Justin P. Levisay

Low profile vascular plugs for paravalvular leaks after TAVR.

Paravalvular leak (PVL) after transcatheter aortic valve replacement (TAVR) is associated with less good outcomes. The use of percutaneous plugs is among the strategies to treat PVL after TAVR. Plugs have been limited by the need to pass 4–6 F delivery sheaths between the TAVR stent frame and the native valve leaflets.

Transseptal transcatheter mitral valve-in-valve: A step by step guide from preprocedural planning to postprocedural care

Transcatheter mitral valve replacement has been successfully performed with the use of aortic transcatheter heart valves in hundreds of patients worldwide with severe dysfunction of a degenerated mitral bioprosthesis and high surgical risk for repeat operation. The delivery approach in the vast majority of the mitral valve‐in‐valve procedures has been transapical. Although the transseptal approach may be more technically challenging, it is less invasive and may be preferred by patients. Data from case series and a large international registry suggest that patients treated with transseptal mitral valve‐in‐valve have faster recovery, more improvement in left ventricular ejection fraction and possibly lower mortality compared with patients treated with transapical approach. A prospective clinical trial, the MITRAL trial (Mitral Implantation of TRAnscatheter vaLves) is evaluating the safety and feasibility of transvenous transseptal mitral valve‐in‐valve. The experience from this trial has allowed us to improve our procedural approach. In anticipation of a wider adoption of the transseptal approach for mitral valve‐in‐valve, we describe our current method step‐by‐step from planning the procedure through postprocedural management. This is an evolving technique that has changed with experience and the transition to newer generation transcatheter heart valve devices. We discuss the use of cardiac computed tomography for planning the procedure including transseptal puncture and valve size selection, provide procedural and technical tips, and discuss postprocedural care.

High pacing rates for management of aortic insufficiency after balloon aortic valvuloplasty or transcatheter aortic valve replacement

Aortic insufficiency (AI) after transcatheter aortic valve replacement (TAVR) is difficult to manage when associated with congestive heart failure. AI after balloon aortic valvuloplasty (BAV) may be catastrophic, especially in patients who are not candidates for TAVR. We describe the use of urgent temporary pacing, followed by permanent pacing, to increase the heart rate to diminish diastolic filling time for the short term management of AI after BAV or TAVR. The strategy is particularly useful in patients who already have permanent pacemakers, which are common in this population.

MitraClip Therapy for Mitral Regurgitation: Secondary Mitral Regurgitation

Therapy for mitral regurgitation (MR) has been synonymous with mitral valve surgery. Operative approaches for degenerative MR repair have been associated with excellent results, with durable long term outcomes. Surgery for functional MR has been less successful. MitraClip has shown promise for functional MR, especiall in patinets who are high risk for surgery. The aggregate of nonrandomized global experience with MitraClip in functional MR has been consistent in showing improvements in symptoms and left ventricular remodeling. It remains to be seen how MitraClip therapy will compare with best medical therapy. The COAPT trial will clarify this question.

Femoral Access for TAVR: Techniques for Prevention and Endovascular Management of Complications

Transcatheter aortic valve replacement (TAVR) has emerged as an option for select patients with aortic stenosis who are high risk for conventional aortic valve surgery. The most common site of percutaneous access for TAVR is the common femoral artery (CFA), where the TAVR system is advanced retrograde into the ascending aorta and the stent valve is deployed within the annulus of the stenotic native aortic valve. The transcatheter aortic valve prostheses currently in use require a minimum 18 French (F) delivery sheath for smaller valve sizes. Larger first-generation Sapien 26 mm prostheses (RF3 delivery system) require a 24 F delivery sheath.

Antegrade approach for TAVR with total occlusion of the descending aorta

The antegrade approach for aortic valve interventions is well known but has not been widely used for transcatheter aortic valve replacement (TAVR) procedures. We encountered a patient with no possibility of retrograde access due to a totally occluded abdominal aorta who had a failed attempt at apical TAVR. We describe antegrade TAVR despite occlusion of the abdominal aorta, with the arterial limb of the requisite veno-arterial loop created using bilateral arm access, a novel version of the previously described antegrade approach.

Transcatheter Repair of Mitral Regurgitation: Other Devices and Novel Concepts

Percutaneous mitral repair has been synonymous with the MitraClip device for the past several years, since no other repair therapies have been available. Over the past 2 years, three additional repair technologies have received EC approval. These four devices, MitraClip, Cardiac Dimensions Carillon, Valtech Cardioband, and Mitralign, are described in the preceding chapters. Numerous other repair devices and concepts have been described, including leaflet repair, annuloplasty, chamber remodeling, and chordal repair approaches. Some have a long history of development, while others have been described only at the concept phase and the spectrum of practical use spans from human experience, preclinical use, or only concept drawings. This review summarizes the novel mitral repair devices in these phases of early development.