Percutaneous interventions for
structural heart diseases
Present & Future
Dr. B. K. Iyer
The past
 Angioplasty
The future - Options for structural
heart diseases
 Primary Method of to date for closure is
surgical
 Recent advances i...
Current popular occlusion devices
 Amplatzer Occluder
– (AGA Medical Corporation)

 CardiaStar Septal Occluder
– ( Cardi...
Current popular occlusion devices
Current popular occlusion devices
Amplatzer Occluder
 AGA Medical corporation, Golden
Valley Mn
 2001- FDA approved for Secundum
lesions
 Nitinol [45% ni...
Amplatzer Occluder
 Filled with fluffy Dacron
fabric patches inside each
disk to promote thrombosis
 Flexible center ste...
Helex Septal Occluder Device
 W.L. Gore & Associates
 Since July 1999
 Nitinol= Nickel+titanium
alloy
 Wire frame in s...
Helex Septal Occluder Delivery
System components
Helex Septal Occluder Device
components
Atrial Septal Defect closure
Trans-catheter device approach
 Surgery : closure of the defect either by direct
suturing or using a patch .
 Trans cath...
Device closure: potential
Complications
 ASD mostly “unsuitable” for device closure
 Air Embolism (via long sheath)
 De...
Patient Selection
 Strict FDA guidelines
 Follow-up at regular intervals- 3, 6, and 12
months the year following the ini...
Amplatzer device - post implant
 24-48 hrs Fibrin deposits;
– ? trapped thrombus

 1-2 weeks
– Neo-endothelialization be...
Ventricular Septal Defect
closure
Conventional Surgical Treatment
vs. others
 Early clinical outcome after surgical repair of
acute ischemic VSD is poor (m...
Technique
1.
2.
3.
4.
5.
6.
7.
8.
9.

General Anaesthesia
Trans-oesophageal echocardiography
Femoral vein/femoral artery
I...
Planning & Preparation
1. Maximize fluids and inotropes
2. IABP but shoot coronaries and consider vital
stenting
3. Allow ...
Conventional Surgical Treatment
vs. others
 Direct surgical closure of an acute iVSD using
an Amplatzer® muscular VSD dev...
Conventional Surgical Treatment
vs. others
 Potential advantages vs. Conventional
surgery
– No incision in the LV
– Reduc...
VSD Closure : CardioSEAL
Device (generic septal occluder)









(NMT Medical Technologies)
FDA approved indicat...
Patent Ductus Arteriosus
Defect closure & coil closure
PDA occlusion with an Amplatzer
duct occluder device
 Example of PDA
occlusion with an
Amplatzer duct occluder
device.
 ...
PDA closure with a Nit-Occlud
PDA occlusion device
 Example of PDA closure
with a Nit-Occlud PDA
occlusion device.
 A, I...
Coil occlusion closure of PDA
 Example of Gianturco
coil occlusion of PDA.
 A, Views of a Gianturco coil in its
stretche...
Device closure of ruptured
sinus of Valsalva
Surgical closure of ruptured
sinus of Valsalva
 Surgical repair mainstay of treatment in the
past –
– Usually successful ...
Device closure of ruptured
sinus of Valsalva
 Though ruptured sinuses of Valsalva have
been traditionally managed surgica...
Device closure of ruptured
sinus of Valsalva - techniques
1.
2.
3.
4.
5.

General anaesthesia [used in most cases];
TOE gu...
Prosthetic Paravalvular leak
device closure
Prosthetic Paravalvular leak
device closure
 Rare complication with surgical replacement of
valves and paravalvular regur...
Prosthetic Paravalvular leak
device closure
 Percutaneous
transcatheter closure
techniques, now
routinely applied in the
...
Prosthetic Paravalvular leak
device closure
 Percutaneous transcatheter closures of PVLs using
a wide array of devices ha...
Prosthetic Paravalvular leak
device closure
 Echocardiographic evaluation of PVL provides
the following information to as...
Prosthetic Paravalvular leak
device closure
 Percutaneous approach:
– Access through the femoral vein and transseptal
pun...
Prosthetic Paravalvular leak
device closure
 After passage of the catheter in the proximity of
the PVL canal, the guidewi...
LA Appendage device closure
LA Appendage device closure
 The left atrial appendage is a small
pouch, shaped like a windsock, which
empties into the l...
LA Appendage device closure
 Once AF develops, patients require
warfarin for the rest of their lives
 Left atrial append...
LA Appendage device closure
[HOCM] Hypertrophic
Cardiomyopathy Obstructive Septal
ablation
HOCM Septal ablation
 This is a less invasive method of
↓the outflow obstruction in
hypertrophic cardiomyopathy.
 In thi...
HOCM Septal ablation
 Another approach is to use a
procedure, called radio frequency
catheter ablation.
 This is more co...
MitraClip Mitral valve
percutaneous repair system
The MitraClip Mitral Valve Repair
System
 The MitraClip Mitral Valve
Repair System received
approval in Europe over 4 yea...
The MitraClip Mitral Valve Repair
System
 https://www.youtube.com/watch?
feature=player_embedded&v=GwDgPDYf3
Qo
Trancatheter Pulmonary valve
implantation
Trancatheter Pulmonary valve
implantation
 Transcatheter pulmonary valve implantation
(TPVI) is an alternative to pulmona...
Trancatheter Pulmonary valve
implantation
 The TPV procedure takes 1-2 hours.
 The catheter is inserted into the patient...
Ductal stenting
Ductal stenting
 Congenital pulmonary artery (PA) branch
stenosis can occur in isolation, as part of a
syndrome or in con...
Ductal stenting
 Ductal stenting is a practical, effective, safer
and minimally invasive procedure to achieve
adequate pu...
Pulmonary artery stenting
Pulmonary artery stenting
 Pulmonary artery stenoses, mainly
encountered in patients with pulmonary
vasculitis (as in Beh...
Valvuloplasty
BMV

BMV (Balloon Mitral
Valvuloplasty)
BAV

BAV (Balloon Aortic
Valvuloplasty)
BPV

BPV (Balloon Pulmonary
Valvuloplasty)
Thank you!
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Presentation on heart valve devices

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Presentation on heart valve devices

  1. 1. Percutaneous interventions for structural heart diseases Present & Future Dr. B. K. Iyer
  2. 2. The past  Angioplasty
  3. 3. The future - Options for structural heart diseases  Primary Method of to date for closure is surgical  Recent advances in interventional closure techniques include Trans-catheter closure technique – Eliminates need for cardio-pulmonary bypass – No need to stop the heart with cardioplegic agents. – Implantation of one or more devices via catheter method
  4. 4. Current popular occlusion devices  Amplatzer Occluder – (AGA Medical Corporation)  CardiaStar Septal Occluder – ( Cardia, Inc.)- extensive European experience  Helex Septal Occluder (general design):  CardioSEAL Septal Occluder – (Nitinol Medical Technologies)  Sideras “Button” device – (Custom Medical Devices)  DAS Angel Wings & Guardian Angel occluders
  5. 5. Current popular occlusion devices
  6. 6. Current popular occlusion devices
  7. 7. Amplatzer Occluder  AGA Medical corporation, Golden Valley Mn  2001- FDA approved for Secundum lesions  Nitinol [45% nickel+ 55% titanium] mesh frame work & separate left / right atrial disks  72 nitinol wires woven; micro-welded ends, super elastic + shape memory  Success rate: – 100% surgery, 96 % Amplatzer  Complication – 24 % surgery, 7% Amplatzer
  8. 8. Amplatzer Occluder  Filled with fluffy Dacron fabric patches inside each disk to promote thrombosis  Flexible center stem between disks with microscrew attach / detach mechanism  Designed to close stretched defects 4-38mm  Completely retrievable through delivery sheath – Cost: – Comparative Surgery cost:
  9. 9. Helex Septal Occluder Device  W.L. Gore & Associates  Since July 1999  Nitinol= Nickel+titanium alloy  Wire frame in shape of coil with Gore-Tex  9 Fr introducer sheath  Cost:  Helex defect device consists of: – Helex Septal Occluder Delivery System components – Helex Septal Occluder Device components
  10. 10. Helex Septal Occluder Delivery System components
  11. 11. Helex Septal Occluder Device components
  12. 12. Atrial Septal Defect closure
  13. 13. Trans-catheter device approach  Surgery : closure of the defect either by direct suturing or using a patch .  Trans catheter device closure: Timing of surgery = after 1st year & before entry in to school, preferably in early childhood .  Device is advanced through an introducer sheath 1. 2. – – Half the device is deployed on left side of atrial septum, The second half is deployed on the right side A “sandwich” is formed over the defect 6-8 weeks, device work as a frame for scar tissue to form. In kids, new tissue formation will continue to grow.
  14. 14. Device closure: potential Complications  ASD mostly “unsuitable” for device closure  Air Embolism (via long sheath)  Device Embolization (transcatheter vs. openheart surgical retrieval)  Arrhythmias (atrial common; PVCs rare; self limiting)  Atrial wall erosion with pericardial tamponade (rare)
  15. 15. Patient Selection  Strict FDA guidelines  Follow-up at regular intervals- 3, 6, and 12 months the year following the initial procedure – Defects smaller than 20-25mm in diameter – Should not have defects in the very upper or lower portions of the septum – Only benefit Ostium Secundum defects – No lower age limit, but must be more than 8-10 kg – Ostium Primum or Sinus Venosus, not valid because defect usually involves heart valves or abnormal venous drainage from the lungs.
  16. 16. Amplatzer device - post implant  24-48 hrs Fibrin deposits; – ? trapped thrombus  1-2 weeks – Neo-endothelialization begins  2-4 months – full neo-endothelium formed
  17. 17. Ventricular Septal Defect closure
  18. 18. Conventional Surgical Treatment vs. others  Early clinical outcome after surgical repair of acute ischemic VSD is poor (mortality 30 -50%) – Cardiogenic shock – Recurrent VSD – Complications from prolonged ITU  Device closure is established as an option for VSD closure in paediatric patients
  19. 19. Technique 1. 2. 3. 4. 5. 6. 7. 8. 9. General Anaesthesia Trans-oesophageal echocardiography Femoral vein/femoral artery Internal jugular vein/femoral artery Angiography +/- Balloon sizing (post-MI only) Amplatzer device placement and release Heparin, antibiotics, antiplatelets Associated procedures (ASD, BAV, RFA, VSD coil, Pulm Valvuloplasty)
  20. 20. Planning & Preparation 1. Maximize fluids and inotropes 2. IABP but shoot coronaries and consider vital stenting 3. Allow recovery from reperfusion injury 4. Early intervention is usually best 5. Minimize procedural time and trauma 6. Surgical back-up 7. Post-Op care 8. Possible hybrid in some cases
  21. 21. Conventional Surgical Treatment vs. others  Direct surgical closure of an acute iVSD using an Amplatzer® muscular VSD device to 1. 2. 3. 4. 5. 6. 7. Reduce cardiac trauma Avoid left ventriculotomy Reduce CPB time Avoid cardiac arrest Achieve full revascularisation Reduce incidence of recurrent VSD Simplify device deployment
  22. 22. Conventional Surgical Treatment vs. others  Potential advantages vs. Conventional surgery – No incision in the LV – Reduced CPB time – No cardiac arrest  Interventional treatment – Device deployed under direct vision – Complete revascularization
  23. 23. VSD Closure : CardioSEAL Device (generic septal occluder)         (NMT Medical Technologies) FDA approved indication: for “high risk” Swiss-Chesse muscular VSD closure Other uses: – – single congenital muscular VSDs post myocardial infarction VSDs Limitations (CardioSEAL): Non self-centering Large delivery system (10-11 Fr) “One chance” deployment with very limited retrievability
  24. 24. Patent Ductus Arteriosus Defect closure & coil closure
  25. 25. PDA occlusion with an Amplatzer duct occluder device  Example of PDA occlusion with an Amplatzer duct occluder device.  A, Image of an Amplatzer duct occluder device.  B through D, Lateral angiograms demonstrating closure of a PDA with an Amplatzer duct occluder device.
  26. 26. PDA closure with a Nit-Occlud PDA occlusion device  Example of PDA closure with a Nit-Occlud PDA occlusion device.  A, Image of a Nit-Occlud coil with its biconical configuration. Note the reversed winding on the proximal end.  B through D, Lateral angiograms demonstrating closure of a PDA with a single Nit-Occlud coil.
  27. 27. Coil occlusion closure of PDA  Example of Gianturco coil occlusion of PDA.  A, Views of a Gianturco coil in its stretched out configuration (top) and in its natural coiled configuration (bottom). Note the attached Dacron fibers, which promote thrombosis, along its length.  B through D, Lateral angiograms demonstrating closure of a PDA with a single 0.038-in diameter Gianturco coil.
  28. 28. Device closure of ruptured sinus of Valsalva
  29. 29. Surgical closure of ruptured sinus of Valsalva  Surgical repair mainstay of treatment in the past – – Usually successful (95% survival after 25 years), but – Recurrence possible (16% reoperation rate)  Surgical techniques include: – Primary suture closures (pledget) and patch closures (if ruptured) – Aortic root reconstruction or replacement – Aortic valve repair or replacement
  30. 30. Device closure of ruptured sinus of Valsalva  Though ruptured sinuses of Valsalva have been traditionally managed surgically, they are amenable to transcatheter closure by using the using the Amplatzer duct occluder (ADO)
  31. 31. Device closure of ruptured sinus of Valsalva - techniques 1. 2. 3. 4. 5. General anaesthesia [used in most cases]; TOE guidance is essential Assess size on TOE and angiogram Aortogram in LAO &/or RAO projections Cross defect with Terumo 0.035” exchange guidewire from the aortic root 6. Snare from right heart and establish AV circuit 7. Usually ADO I of 2-4 mm larger size than the aortic opening of sinus 8. AGA Torqueview sheath from femoral vein to aorta over guidewire circuit 9. Deploy device under TOE guidance and assess aortic valve 10. Ensure no increase in AR & encroachment on coronary arteries prior to release of device
  32. 32. Prosthetic Paravalvular leak device closure
  33. 33. Prosthetic Paravalvular leak device closure  Rare complication with surgical replacement of valves and paravalvular regurgitation affects 5-17% of all surgically implanted prosthetic heart valves.  Prosthetic Paravalvular leak occurs with mechanical prostheses [aortic / mitral], bioprostheses or valved stent  Patients with paravalvular regurgitation can be asymptomatic or have hemolysis /heart failure/both.  Reoperation is associated with increased morbidity and is not always successful because of underlying tissue friability, inflammation, or calcification.
  34. 34. Prosthetic Paravalvular leak device closure  Percutaneous transcatheter closure techniques, now routinely applied in the management of pathological cardiac and vascular communications are adapted to PVL closure.
  35. 35. Prosthetic Paravalvular leak device closure  Percutaneous transcatheter closures of PVLs using a wide array of devices have been reported in the literature, although the procedural success rate of this approach remains variable  One major challenge of transcatheter PVL closure lies in the ability to adequately visualize the area of interest to facilitate defect crossing and equipment selection.  Detecting of paravalvular leaks is done by 1. TTE (Transthoracic Echocardiagraphy) 2. TEE (Transesophageal Echocardiagraphy) 3. ICE (Intracardiac Echocardiagraphy).
  36. 36. Prosthetic Paravalvular leak device closure  Echocardiographic evaluation of PVL provides the following information to ascertain intervention: – – – – – Shape and orientation of the jet Number of jets Maximum velocity Presence of the distal flow reversal Pulmonary pressures  The transcatheter approach involves deployment of occlude devices or coils and adopting either a percutaneous or a transapical approach.
  37. 37. Prosthetic Paravalvular leak device closure  Percutaneous approach: – Access through the femoral vein and transseptal puncture (mainly for treatment of mitral valve PVL) – Retrograde approach through femoral artery (mainly for treatment of aortic PVL)  Transapical approach – involves puncture of the apex either using small thoracotomy or percutaneous access (direct puncture).
  38. 38. Prosthetic Paravalvular leak device closure  After passage of the catheter in the proximity of the PVL canal, the guidewire is passed across the canal and the guide is advanced inside.  Using TEE guidance, the dedicated occluder (plug) is deployed and the results checked. – For this procedure either purpose-specific plugs (Vascular Plug III) or other types of occluders used commonly for closure of ventricular septal defects or patent ductus arteriosus can be used. – Use of coils for narrow PVL canal closure is also useful.
  39. 39. LA Appendage device closure
  40. 40. LA Appendage device closure  The left atrial appendage is a small pouch, shaped like a windsock, which empties into the left atrium, one of the top chambers of the heart  Atrial fibrillation is a common rhythm disturbance in which the top chambers of the heart do not beat regularly. – When the left atrial appendage does not squeeze consistently the blood inside the pouch becomes stagnant and may form clots.
  41. 41. LA Appendage device closure  Once AF develops, patients require warfarin for the rest of their lives  Left atrial appendage (LAA) closure is done in nonvalvular atrial fibrillation (AF) patients ineligible for warfarin therapy.  The Watchman device (Boston Scientific) has been observed to be noninferior to warfarin therapy in various studies.
  42. 42. LA Appendage device closure
  43. 43. [HOCM] Hypertrophic Cardiomyopathy Obstructive Septal ablation
  44. 44. HOCM Septal ablation  This is a less invasive method of ↓the outflow obstruction in hypertrophic cardiomyopathy.  In this procedure, a few drops of an alcohol-based solution are injected into a small branch of the main artery supplying the thickened heart muscle.  This causes part of the muscle to die (in effect, a small heart attack) and this in turn reduces the obstruction to blood flow.
  45. 45. HOCM Septal ablation  Another approach is to use a procedure, called radio frequency catheter ablation.  This is more commonly used to destroy - or ablate - tissues in the heart causing rhythm disturbances.  But research has shown it may also help children who have HOCM with thickened heart muscle that obstructs blood flowing out of their hearts.  The procedure, performed via catheters inserted into the groin, has shown significant improvement
  46. 46. MitraClip Mitral valve percutaneous repair system
  47. 47. The MitraClip Mitral Valve Repair System  The MitraClip Mitral Valve Repair System received approval in Europe over 4 years ago and is eventually in the U.S. market since July, 2013  The MitraClip is intended to repair diseased mitral valves without open heart surgery, an important option for patients not eligible for such invasive procedures.
  48. 48. The MitraClip Mitral Valve Repair System  https://www.youtube.com/watch? feature=player_embedded&v=GwDgPDYf3 Qo
  49. 49. Trancatheter Pulmonary valve implantation
  50. 50. Trancatheter Pulmonary valve implantation  Transcatheter pulmonary valve implantation (TPVI) is an alternative to pulmonary valve replacement by open surgery.  It is intended for patients who have previously had a pulmonary valve repair for congenital heart disease, in whom dysfunction of the repaired valve necessitates further intervention.  This valve is for designed for use in pediatric and adult patients with a regurgitant or stenotic Right Ventricular Outflow Tract (RVOT) conduit (≥ 16 mm in diameter when originally implanted).  This valve is delivered by catheter with fluoroscopic guidance through the body’s cardiovascular system.
  51. 51. Trancatheter Pulmonary valve implantation  The TPV procedure takes 1-2 hours.  The catheter is inserted into the patient’s femoral vein through a small access site.  The catheter holding the valve is placed in the vein and guided into the patient’s heart.  Once the valve is in the right position, the balloons are inflated.  The valve expands into place and blood will flow between the patient’s right ventricle and lungs.  The catheter is removed. After confirming with fluoroscopy that the valve is functioning properly, the access site is closed.
  52. 52. Ductal stenting
  53. 53. Ductal stenting  Congenital pulmonary artery (PA) branch stenosis can occur in isolation, as part of a syndrome or in conjunction with other cardiac defects; quite often, PA branch stenosis occurs after surgical repair of congenital heart disease. – Significant narrowing of the pulmonary artery origins can lead an overall reduction in pulmonary blood flow or to disproportionate distribution to the two lungs. – In addition, an increase in right ventricular systolic pressure will result in right ventricular hypertrophy and possible failure.
  54. 54. Ductal stenting  Ductal stenting is a practical, effective, safer and minimally invasive procedure to achieve adequate pulmonary artery growth for subsequent palliative or corrective surgery.  Ductal stenting for pulmonary blood supply in newborns with cyanotic congenital heart disease (CHD) is a low risk and safe alternative to the surgical aorto-to-pulmonary artery (AP) shunt in dual-source lung perfusion.
  55. 55. Pulmonary artery stenting
  56. 56. Pulmonary artery stenting  Pulmonary artery stenoses, mainly encountered in patients with pulmonary vasculitis (as in Behçet disease or Takayasu arteritis), may be treated with balloon angioplasty and stent placement.
  57. 57. Valvuloplasty
  58. 58. BMV BMV (Balloon Mitral Valvuloplasty)
  59. 59. BAV BAV (Balloon Aortic Valvuloplasty)
  60. 60. BPV BPV (Balloon Pulmonary Valvuloplasty)
  61. 61. Thank you!

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