Ribichini

TAVI: New indications
Prof. Flavio L. Ribichini
Director Division and School of Cardiology
University of Verona, Italy

No conflict of interest
Proctor for Edwards and Medtronic
Prof. Flavio L. Ribichini
Director Division and School of Cardiology
University of Verona, Italy

New indications now: the intermediate risk

New indications now: the intermediate risk

TAVI: new indications in the near future
Low-risk AS patients
Asymptomatic AS patients

TAVI: new indications (off label)
Pure, non-calcific aortic regurgitation
Bridge o Heart Mate or heart transplant
AS and aortic dissection
AS and associated mitral valve disease
Bicuspid aortic valve
Mitral and tricuspid VIV
Aortic VIV and severe high-risk CAD

Emergency TAVI for severe aortic regurgitation –
procedural and technical considerations
We report 14 consecutive inoperable patients with non-calcific, pure Aortic Regurgitation and
advanced heart failure treated with emergency percutaneous trans-femoral implantation with
self-expandable CoreValves at our institution, between July 2011 and February 2018.
✓ Computed tomography scan (CTS) of the aortic root was performed in 11 patients to obtain
accurate measures of the aortic annulus and root.
✓ Extremely unstable hemodynamics in 3 patients prevented CTS, and the valve sizing was
decided by intra-procedural trans-esophageal echocardiography (TEE).
✓ The immediate and long-term clinical outcome was prospectively assessed according to the
VARC-2 criteria for device success and safety.

Pure AR in extensive aortic dissection
Two cases of massive residual AR after aortic valve reconstruction performed during the replacement of the ascending aorta due to
acute type 1 aortic dissection, with a residual type III dissection from the aortic arch to the iliac arteries.

Diagnostic catheterization

Aortic Dissection
as seen with the
intra-procedural IVUS

Pure AR in extensive
aortic dissection

Pure AR and aortic Root Aneurysm
Patient’s and procedural characteristic
Pt #2 was implanted electively two 31mm CoreValves in a large aortic root aneurysm, as a planned strategy. The first 31mm CoreValve was
used for anchoring a second 31mm device with optimal final result and complete resolution of the AR.
CT scan of pt #2
• c-d) dilated ascending aorta (55mm);
• e) diameters perimeter and area of the aortic annulus;
• f) sagital view of its aortic valve without calcifications;
• g) sagital view of a thoracic CT scan after the implantation of two
CoreValves in the aortic annulus;
• h) frontal view with the two valves in place.

CT scan at level of the aneurysm of the
Valsalva simus (56mm)

“Valve in valve” implantation of two self-expandable trans-catheter aortic
valves to exclude aortic root aneurysm and treat massive aortic regurgitation.
75 years old male
Massive aortic
insufficiency,
LVEF 50%
Large aneurysm of
the aortic root.
Two previous
cardiac surgeries:
CABG and plastic of
the aortic valve.
Aortic dissection
with implantation of
a Dacron tube in
ascending aorta.

First CoreValve 31mm in the ascending aorta
Valve implantation in the conventional
possition

After 5 years the patient is in NHYA class I

CT scan of the aortic root showing the
valve in valve in correct possition.

Pure AR secondary to Heart Mate or as bridge to
transplant
Heart-Mate II
CT scan showing non-calcified aortic valves
All of them presented multiorgan failure at
the time of TAVI.
One patient had an extremely dilated and
calcified homograft
Now performing TAVI BEFORE Heart Mate
to avoid emergency treatment

Patient survvived, underwent heart transplantation and is alive after 6 years

Intra-op TEE showing AR pre and post
Heart Mate
After the activation of the LVAD
the CO decreased from 3.0l/min
to 2.0 l/min due to the worsening
of the AR

2014: Traumatic aortic aneurysm treated with
Thoracic Endovascular Aortic Repair (TEVAR)
Before…
After TEVAR…

10/2017: Endoleak type 1a at the level
of aortic arch with growth of aneurysm

10/2017: Complete resolution of the endoleak with 2nd endovascular prothesis
(after debranching of the supraortic trunks)
Anastomosis with
supraortic trunks
2nd endovascular prothesis
Calcifications on the aortic valve

11/2017: worsening of aortic stenosis
For episodes of chest pain and dyspnea
(NYHA III) echocardiography was
performed with evidence
of severe aortic stenosis (Peak
Gradient 62mmHg, Mean Gradient 42
mmHg)
The aortic stenosis was confirmed at the heart catheterization
with a peak to peak gradient of 45 mmHg.

PRE-TAVI Evaluation
At the CT scan evidence of an horizontal aorta
with a LVOT diameters of 27,9 mm and 22,1 mm,
perimeter of 79,7 mm, area of 479,5 mm 2 and no
signs of residual dissections.
A CoreValve Evolute R 29 mm was chosen.

1/2018: TAVI Procedure
Evidence of a false lumen due to
an undiagnosed Type 1 aortic
dissection during aortography
prior to TAVI: The 5F pigtail
catheter easily entered a large
false lumen at the level of the
aortic root/ascending aorta
while negotiating the noncoronary
Valsalva synus.

1/2018: TAVI Procedure
5Fr Amplatz AL-1 was used to opacify the true lumen and direct
the straight soft 0.35’’ angiographic wire through the aortic valve
into that horizontal aortic root.
After crossing the aortic valve, thus confirming the correct
placement of the wire, a 2 nd supportive 0.35’’ wire was placed into
the LV, to act as a rail for the CoreValve through the endoprostheses
and the horizontal aortic root.

Before deployment of the CoreValve the buddy wire was removed
from the LV to avoid unwanted trapping and possible
dislodgement of the valve during retrieval
1/2018: TAVI Procedure
Final angiogram showing satisfactory position of the
CoreValve, no relevant aortic regurgitation and no acute aortic
damages or clear images of dissection left.

Post-TAVI CT-SCAN
Evidence of dissection
of ascendent aorta
partially covered at the
entry site by the Evolute
R.
10 months f-up, OK.

Associated mitral valve disease

Male 83. Mitral para-valvular leak
1 2
Four chamber echo view showing the mitral bioprosthesis
Trans-esophagic image showing severe mitral peri-prosthetic leak
EDV pre intervention showing severe LV chamber diatation

…and severe aortic valve regurgitation
Short and
long axis
images and
color Doppler
(long axis and
M mode)
showing
severe aortic
regurgitation.
The aortic
valve has mild
calcifications
without
gradient

Mitral valve intervention
Release of the vascular plug AGA III 10x5mm
Percutanaous occlusion of the mitral peri-valvular leak

Aortic valve intervention
Percutaneous Trans-catheter Aortic Valve Implantation
CoreValve in place with a trivial
residual aortic insufficiency

TTE at discharge
Trans-aortic Doppler before discharge
Residual mean aortic gradient: 9 mmHg.
4 years
F-up in
NYHA
class I

Male, 77 yo, severe AVS and severe MR cord rupture
Percutaneous Trans-catheter Aortic Valve Implantation

Male, 77 yo, severe AVS and severe MR cord rupture
Percutaneous Trans-catheter Mitral Valve Repair

Male, 77 yo, severe AVS and
severe MR cord rupture

VIV of a tricuspid bioprosthesis
- Male born in 1954, aged 62 at the time of referral.
- Rheumatic fever in childhood
- Chronic AF since the age of 25 and since then in OAC
- 1981: Aortic and mitral valve replacement (mechanic valves)
- 2001: Severe tricuspid regurgitation: Perimount Magna
31mm bioprosthesis.
- COPD with recent worsening, in domiciliary oxygen therapy
- Several recurrent TIA of embolic origin
- Severe right heart failure with anasarca

Thoracic angio CT scan
Right atrium volume= 1300-1400 ml

Balloon inflation and valve release
N

Operative result
Intra-operative mean
gradient 3.2 mmHg
Prosthesis in-place

Pre-discharge echographic control: 4 chambers
Mean gradient: 4.1 mmHg
5 years f-up: uneventful with normal function of the valve

Evolut R 34 in Bicuspid
Aortic Valve
76 y o female
Normal coronary arteries
Higly fragile
Severe reumatoid artritis on steroids
CKD (eGFR 30)
Several major bleedings
TF TAVI performed February 10 2017

Calcium
distribution
Implanting view

The valve

• Elective follow-up at 12 months
• Clinically uneventful
• CT scan 12/02/2018
• TTE 31/01/2018

Valve at LVOT and lack of contact to the annulus
Valve at the leaflets @10mm (raphe)

VIV on high risk stentless bioporsthesis and low
coronary ostia
89 years old female
Previous AVR in 2000 with Stentless Sorin 23mm
Well being until beginning of 2015
Rapid progression to NYHA class III-IV
TT echocardio: (oct 2015) mean aortic gradient 58mmHg
Normal coronary arteries
Preserved LV function (EF 66%)
Moderate renal dys-function (eGFR 45)

CT scan and type of valve
CT scan showing the distance beween the aortic valve
annulus and the origin of the coronary arteries (4.7
and 5.4mm)
SORIN Pericarbon Freedom 23mm
stentless aortic bio-prosthesi (a),
and the surgical technique of valve
sewing very close to coronary ostia (b)
a
b

Two BMW guide wires in the coronaries
Left femoral access for the
valve sheath.
The rigth femoral artery
was used for the left
coronary artery guiding
catheter.
The right coronary guiding
catheter was advanced
through the right radial artery

Rapid pacing and
valve inflation

Implantation of the stent in the RCA first and then in the left main

Final aortic
angiogram

Complete normalization of the
rhythm, ECG QRS width, and
blood pressure after implantation of the
two stents.
Aortic angio shows the XT Sapien 3
valve in place, and patent RCA and left
coronary artery.
Intra-operatory TT echo shows no
residual aortic leak in diastole (a)
Residual trans-valvular
PG (18mmHg) (b).
a
b
The patient
had
uneventful
Hospital stay
and was
discharged on
day 6 on DAPT
advised for 6

Considerations
Currently available TAVI technology allows
treatment of a wide spectrum of complex heart
valvular disease, in particular in patients that have
undergone previous cardiac surgery and present
high risk of re-operation.
The success of the procedure is based on a
thougthful planning of the strategy before hand.