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TAVIXIONGRAN2014-11-25QUIZ•Street•AvenueStreetAvenueHospitalofUAHospitalofUAHospitalofUAHospitalofUASummarizeofTAVI•Transcatheteraorticvalveimplantation(TAVI)•Itwasintroducedasanalternativetreatmentinpatientswithsevereaorticvalvestenosis(AS)CribierA,EltchaninoffH,BashA,Circulation2002;106:3006–3008.FirstCaseofTAVI•In2002,CribieretaldemonstratedforthefirsttimethefeasibilityofapercutaneousvalveimplantationinapatientwithAS•ProvidingapromisinglessinvasivealternativetreatmentforvalvularheartdiseaseCribierA,EltchaninoffH,BashA,Circulation2002;106:3006–3008.•twodifferentTAVIdevicesarewidelyused–theballoon-expandableEdwardsSAPIENTranscatheterHeartValve–theself-expandingMedtronicCoreValve™•BothreceivedCEMarkapprovalforEuropeancommercialsalein2007•EdwardsSAPIENvalvereceivedFDApre-marketapprovalintheUSAinNovember2011TwodifferentTAVIdevicesEdwardsballoonexpandabledeliverysystemsCoreValveReValvingSystem(a)schemataand(b)followingdeploymentwithaortographyPatientsSelection•Feasibleinmostpatientswithsevereaorticstenosis•GenerallyutilizedinpatientsnotsuitableforsurgicalAVR,whoarelikelytoderivefunctionalandsurvivalbenefit•Tworiskscoresareusedtocalculatetheriskofcardiacsurgery•“High-risk”surgicalpatients–HavingaSocietyofThoracicSurgeonsPredictedRiskofMortality(STS-PROM)at30daysofgreaterthan10%–LogisticEuroSCOREofgreaterthan20%•Limited–Donotaccountforseveralpertinentclinicalriskfactors,suchaspreviousCABG,porcelainaorta,previouschestradiotherapy,severelungdisease,andlivercirrhosisTworiskscoresTworiskscoresAssessmentsofTAVI•Toassesstheaorticannulusdimensionsandgeometry,accesssite,andapproach–Transthoracicechocardiography–Coronaryangiography–Aorticangiography–MDCTAssessmentofarterialaccess•TheevaluationisfundamentalintheassessmentoftheTAVIpatientinminimizingpotentialmajorvascularcomplications–Arterialdimensions–Thepresenceorabsenceofatheroma,–Calcification–TortuosityAssessmentofarterialaccess•Arterialaccessisassessedwiththecombinationofinvasiveangiographyandcontrast-enhancedCTIliofemoralassessmentwith(a)angiographyand(b)MDCTAssessmentofaorticroot•UsinginvasiveangiographyandcontrastMDCT–evaluaterootandvalvularcalcification–leftmainheightfromtheleftcoronarycuspinsertion(duetoriskofcoronaryobstruction)–technicalissuesrelatedtoeachvalvetypeanddeliverysystemEuropeanHeartJournal(2014)35,2627–2638Assessmentofaorticroot(1)aorticannulusdiameter,(2)sinusofValsalvawidth(3)ascendingaortawidth,(4)sinusofValsalvaheightAssessmentofaorticrootAssessments•Leftandrightheartcatheterizationsarealsoperformed–assessthepresenceofpulmonaryhypertension–coronaryischemiaandtheneedforrevascularizationpriortoTAVIRequirementsofTAVI•TAVIshouldbeperformedinregionalcentersofexcellencewithadedicatedheartvalveprogramandhighproceduralvolumes•Theproceduremaybeundertakeninacardiaccatheterizationlaboratorywithmodificationsorinahybridoperatingroomequippedwithhigh-qualityfluoroscopicimagingRequirementsofTAVI•ThefacilitiesneedtobelargeenoughtoaccommodatesophisticatedX-rayimagingintegratedwithechocardiography,cardiopulmonarybypassandintra-aorticballoonpumpmachines,andanesthesiaequipment,withsurgicalsterilitystandardsmandatoryTechniquesofTAVI•TAVIismostoftenperformedutilizingthetransfemoralretrogradeapproach•Alternativeaccessapproachesusuallyreservedforpatientswithconcomitantsevereperiphera...