Thread by @iamritu

1/Tweetorial on #TMVR for #ASEchoJC 12/11 8 pm
bit.ly/2EiJQ1v

transcatheter mitral valve replacement #TMVR for failed valve & ⬆️ #STS risk

#VHD 2017 update reoperation➡️ reintervention bit.ly/2P9bX4G

🎈expandable SAPIEN S3 only @FDA bioprosthesis for implant

2/#Transeptal developed @MayoClinicCV 48 pts

After 🇨🇦 initial experience with #transapical 2009

sick patients with ⬇️ EF #transeptal preserves EF better avoids apical purse string suture

Currently #TMVR registry
>50 % are transeptal & in house mortality 7%

3/#EchoFirst #TTE
#PLAX & off-axis( inflow can be II to septum not apex/posteriorly & eccentric/coanda
👀 origin MR➡️#TMVR may 🚫resolve severe paravalvular MR
#Apical
#CWD #MV proximal flow convergence location: on ventricular side in regurgitation & on atrial side in stenosis

4/ #echofirst measure:
mean gradient,#PHT,#DVI, for
#EOA use continuity not #PHT

if Significant #MR,#valve #area #underestimated by the #continuity

👀 valve leaflet mobility
R/O obstructing #thrombus/#vegetation-contraindications for #TMVR

5/#TEE ⬇️cusp mobility?
structural deterioration or #thrombus➡️typically located on the #ventricular side of #mitral #prosthesis & has soft echotexture 🆚 pannus or structural failure usually brighter echotexture,
c/w fibrous tissue deposition (pannus) or calcification

6/Avoid #LVOT obstruction
Old valve stented open by #TMVR creating elongated & potentially narrow “neo” LVOT( measure)

small LVOT, basal septal bulge, large < b/w existing SHV & A root predispose to obstruction

Final common pathway:How close to the septum is the stent/#TMVR

7/#3D #TEE sizing
3D multiplanar reconstruction MPR allows alignment of the cross-sectional plane perpendicular to the long axis (blue lines) of prosthesis. area measured by MPR correlates better with CT & appears larger than the one measured directly en face on 3D rendering

8/ #intraprocedure #TEE 2D orthogonal guides #transseptal puncture.
⬆️Temporal & spatial resolution #2D easy orientation (3D of septum fewer points of reference)
AP sup infer orientation precise selection of septal puncture site catheter tip could be outside the 3D imaging vol

9/#Guiding & #deployment
#prosthetic MV is crossed initially with #guide catheter & a stiff delivery wire is 🔁
prosthesis position (how much in LV 🆚 LA) by fluoro
delivery 🎈is positioned across the bioprosthesis under fluro
new valve is then deployed by inflating delivery🎈

10/#Postdeployment #TEE
(1) Is the valve deployed in stable position? positioned well inside the old valve sewing ring?
(2) Is valve function normal?
(3) Are there any complications?
(4) stability, degree & symmetry of cusp motion?
#FITSurvivalGuide @ASE360 @mirvatalasnag