TAVR?

4. What is delayed coronary obstruction after TAVR?

5. What are the symptoms of coronary artery obstruction in TAVR?

6. What are the outcomes for patients that have coronary artery obstruction with TAVR?

7. What are risk factors for coronary artery obstruction with TAVR?

8. How do you prevent coronary artery obstruction with TAVR?

9. What is the treatment for coronary artery obstruction with TAVR?

10. What is preparatory coronary protection?

11. Explain the BASILICA procedure.

Bibliography

14 Coronary Artery Disease and Transcatheter Aortic Valve Replacement

1. How common is coronary artery disease (CAD) in patients with severe aortic stenosis (AS)?

2. What is the clinical impact of CAD on TAVR outcomes?

3. How do you assess for CAD prior to TAVR?

4. Can you use the instantaneous wave-free ratio (iFR) in patients with severe AS?

5. What is the role of percutaneous revascularization in TAVR?

6. What is the recommendation for the management of left main (LM) disease prior to TAVR?

7. What is the optimal timing for revascularization in patients being evaluated for TAVR?

8. What about completeness of revascularization in patients undergoing TAVR?

9. Are there technical considerations in patients undergoing PCI post-TAVR?

10. What is the current guideline for revascularization in patients undergoing TAVR?

Bibliography

15 Conduction Disturbances Associated with TAVR

1. What is the relationship between the aortic valve structures and the conduction system?

2. What is the incidence of conduction disturbances associated with TAVR?

3. What is the clinical impact of conduction disturbances after TAVR?

4. What are the predictors of conduction disturbances and PPI associated with TAVR?

5. What strategies can be implemented to prevent or minimize conduction disturbances associated with TAVR?

MIDAS Approach

Cusp Overlap Technique

Advantages of the Cusp Overlap Technique

Disadvantages of the Cusp Overlap View

High-implantation Technique for the Balloon-Expandable SAPIEN 3 Valve

6. Describe post-procedural monitoring and electrophysiological assessment after TAVR.

Bibliography

16 Management of Conduction Disturbances Post-TAVR

1. What are the components of normal conduction from sinus node to ventricular tissue?

2. Match the components of the conduction system to the following intervals

3. What components of the conduction system are susceptible to injury during

transcatheter aortic valve replacement

(

TAVR

) implantation?

4. At what operative stage can AV conduction abnormalities be encountered?

5. What changes to the EKG can be anticipated after TAVR?

6. What pre-operative EKG finding is the strongest predictor of post-TAVR conduction disturbances and pacemaker requirement? Why?

7. What procedural factors have been associated with higher risk of post-TAVR conduction disturbances?

8. At what point should a 12-lead EKG be performed to determine the duration of temporary pacing wire and post-operative telemetry?

9. A patient with the pre-operative EKG shown here undergoes TAVR. No change in EKG is seen at the end of the procedure. What is recommended for the duration of temporary pacing and telemetry monitoring?

10. What is the likelihood that a patient with this EKG will require a pacemaker implant after TAVR?

11. The patient in question 10 has no change in the 12-lead EKG at the end of the procedure. How long after the TAVR procedure is temporary pacing recommended?

12. A patient who undergoes TAVR has the pre-operative EKG shown in (a) and the post-procedure EKG shown in (b). What management decisions are recommended for this scenario?

13. The patient from question 12 develops the following EKG 10 hours after LBBB was noticed after TAVR. What pacemaker configuration will maintain atrioventricular synchrony?

14. A patient with severe aortic stenosis and moderately reduced systolic function receives TAVR and develops the rhythm shown here, associated with dizziness, post-TAVR. What kind of pacing configuration is less likely to result in persistent systolic dysfunction?

15. Pre-operatively, an 88-year-old man has the EKG shown in (a); 48 hours after TAVR, he has the EKG shown in (b). An electrophysiology study is performed. The intra-cardiac electrocardiograms are shown in (c). Does this patient require a pacemaker?

Bibliography

17 TAVR Mechanical Complications Prevention and Management

Annular Rupture

1. What constitutes annular rupture in TAVR?

2. How do you classify annular rupture after TAVR?

3. How often does annular rupture occur?

4. Why does annular rupture happen with TAVR?

5. What are the risk factors for annular rupture with TAVR?

6. What are the outcomes of annular rupture?

7. How do you diagnose annular rupture?

8. How do you treat annular rupture?

9. How do you prevent annular rupture?

Perforation and Tamponade

10. How does cardiac tamponade occur in TAVR?

11. Why does ventricular perforation occur?

12. How common is ventricular perforation in TAVR?

13. How do you diagnose and manage perforation?

14. What are the outcomes after perforation?

15. How can you prevent cardiac perforations in TAVR?

Bioprosthetic Valve Infolding

16. What is prosthetic valve infolding?

17. What are the consequences of prosthetic valve infolding?

18. Why does valve infolding occur?

19. What are risk factors for valve infolding?

20. How common is valve infolding?

21. How can you diagnose valve infolding?

22. How do you treat valve infolding?

Valve Embolization

23. What is transcatheter valve embolization?

24. How common is valve embolization?

25. What is the cause of TVEM?

26. How do you treat TVEM?

27. How can you prevent TVEM?

Bibliography

18 Pathological Insights of TAVR Degeneration and Thrombosis

Introduction

Bioprosthetic Valve Failure (BVF)

1. What types of valve failure modes are observed in TAVR bioprostheses?

Infective Endocarditis

2. What are the incidence and causative microorganisms of IE after TAVR?

3. What are the pathological findings of IE?

Leaflet Thrombosis

4. What are the clinical relevancies of leaflet thrombosis?

5. What are the pathological findings of valve thrombosis?

Neointimal Coverage and Pannus Formation

6. Is pannus formation seen in the TAVR valve?

7. What are the pathological findings of pannus formation and leaflet endothelialization in TAVR bioprostheses?

Leaflet Calcification

8. What is the cause of leaflet calcification?

9. When is leaflet calcification seen after implantation?

10. What are the pathological findings of leaflet calcification?

Structural Changes (Non-calcific Structural Valve Deterioration)

11. What are the other causes of SVD besides calcification?

Durability of Bioprosthetic Valves

12. Is the durability of TAVR bioprostheses similar to that of SAVR bioprostheses?

13. Is the long-term durability the same in both TAVR and SAVR bioprostheses?

Conclusion

Bibliography

19 Clinical Implications of Valve Thrombosis and Early Thickening

1. What are the risk factors for transcatheter heart valve (THV) thrombosis?

2. What is the role of the routine use of anticoagulation post-

transcatheter aortic valve implantation

(

TAVI

) in the absence and a concurrent anticoagulation indication (such as atrial fibrillation)?

3. For bioprosthetic TAVI patients who do not have other indications for anticoagulation, is it appropriate to use a single antiplatelet agent, or is dual antiplatelet always necessary?

4. In the setting of bioprosthetic TAVI, for whom would dual antiplatelet therapy be indicated?

5. For bioprosthetic TAVI patients who have a stroke while on antiplatelet therapy, would it be reasonable to start on oral anticoagulation in place of antiplatelet therapy?

6. For bioprosthetic TAVI patients who have suspected valve thrombosis and are clinically stable, what would be the initial anticoagulation choice?

7. In the setting of bioprosthetic TAVI, what regimen would be indicated for a patient with concurrent atrial fibrillation and a CHA

2

DS

2

-Vasc Score of 4, but no other indication for antiplatelet therapy?

8. In the setting of bioprosthetic TAVI, what regimen would be indicated for a patient with concurrent atrial fibrillation and a CHA

2

DS

2

-Vasc Score of 4, as well as a recent coronary artery stent?

9. Which bioprosthetic TAVI patients should be on concurrent dual antiplatelet therapy as well as anticoagulation (i.e. triple therapy)?

10. For bioprosthetic TAVI patients with a concurrent indication for anticoagulation, are DOACs a reasonable alternative to VKAs?

11. What are the clinical implications of subclinical valve thrombosis, also called hypoattenuating leaflet thrombosis (HALT)?

Bibliography

20 TAVR and Stroke

Introduction

1. Describe the evidence for TAVR.

Stroke Following TAVR

2. What is the incidence of stroke following TAVR?

3. What are the predictors and impact of stroke associated with TAVR?

Management of TAVR-Related Stroke

4. How can you prevent stroke related to TAVR?

5. What is the best way to treat stroke related to TAVR?

Conclusions

Bibliography

21 Current Evidence of Neuroprotection in TAVR

Peri-Procedural Stroke

1. Is the occurrence of peri-procedural strokes still the Achilles' heel of TAVR?

2. What is the underlying mechanism of stroke in TAVR patients?

3. What are the consequences of debris embolizing to the brain?

The Rationale for Cerebral Embolic Protection Devices

4. How many TAVR patients are affected by embolized debris?

5. What kind of EPDs are currently available for TAVR?

6. Are other technologies in the pipeline?

Characteristics of Dislodged Debris

7. What kind of debris may embolize toward the brain?

8. What is the captured debris size?

9. Are there any predicting factors for the dislodgement of debris?

10. Who might benefit most from protected TAVR?

Clinical Evidence of Neuroprotection In TAVR

11. Is there a proven clinical benefit from randomized controlled trials (RCTs) to underpin the systematic use of cerebral embolic protection in TAVR?

12. What will the future bring?

Bibliography

22 Difficult Transfemoral Access for TAVR and Bailout Techniques

1. What are the benefits of transfemoral access?

2. What is considered “high-risk” vascular anatomy for transfemoral TAVR?

3. How common is severe peripheral arterial disease in severe aortic stenosis patients?

4. How do you plan for a successful transfemoral TAVR procedure?

5. What are the most important technology developments for TF access success?

How to Approach High-Risk Vascular Anatomies

6. How do you approach small vessels?

7. Can endovascular pretreatment of iliofemoral atherosclerotic disease be performed?

8. How do you approach significant calcific peripheral disease?

9. How do you approach severe vascular tortuosity?

10. Can TF TAVR be performed in patients with abdominal aortic aneurysms?

Bibliography

23 Alternative Access for TAVR

1. Why is TF access the gold standard for TAVR?

2. How are transapical and direct aortic access performed?

3. What are the important considerations when selecting transaxillary (TAx) access for TAVR?

4. How is TAx TAVR performed?

5. What are the advantages and important considerations of transcarotid (TC) access?

6. What is the physiology that allows for transcaval (TCV) access and prevents a life-threatening retroperitoneal bleed?

7. How is TCV access for TAVR performed?

8. How is TCV access closure performed?

Conclusion

Bibliography

24 Vascular Access and Closure Options for TAVR

1. What constitutes pre-procedural vascular access evaluation?

2. What is the gold standard imaging technique for the anatomic evaluation of arterial access sites before TAVR?

3. What is the optimal arterial puncture technique for common femoral artery access?

4. What is the best technique for fluoroscopic confirmation of vascular sheath insertion in the common femoral artery?

5. What are the technical considerations to obtain optimal carotid and axillary artery access?

6. What are the technical considerations to obtain optimal transcaval access, and what techniques are helpful to achieve hemostasis after removal of large-caliber sheaths following transcaval approach?

7. What vascular closure devices are currently recommended after transfemoral interventions with large-caliber vascular sheaths?

8. What accounts for vascular access-site and access-related complications?

9. What is the incidence of vascular access complications?

10. What is the most appropriate management of an arterial dissection?

11. What is the most appropriate management of an arterial perforation?

12. What is the most appropriate management of retroperitoneal bleeding?

13. What is the most appropriate management of acute limb ischemia?

14. What methods can be used to prevent ischemic limbs when large bore access is occlusive?

Bibliography

Part II: Structural Interventions for the Mitral Valve

25 The Natural History of Mitral Valve Disease

Mitral Stenosis

1. What are the causes of mitral stenosis (MS)?

2. What are the hemodynamic consequences of MS?

3. How are the hemodynamics of MS translated into symptoms?

4. How are the hemodynamics of MS translated into physical exam findings?

5. How is MS diagnosed (imaging and invasive hemodynamics)?

6. What are the indications for medical therapy of MS, and what do those therapies consist of?

7. What are the indications for mechanical therapy of MS, and what do those therapies consist of?

8. What is the prognosis of MS?

Mitral Regurgitation

9. What are the two major classes of MR? How do they differ in prognosis and therapy?

Primary Mitral Regurgitation

10. What are the major etiologies of PMR?

11. What are the hemodynamics of PMR?

12. How are PMR hemodynamics translated into symptoms?

13. How are PMR hemodynamics translated into physical signs?

14. How is PMR diagnosed (imaging and invasive hemodynamics)?

15. What are the indications for medical therapy in PMR, and what do those therapies consist of?

16. What are the indications for mechanical therapy of PMR, and what do those therapies consist of? What is the prognosis following treatment?

Secondary Mitral Regurgitation

17. What are the major etiologies of SMR?

18. What are the hemodynamics of SMR?

19. What are common myths about the hemodynamics of SMR?

20. How are SMR hemodynamics translated into symptoms?

21. How are SMR hemodynamics translated into physical signs?

22. How is SMR diagnosed (imaging and invasive hemodynamics)?

23. What are the indications for medical therapy in SMR, and what do those therapies consist of?

24. What are the indications for mechanical therapy of SMR, and what do those therapies consist of?

25. What is the prognosis of SMR?

Bibliography

26 Hemodynamic Assessment of the Mitral Valve

Mitral Stenosis

1. Why is it important to distinguish between rheumatic and nonrheumatic calcific mitral stenosis?

2. What is the pathophysiology leading to the hemodynamic consequences of MS?

3. When is it reasonable to consider intervention for MS?

4. What are the findings on invasive hemodynamic assessment to suggest severe MS?

5. What are the pitfalls of using PCWP as surrogate for LA pressure?

6. What can cause an elevated transmitral gradient?

7. What are the expected hemodynamics before and after PMBV?

8. What is a dreaded immediate complication to monitor for during PMBV?

Mitral Regurgitation

9. What are the common causes of primary and secondary MR?

10. What is the difference in pathophysiology leading to the hemodynamic consequences of acute vs. chronic MR?

11. What are mimickers that lead to a prominent

v

wave on PCWP or LA pressure tracings?

12. When is it reasonable to consider percutaneous intervention for MR?

13. What is the concept of

proportionately

and

disproportionately

severe secondary MR?

14. Alternatively, what is the difference between atrial and ventricular functional MR (AFMR vs. VFMR)?

15. What are the percutaneous MV interventions currently available and under investigation?

16. What are the expected hemodynamic changes after the most common percutaneous edge-to-edge repair with MitraClip?

Bibliography

27 Echocardiographic Assessment Prior to Mitral Valve Edge-to-Edge Repair

1. What is edge-to-edge mitral valve repair?

2. What is the role of pre-procedural transthoracic echocardiography (TTE) prior to edge-to-edge mitral valve repair?

3. How is MR classified?

4. Which patients with primary MR would benefit the most from percutaneous edge-to-edge repair?

5. Which patients with secondary MR would benefit the most from percutaneous edge-to-edge repair?

6. Which are the most important views in the pre-procedural TTE?

7. Why is pre-procedure transesophageal echocardiography (TEE) important?

8. Which are the most important pre-procedural TEE views to assess for edge-to-edge mitral valve repair?

9. What are the applications of 3D pre-procedural TEE for edge-to-edge repair?

10. What are the differences between real-time 3D and multi-beat 3D acquisition, and how does this affect edge-to-edge mitral valve repair?

11. Does 3D TEE add any information to the quantification of MR?

12. From the EVEREST trial, which anatomy is considered suitable?

13. Pair the figures with the appropriate measurements: (a) coaptation length, (b) coaptation depth, (c) flail gap, and (d) flail width.

14. Which is the appropriate location for transseptal puncture?

Bibliography

28 Intra-procedural Transesophageal Echocardiography for Mitral Valve Structural Interventions

1. Who is “qualified” to perform intra-procedural transesophageal echocardiography (TEE) for structural interventions on the mitral valve (MV)?

2. Which structural mitral interventions is TEE most used for?

3. What are the major views in 2D TEE used for MV structural interventions?

4. Are there any advanced 2D imaging techniques that are useful in guiding structural heart interventions?

5. What are the major views in 3D TEE used for MV structural interventions?

6. Which 3D imaging modalities are most used in structural mitral interventions?

Septal Puncture

7. How is TEE used to guide TSP?

8. What are the procedural-specific considerations for the echocardiographer during TSP?

Edge-to-Edge Repair

9. What measurements are commonly made by echocardiography prior to an edge-to-edge repair?

10. What are the steps and imaging considerations for edge-to-edge repair?

11. What are the unique features of the different generations of MitraClip devices that echocardiographers should be familiar with?

12. What are some common “tricks” that can be used to help with leaflet grasp during the clip procedure?

13. What are the key complications during MitraClip that echocardiographers need to consider?

TMVR

14. What is the role of the echocardiographer in TMVR?

15. How do echocardiographers assist in sizing a valve during valve-in-valve and native valve TMVR?

16. How do echocardiographers aid in valve deployment?

17. Which echocardiographic parameters can predict LVOTO in native valve TMVR?

Balloon Valvuloplasty

18. Are there any special considerations the echocardiographer should be aware of during balloon valvuloplasty?

19. What echocardiographic guided procedures are on the horizon?

20. What are the health system implications of a growing field of structural heart interventions, as it relates to echocardiography?

Paravalvular Leak Closure

Bibliography

29 Surgical Trials in Mitral Valvular Disease

1. Describe the surgical therapy for acute MR.

2. Discuss recent publications on mitral valve reconstruction being superior to replacement in chronic structural MR.

3. Discuss recent publications about MV replacement having similar and non-inferior results in patients with secondary MR.

4. Describe two published randomized trials assessing the outcome of percutaneous MV repair using the MitraClip for therapy of secondary MR.

5. What are the surgical indications for MV repair?

6. Describe the “double-orifice” surgical repair technique described by Alfieri et al.

7. What are the surgical details of performing mitral ring annuloplasty?

8. Should you resect the entire leaflet when replacing the valve?

9. What is the ideal vascular access for VA extracorporeal membrane oxygenation (ECMO) implantation in patients undergoing mitral clip implantation?

10. What are the possible surgical complications during and/or post surgical MV insertion?

11. What size of surgical MV prosthesis placement enables later valve-in-valve implantation?

12. Is persistent MR a negative predictive factor for patients requiring left ventricular assist device (LVAD) insertion?

13. Why should the Heart Team discuss structural cases in detail before the procedure?

14. The Heart Team is consulted on a case with persistent atrial septal defect (ASD) and a left-to-right shunt following mitral clip placement. What is the therapeutic intervention?

Bibliography

30 Surgical Techniques for Mitral Valve Repair

1. What are the stages of primary mitral regurgitation (MR)?

2. When should patients be considered for surgical repair of their MR?

3. Should mitral valves (MVs) be repaired or replaced? What are the advantages?

4. What is SAM, and what are the risk factors for developing it?

5. What is the best initial step when SAM is identified while coming off cardiopulmonary bypass?

6. What should a surgeon do if SAM is still present after initial conservative measures to slow the heart rate and reduce inotropic support?

7. Describe standard surgical approaches to the MV

8. Which patients should be considered for MitraClip or other transcatheter edge-to-edge repair?

9. When should a surgeon consider a MV replacement? What techniques should be used?

10. What is a papillary muscle sling, and when may it be of benefit?

11. How much MR is acceptable following a mitral repair?

12. When is the appropriate time to assess the success of MV repair?

13. What are the advantages of a Heart Team and center of excellence?

Bibliography

31 Structural Interventions for Mitral Stenosis

1. What are the current classification criteria for mitral stenosis (MS)?

2. What are the current indications and contraindications for percutaneous MV intervention in rheumatic MS?

3. What are the predictors of successful/failed PMV?

4. What are the techniques for PMV?

Mitral Balloon Valvuloplasty

5. What are the steps to perform PMV with the Inoue technique?

Equipment List

Balloon Selection

Procedure Detail

6. What are the steps to perform PMV with the antegrade double-balloon technique?

Balloon Selection

Procedure Detail

7. What is the follow-up protocol after PMV?

8. What are the potential complications of PMV?

Hemopericardium

Mitral Regurgitation

Iatrogenic Interatrial Septal Defect

9. What is the role of transcatheter therapy for rheumatic MS in women who are pregnant or contemplating pregnancy?

Before Pregnancy

During Pregnancy

10. What is the role of PMV in patients with aortic regurgitation?

11. What is the role of PMV in patients with concomitant severe tricuspid regurgitation?

12. Should PMV be attempted in patients with MV calcification?

13. Can PMV be done in patients with previous PMV?

14. What are the roles of transcatheter intervention in patients with nonrheumatic calcific MS?

15. What are the current and future transcatheter therapies for nonrheumatic MS?

Transcatheter Mitral Valve Replacement (TMVR) Using Balloon-Expandable Transcatheter Aortic Valves in Mitral Position

Future Directions of TMVR in Non-rheumatic MS

Bibliography

32 Transcatheter Edge-to-Edge Repair Trials

Edge-to-Edge Mitral Valve Repair (EVEREST Trials)

1. What is the difference between primary and secondary mitral regurgitation?

2. What is the basis of edge-to-edge mitral valve (MV) repair?

3. What was the purpose of the EVEREST Phase I clinical trial?

4. What were the results of EVEREST Phase 1?

5. What was the basis of the EVEREST II trial?

6. Describe the patient population in EVEREST II

7. What were the endpoints for comparison used in EVEREST II?

8. What were the results of EVEREST II?

9. What are the takeaway messages of EVEREST II?

Secondary MR and Transcatheter Repair (COAPT Trial)

10. What was the purpose of the COAPT trial?

11. Describe the patient population of the COAPT trial.

12. What were the endpoints of the COAPT trial?

13. What were the results of the COAPT trial?

14. What are the takeaway messages from the COAPT trial?

15. What are the guidelines for transcatheter MV repair in secondary MR?

Bibliography

33 Mitral Valve TEER

Introduction

1. What are the anatomical and pathophysiologic considerations of the mitral valve in evaluating patients for TEER?

2. What is the difference between primary mitral valve insufficiency related to degenerative mitral valve disease and secondary functional mitral insufficiency?

3. What is the Heart Team approach to evaluation for mitral valve therapies?

4. What patients are appropriate to consider for surgical mitral valve repair vs. the TEER procedure using the MitraClip device?

5. What are the current indications for the TEER procedure using the MitraClip device?

6. Are there any absolute contraindications to TEER?

7. Aside from the absolute contraindications, what are the relative contraindications to be aware of for TEER?

8. Is the presence of a transcatheter atrial septal defect (ASD) occlusion device a contraindication for TEER?

9. What are the important aspects and key questions in the pre-procedural imaging during the pre-operative evaluation for TEER?

10. In degenerative valve disease including mitral valve prolapse and/or flail mitral valve leaflets, what are the important aspects to assess during the pre-procedural TEE?

11. What are the anatomical considerations for percutaneous TEER?

12. What are the minimal MVA requirements for TEER?

13. What are the important aspects in the assessment of the atrial septum for adequate transseptal access?

14. What are the current literature and trial results using TEER for the treatment of degenerative mitral valve insufficiency?

15. What are the current data for the treatment of functional mitral valve insufficiency?

16. Why do the results from the MITRA-FR and COAPT studies differ so significantly?

17. What are the real-world experience and outcomes using the MitraClip for TEER?

The MitraClip Device

18. What are the components of the MitraClip catheter system?

19. What are the differences between the currently available clips?

20. Are there any evidence-based recommendations for using the NTR vs. XTR clips?

Echocardiographic Imaging

21. What is the role of echocardiography and TEE during TEER?

22. What are the essential TEE views to obtain during TEER?

Procedure

23. What are the steps involved in TEER?

24. What are the preferred access site and vascular closure approaches during TEER?

25. What equipment is necessary for transseptal puncture for TEER?

26. What is the procedure for transseptal puncture for TEER?

27. What are the optimal TEE views during transseptal puncture?

28. What is the optimal positioning for transseptal puncture for TEER?

29. How is the delivery system advanced into the LA?

30. How is the delivery system advanced into the LA and directed toward the mitral valve leaflets?

31. What are the steps for grasping the leaflets with the MitraClip?

32. Prior to deployment, how is the MitraClip assessed to ensure adequate position, grasp, and results?

33. How do you assess mitral valve stenosis during clip deployment?

34. What should you do if the device becomes entrapped in the chordal apparatus during TEER?

35. After deployment, how is the adequacy of the edge-to-edge repair assessed?

36. If there is residual MR after the initial MitraClip, can additional clips be placed? How does the operator decide when and how to deliver additional clips during TEER?

Special Patient Subgroups and Considerations

37. Can TEER still be used in patients with complex mitral valve pathology?

38. Can TEER still be used in patients with mitral valve and/or mitral annular calcification?

39. What are the applications and limitations of TEER in patients with restricted posterior mitral valves, mitral valve clefts, and/or flail mitral valve leaflets?

Conclusion

Bibliography

34 TEER Challenging Anatomy and MitraClip Tips and Tricks

Introduction

1. What are the Alfieri stitch and transcatheter edge-to-edge repair techniques?

2. What is the MitraClip system?

MitraClip for the Myxomatous Mitral Valve

3. What are the anatomical findings of myxomatous mitral valve disease?

4. Where are some key strategies to increase success in TEER treatment of DMD?

5. When should an additional clip be placed?

MitraClip for Wide Flail Leaflets

6. What is considered a wide flail MV prolapse?

7. What are the technical considerations when treating wide flail mitral leaflets?

Noncentral and Commissural Lesions

8. How common is noncentral MR, and can it be treated using TEER?

9. Where should the transseptal puncture be positioned for medial mitral regurgitant lesions?

10. How is the optimal MitraClip arm angle determined?

11. What are the strategies to avoid and deal with entanglement?

12. How can vascular plugs and cardiac occluders be used to treat commissural lesions?

Calcified Mitral Valve

13. Did the EVEREST and COAPT trials include patients with calcification of the MV?

14. Is TEER feasible in patients with calcified MV apparatus?

Secondary Mitral Regurgitation

15. What are the anatomical considerations of secondary MR?

16. What are the key strategies to success in treating secondary MR?

17. When should an additional clip be placed?

Bibliography

35 MitraClip Complications

Introduction

1. What is the incidence of vascular complications from the MitraClip procedure?

2. How can you prevent vascular complications during the MitraClip procedure?

Transseptal Puncture Complications

3. What are the complications of a transseptal puncture during the MitraClip procedure?

Complications from Device Navigation in the Left Atrium: Air Embolism and Thrombus Formation

4. What are the complications of device navigation in the LA?

Complications from Leaflet Grasping

5. What complications may occur during leaflet grasping?

6. What is a single leaflet device attachment?

7. How is SLDA treated?

8. How is SLDA prevented?

9. What is the incidence of MitraClip embolization?

10. How can you manage clip embolization?

Complications from Device Deployment

11. What is the incidence of residual MR after the MitraClip procedure?

12. How is residual MR treated?

13. What is the incidence of iatrogenic MS after MitraClip implantation?

14. What are the complications of elevated mean MV gradients post-MitraClip implantation?

15. How can you prevent iatrogenic MS?

16. What is the incidence of iatrogenic atrial septal defects post-MitraClip procedure?

17. What are the clinical implications of persistent iASD?

18. What are the indications for device closure of persistent iASD?

Bibliography

36 CT Imaging for TMVR

1. What are the important components of the mitral valve apparatus that are important to know for TMVR planning?

2. What is the role of echocardiography in TMVR?

3. What are the advantages of utilizing multi-detector computed tomography (MDCT) in TMVR planning?

4. What are the basic CT scanner image acquisition concepts and technical protocols required for obtaining a usable mitral CT?

5. How is the TMVR landing zone sized and evaluated?

6. What is the neo-LVOT?

7. How can neo-LVOT be predicted?

8. What factors make neo-LVOT prediction modeling complex?

9. Which type of TMVR is at greatest risk of LVOT obstruction: valve-in-valve, valve-in-ring, or valve-in-MAC?

10. How can CT imaging estimate the coplanar fluoroscopic angle?

11. What are other relevant adjacent structures to consider in CT planning for TMVR?

12. What are the important measurements and characteristics to define prior to the transseptal approach for TMVR?

13. What are the important measurements and characteristics to define prior to the transapical approach for TMVR?

14. What is the role of CT in post-procedural imaging?

Conclusion

Bibliography

37 Transcatheter Mitral Valve Replacement

1. What is the best way to approach a patient with a failing bioprosthetic mitral valve?

2. What are the important anatomic variables on cardiac computerized tomography to consider when evaluating a patient for TMVR suitability?

3. What is the best way to approach and evaluate a patient with a failing mitral ring in preparation for a ViR procedure?

4. What are the ideal rings in the market for ViR procedures?

5. What fluoroscopic landmarks are important for positioning THVs for ViV and ViR procedures?

6. What are the available treatment options for severe mitral annular calcification?

7. What are favorable characteristics for transcatheter valve anchoring in severe mitral annular calcification?

8. What is the ideal location for a transseptal puncture for TMVR?

9. What are the indications to close the transseptal septostomy site after TMVR?

10. What are the steps taken to perform the procedure?

11. What are potential complications associated with TMVR and the solutions to managing them?

12. What are the contraindications for ViV or ViR procedures?

13. What are the procedural success rates and complications associated with TMVR?

14. What factors are responsible for left ventricular outflow tract obstruction (LVOTO) after ViV and ViR?

15. What is the anticoagulation/antiplatelet strategy after TMVR?

16. What cases are better performed transseptal vs transapical?

Conclusion

Bibliography

38 Transseptal Transcatheter Mitral Valve-in-Valve Replacement (TS MViV)

1. What are the important pre-procedural considerations in transseptal mitral valve-in-valve replacement ?

2. What are the important recommendations for patient preparation and the room setting for the TS MViV procedure?

3. What steps should be followed for a successful TS MViV procedure?

4. What is important for vascular access during TS MViV?

5. Should the femoral vein access be pre-closed?

6. How do you obtain baseline LVOT hemodynamics during TS MViV?

7. How do you perform a safe transseptal puncture at an optimal location for TS MViV?

8. When do you insert the Edwards E sheath?

9. How do you cross the surgical mitral valve into the LV?

10. How do you perform atrial septostomy dilation?

11. How do you prepare the transcatheter valve for the TS MViV?

12. Should the surgical mitral valve be pre-dilated?

13. How do you advance and position the delivery system?

14. How do you cross the septum and the mitral valve with the delivery system and THV?

15. How do you position and implant the THV during TS MViV?

16. What is important in the post–valve deployment assessment?

17. When should atrial septostomy closure be considered?

18. How do you obtain adequate hemostasis at the vascular access site?

Potential Obstacles and Bailout Strategies

19. What can be done if the THV is not crossing the septum?

20. What can be done if the THV is not crossing the mitral orifice?

Bibliography

39 Transseptal Systems for TMVR and Transcatheter Devices for Mitral Annuloplasty

1. Is there any role for percutaneous treatment of mitral valve disease?

2. What are the different transcatheter MV techniques?

3. What is transcatheter mitral valve replacement (TMVR), and how does it differ from transcatheter aortic valve replacement (TAVR)?

4. What TMVR devices are available?

5. What is transcatheter MV repair?

6. What is transcatheter MV annuloplasty?

7. What are some devices for transcatheter indirect MV annuloplasty?

8. What are some devices for transcatheter direct MV annuloplasty?

9. What are some other devices for transcatheter MV repair?

10. What is the future of transcatheter treatment of MV disease?

Bibliography

40 Transcatheter Mitral Valve Replacement

1. What is the rationale for the Tendyne transcatheter mitral valve replacement system?

2. What are the indications and contraindications for considering TMVR with the Tendyne system?

3. What are the anatomic variables to consider on pre-operative imaging when evaluating a patient for TMVR using Tendyne?

4. What is the approach to Tendyne valve implantation, and what are the unique features?

5. What are specific challenges and potential complications of TMVR with the Tendyne system?

Conclusions

Acknowledgments

Bibliography

41 Self-Expanding Transcatheter Mitral Valve Replacement Systems

1. What are the key features of the Medtronic Intrepid transcatheter mitral valve replacement (TMVR) valve?

2. How does the Medtronic Intrepid valve achieve fixation and sealing?

3. How does the Medtronic Intrepid valve heal in the heart?

4. What are the available delivery systems for the Medtronic Intrepid valve?

5. How is the Medtronic Intrepid valve deployed via transapical delivery?

6. What has been the experience with the Medtronic Intrepid transapical delivery system?

7. What has been the experience with the Medtronic Intrepid transseptal delivery system?

Conclusions

Bibliography

Part III: Structural Interventions for the Tricuspid Valve

42 Natural History and Hemodynamic Assessment of Tricuspid Valve Diseases

Epidemiology, Natural History, and Prognosis

1. How prevalent is tricuspid regurgitation?

2. What is the significance of TR?

Anatomy

3. What are the four components of the tricuspid valve?

4. How do we classify TR, and what diseases fall into each category?

5. What are the signs and symptoms of TR?

Evaluation/Diagnosis

6. What are the major imaging modalities used to assess the tricuspid valve?

7. What are the advantages of each of these imaging modalities?

8. How is the tricuspid valve evaluated with echocardiography?

9. What are the characteristics of severe TR?

Management

10. What are the broad categories of TR management?

11. When is surgery considered the preferred option?

12. What are the surgical methods for TR management?

13. Which patients are considered for TTVI?

14. What challenges are associated with TTVI?

15. What are the major categories of TTVI?

Bibliography

43 Indications and Outcomes for Surgical Tricuspid Valve Repair

Tricuspid Regurgitation (Tricuspid Valve Insufficiency)

1. What are known etiologies associated with TR?

2. What is the reported mortality rate for surgical repair of TR?

3. Are there better clinical results using transcatheter tricuspid valve intervention (TTVI)?

4. Describe a surgical assessment and repair technique to repair a tricuspid valve

5. Which transcatheter annuloplasty technique resembles the surgical DeVega and Kay techniques?

6. What are some of the most frequently described surgical annuloplasty systems in the literature?

7. What is the outcome of TR repair and LVAD implantation in patients not responding to advanced medical heart failure therapy?

Bibliography

44 Intra-Procedural Imaging of Tricuspid Valve Edge-to-Edge Interventions

Introduction

1. Is it important to understand the structures adjacent to the tricuspid valve?

2. What should the transesophageal imaging protocol be?

3. Why is Tricuspid valve imaging challenging?

4. What are the steps in TV imaging?

5. How is TR graded?

6. How should post-procedural imaging be graded?

Bibliography

45 Transcatheter Tricuspid Valve Device Landscape

1. What is the magnitude of tricuspid regurgitation disease and its impact on patient outcomes?

2. What is the pathophysiology of TR?

3. What are the current medical and surgical recommendations for managing TR?

4. What are the main surgical TV repair techniques?

5. What are the main challenges associated with transcatheter TV interventions?

6. What transcatheter repair and replacement options are available?

Leaflet-Directed Therapies

Annular-Reshaping Therapies

Direct Ring Annuloplasty Therapies

Indirect Ring Annuloplasty Therapies

Direct Suture Annuloplasty Therapies

Heterotopic Caval Valve Implantation (CAVI)

Bibliography

46 Progress in Transcatheter Tricuspid Valve Repair and Replacement

1. Describe the anatomy of the tricuspid valve.

2. What are the causes and pathophysiology of tricuspid regurgitation?

3. What are the signs and symptoms of TR?

4. What are the indications of treatment of TR in the current guidelines?

5. What constitutes the pre-procedural planning for tricuspid valve intervention?

6. What are the indications of transcatheter tricuspid valve replacement?

7. What are different types, outcomes, and complications of transcatheter tricuspid valve replacement devices?

8. What are the limitations of transcatheter tricuspid valve replacement?

Bibliography

47 Tricuspid Valve-in-Valve and Valve-in-Ring

Tricuspid Regurgitation

1. How is tricuspid regurgitation classified?

2. When should TR be treated?

Surgical TV Annuloplasty

3. What is the rationale behind TV annuloplasty?

4. What are the most common suture-based annuloplasty techniques?

5. What are the properties of prosthetic rings?

6. What are the outcomes of TV annuloplasty?

7. How can the results of TV annuloplasty be predicted?

8. What is the role of imaging after a failed surgical TV annuloplasty?

9. What information can be obtained from computed tomography?

10. How do you manage a failed tricuspid annuloplasty?

Transcatheter Tricuspid Valve-in-Ring Procedure

11. Can you always perform a TTViR?

12. What does the literature say about TTViR procedures?

Transcatheter Tricuspid Valve-In-Valve Procedure

13. What is the rate of bioprosthetic TV failure?

14. What does the literature say about TTViV procedures?

Conclusions

Bibliography

48 Caval Valve Implantation (CAVI) for the Treatment of Severe Tricuspid Regurgitation

1. What is the concept behind caval valve implantation (CAVI)?

2. What is the initial data to support CAVI as a treatment for TR?

3. Who is a candidate for CAVI?

4. What information is needed to perform CAVI?

5. What are the steps in CAVI?

6. What are the current data with CAVI?

7. What is the future of CAVI?

8. What are the unknowns of CAVI?

Bibliography

Part IV: Structural Interventions for Management of Paravalvular Leaks

49 Aortic Paravalvular Leak Closure

1. What are the indications for percutaneous aortic paravalvular leak (PVL) closure?

2. What are the contraindications for percutaneous aortic PVL closure?

3. How do you plan an aortic PVL closure procedure?

4. How do you cross the aortic PVL defect?

5. What are the techniques to deliver occluder devices?

6. How to negotiate an uncrossable defect?

7. What are the device choices for aortic PVL closure?

8. What are the mechanisms and treatments for post-transcatheter aortic valve replacement (TAVR) PVL?

9. What are the specific anatomical challenges to close post-transcatheter aortic valve PVLs?

10. What are some tips and tricks while closing post-TAVR PVLs?

11. What are the potential complications of aortic PVL closure?

Bibliography

50 Mitral Paravalvular Leak: Imaging and Interventional Approaches

Imaging

Echocardiography

1. What imaging modality should be considered first with suspicion of mitral PVL following repair?

2. What are the limitations of TTE in assessing mitral PVL? What are adjunctive quantitative measures used to ascertain mitral PVL?

3. What is the next study considered after screening TTE for better visualization of the MV?

4. What nomenclature is used to anatomically define the PVL location? Where are severe mitral PVLs most often found?

5. What echocardiographic parameters exist for grading the severity of mitral PVLs?

6. What role does 3D TEE play in evaluating mitral PVLs?

7. What role does cardiac MRI play in evaluating mitral PVLs?

8. What role does cardiac CT play in evaluating mitral PVLs? What are some of its limitations?

9. What are the potential benefits of using intracardiac echocardiography in percutaneous leak closure?

10. What combination imaging modalities are useful when evaluating and intervening in mitral PVLs?

Transcatheter Closure of Mitral PVLs

11. What is the most common approach to mitral PVL closure?

12. Describe the approach an interventionalist should take with transseptal puncture. How does this change with (a) posterior defects, (b) anterior defects, and (c) medial defects?

13. In what position should the fluoroscopic gantries be oriented for transseptal puncture? What techniques or equipment should be considered when performing transseptal puncture?

14. Describe the retrograde transapical approach to mitral PVL closure

15. Describe the retrograde femoral approach to mitral PVL closure

Defect Crossing and Telescoping Catheters

16. Describe the steps required to cross a mitral PVL

17. Describe the concept of telescoping catheters for mitral PVL closure

Device Selection

18. What are common devices used for mitral PVL closure?

Device Deployment

19. What technique should be used for single-device deployment?

20. What techniques should be considered with multiple-device deployment?

21. What technique can be used to increase stability for catheter passage across a serpiginous defect that is difficult to cross?

Conclusion

Bibliography

Part V: Left Atrial Appendage Closure

51 Current Indications for Percutaneous Left Atrial Appendage Occlusion

1. Is there a rationale for left atrial appendage occlusion (L AAO)?

2. Left atrial appendage occlusion: why percutaneous?

3. What is the level of evidence supporting percutaneous L AAO?

RCTs for Percutaneous L AAO

Registries for Percutaneous Left Atrial Occlusion

4. What are the current US society recommendations for percutaneous L AAO?

5. Are there additional considerations related to L AAO?

Bibliography

52 Imaging for LAA Interventions

Cardiac CT Pre-procedural Planning

1. What are the main objectives of pre-procedural cardiac tomography in left atrium appendage occlusion?

2. How should the patient be prepared before CT?

3. What is the technical protocol for imaging acquisition?

4. Explain how to exclude the presence of thrombus in the LAA with CT

5. How is anatomic feasibility of LAAO assessed by CT?

TEE Pre-procedural Planning

6. What is the role of transthoracic echocardiography (TTE) before LAA closure procedure?

7. What are the objectives of TEE in pre-procedural planning for LAAO?

8. How should the measurements of the LAA be performed during pre-procedural TEE?

9. What is the advantage of using 3D TEE compared with 2D TEE?

10. Apart from LAA sizing, what other information is relevant during pre-procedural planning with TEE?

11. Which imaging technique is preferred for pre-procedural planning for LAAO?

Intra-procedural TEE and ICE Guided Intervention

12. Which imaging modalities can be used for intra-procedural guidance in LAA closure?

13. What are the main objectives of intra-procedural TEE during LAAO?

14. What are the best perspectives for each of the steps of the procedure?

15. Explain how transseptal puncture is guided with TEE

16. When is the device considered to be correctly placed within the LAA?

17. When intracardiac echocardiography is used to guide TEE, where should the probe be placed?

18. What are the advantages of double transseptal puncture for ICE probe transseptal crossing?

19. Is ICE a safe and effective alternative to TEE for intra-procedural LAAO guidance?

Bibliography

53 Devices for Left Atrial Appendage Closure

1. LAA occlusion: does one device fit all?

2. What are the main differences among LAA occlusion device designs?

3. What are the characteristic of the WATCHMAN FLX device?

4. What are the characteristics of the Amulet device?

5. What are the characteristic of the LAmbre device?

6. Lobe and disc vs. plug: is one approach superior to the other?

7. What is in the pipeline?

Bibliography

54 LAA Occlusion Technique and Challenging Scenarios

1. What are the main prerequisites for left atrial appendage occlusion (LAAO)?

2. What are the main imaging techniques employed to guide LAAO?

3. What are the mains steps of LAAO?

4. What features of femoral venous access are most relevant for LAAO?

5. What are the keys steps for TSP?

6. Can LAAO be performed through a patent foramen oval (PFO) or atrial septum defect (ASD)?

7. What steps are required to position the delivery system at the LAA?

8. How is device sizing performed?

9. What are the anatomical landmarks for LAAO device implantation?

10. What specific considerations must be taken into account with each dedicated LAAO device?

Ultraseal

11. What are the main steps to perform a “sandwich technique”?

12. What other LAA anatomies can pose a challenge for LAAO?

13. Can LAAO be performed in the presence of LAA thrombus?

References

55 Preventing and Managing Complications of LAA Closure

1. What is the relevance of this topic?

Pericardial Effusion (PE)

2. What is the current incidence of PE?

3. What are the causes of PE, and how can they be prevented?

4. How do you manage a LAAC-related PE?

Device Embolization

5. What is the current incidence of

device embolization

(

DE

)?

6. What are the causes of DE, and how can it be prevented?

7. What can be clinical manifestations of DE?

8. How can you perform a device retrieval?

Air Embolism (AE)

9. What are the manifestations of AE?

10. What are the causes of AE, and how can it be prevented?

11. How do you treat AE?

Periprocedural Ischemic Stroke

12. What is the current incidence of

periprocedural ischemic stroke

(

PIS

)?

13. What are the causes of PIS, and how can it be prevented?

Complications Related to Vascular Access

14. What are the complications related to access, and how can they be prevented?

Peri-device Leaks (PDLs)

15. What are the clinical relevance and incidence of PDLs?

16. What are the related factors or mechanisms?

17. What are the treatment options for PDL?

Device-Related Thrombus (DRT)

18. What are the incidence and clinical relevance of DRT?

19. What factors predispose patients to DRT, and how can it be prevented?

20. How do you diagnose DRTs?

21. How do you treat DRTs?

22. What other complications have been described?

Bibliography

Part VI: Selected Structural Interventions for Cardiomyopathies

56 The Natural History of Hypertrophic Cardiomyopathy

1. What is hypertrophic cardiomyopathy?

2. What is the prevalence of HCM?

3. Is left ventricular outflow tract obstruction a common occurrence in patients with HCM?

4. What is the prognosis of an individual with HCM?

5. Are there predictors of sudden cardiac death?

6. How is a diagnosis of HCM made?

7. Is genetic testing helpful?

8. Are there multiple HCM-related genes?

9. Are all individuals with HCM affected similarly?

10. What kind of symptoms does HCM cause?

11. Are there measures that should be undertaken in all individuals with HCM, even those with no symptoms?