Preface

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This handbook is intended for all of those involved with treating patients with structural heart disease. In developing this resource, our goal was to provide a single source of introductory information on aortic, mitral, and pulmonary transcatheter valve technology. As this field is evolving rapidly, standard textbooks do not provide the necessary content for trainees who wish to develop an understanding of this technology as they proceed through their rotations in structural heart disease.

While the intent of this handbook is not to be all encompassing, it will provide the reader with a fundamental understanding of the basic clinical science, pre- and post-procedure assessment and management, and technical aspects of modern transcatheter heart valve therapies. As the field of transcatheter valve technologies continues to evolve, so too will the contents of this handbook. Therefore, we anticipate that this handbook will continue to be revised and expanded in the future and we look forward to the continued advances in the field that will provide innovative treatment options for patients.

We also acknowledge that as this resource will be used nationally and internationally, some physicians may observe areas where we can edit, revise, and improve upon in future versions. We welcome your comments, edits, and suggestions and ask that you please email our copy editor, Abby Cestoni (acestoni@acc.org) with any suggestions. We would also like to acknowledge the contributions of our authors and peer reviewers for which this publication would not have been possible as well as the support of the American College of Cardiology.

Alexander Iribarne, MD, MS, FACC
Ada C. Stefanescu Schmidt, MD, MSc
Tom C. Nguyen, MD, FACC

  Handbook Editors
  Handbook Editors

Editors
Alexander Iribarne, MD, MS, FACC1; Ada C. Stefanescu Schmidt, MD, MSc2; Tom C. Nguyen, MD, FACC3

  1. Section of Cardiac Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
  2. Division of Cardiology, Massachusetts General Hospital, Boston, MA
  3. Department of Cardiothoracic and Vascular Surgery, University of Texas, Houston, TX

Copy editor
Abby B. Cestoni, American College of Cardiology, Washington, DC

  Disclaimer and Copyright Information
  Disclaimer and Copyright Information

Disclaimer
The Transcatheter Heart Valve Handbook is an overview document developed by the ACC’s Surgeons’ and Interventional Member Sections. The information is provided as a basic overview for the study transcatheter valve therapies and should be used as an adjunct to other educational texts, journal articles, and clinical experiences. The material presented in this handbook is, to the best of our knowledge, accurate and factual to date at the time of publication and has undergone peer review. The material presented herein in this handbook is, to the best of our knowledge, accurate and factual to date at the time of publication and has undergone peer review. The information is provided as a basic overview for the study transcatheter valve therapies and should be used as an adjunct to other educational texts, journal articles, and clinical experiences. The field of transcatheter valve therapies is rapidly evolving, therefore, this work is presented “as is” and the publisher disclaims any and all warranties, express or implied, including any warranties as to the accuracy, comprehensiveness, or currency of this work. This resource is no substitute for individual patient assessment based on a healthcare professional’s evaluation of each patient. The publisher does not provide medical advice or guidance and this text is a merely a reference tool. Healthcare professionals are solely responsible for use of this work and ultimately all medical judgements and resulting diagnoses and treatments.

All rights reserved
This book is protected by copyright by the American College of Cardiology. No part of this book may be reproduced in any form or by any means, electronic or mechanical, including photocopying or the use of any information storage and retrieval system without written permission from the American College of Cardiology.

Copyright © 2018 by the American College of Cardiology, Washington, DC

  Authors and Peer Reviewers
  Authors and Peer Reviewers

Varun Aggarwal, MD
Texas Children’s
The history and evidence base for transcatheter pulmonic valve replacement

Saif Anwaruddin, MD, FACC
Hospital of the University of Pennsylvania
Diagnostic workup and evaluation: eligibility, risk assessment, FDA guidelines

Vinay Badhwar, MD, FACC
Duke University
The history of transcatheter mitral valve technology

Muath Bishawi, MD
Duke University
The evidence base for TMVr: the EVEREST Trials

Prakash Balan, MD, FACC
McGovern Medical School
Standard wires and balloons used in TAVR

Colin M. Barker, MD, FACC
Houston Methodist
Step-by-step guide: transfemoral Corevalve Evolut TAVR

Sukhdeep S. Basra, MD, MPH
Baylor Scott and White Health
Current controversies, ongoing trials, new valves, and future directions

Peter Bittenbender, MD
Akron City Hospital
Diagnostic workup and evaluation: eligibility, risk assessment, FDA guidelines

Chase R. Brown, MD
Penn Medicine
Step-by-step guide: Transapical Sapien S3 TAVR

Joaquin E. Cigarroa, MD, FACC
Oregon Health & Sciences University
Fluoroscopy and contrast: angles, doses, and radiation safety

Joseph S. Coselli, MD, FACC
Texas Heart Institute and Baylor College of Medicine
Post-procedure management: complications; anticoagulation, standard pathways, discharge instructions and follow-up

Jacob Dal-Bianco, MD, FACC
Massachusetts General Hospital
Cardiac imaging for TMVr - TTE and TEE

Adrian DaSilva – DeAbreu, MD
UT Houston
Basics of echocardiography for transcatheter interventions

Charles J. Davidson, MD, FACC
Northwestern Memorial Hospital
Transfemoral/Transseptal Mitral Valve-in-Valve using Sapien 3

Nimesh Desai, MD, PhD
Penn Medicine
Step-by-step guide: Transapical Sapien S3 TAVR

James T. DeVries, MD, FACC
Dartmouth-Hitchcock
Valve-in-valve TAVR

Justin M. Dunn, MD
Akron City Hospital
Diagnostic workup and evaluation: eligibility, risk assessment, FDA guidelines

Rachel Easterwood, MD
Columbia University Medical Center
The evidence base for TAVR: landmark trials

Ahmed El-Eshmawi, MD
Mount Sinai Medical Center
Future transcatheter mitral valve repair/replacement technology

Sammy Elmariah, MD, MPH, FACC
Massachusetts General Hospital
Step-by-step guide: Transseptal MitraClip

Amy Fiedler, MD
Massachusetts General Hospital
The role of the heart team

Michael S. Firstenberg, MD, FACC
The Medical Center of Aurora, Denver, CO
Diagnostic workup and evaluation: eligibility, risk assessment, FDA guidelines

David Fullerton, MD, FACC
University of Colorado Denver
Surgical anatomy of the aortic and mitral valves

Jeffrey Gaca, MD
Duke University School of Medicine
Step-by-step guide: Subclavian Corevalve Evolut TAVR

Brian B. Ghoshhajra, MD, MBA
Massachusetts General Hospital
Cardiac imaging for TAVR: CTA, TTE, TEE, and valve sizing

Amy Gin, MD, FACC
Massachusetts General Hospital
Step-by-step guide: Transseptal MitraClip

Donald Glower, MD, FACC
Duke University
The evidence base for TMVr: the EVEREST Trials

Omar Hadidi, MD
UT Houston
Step-by-step guide: transfemoral Sapien S3 TAVR

Jordan Hoffman, MD
University of Colorado Denver
Surgical anatomy of the aortic and mitral valves

Ignacio Inglessis, MD
Massachusetts General Hospital
The role of the heart team

Alexander Iribarne, MD, MS, FACC
Dartmouth-Hitchcock Medical Center
Cost-effective Analysis of TAVR

Michael E. Jessen, MD, FACC
UT Southwestern
Other alternate access options: trans-carotid, trans-caval, direct aortic

Thomas Jones, MD, FACC
University of Washington
Step-by-step guide: Melody valve implantation

Ankur Kalra, MBBS, FACC
Houston Methodist
Step-by-step guide: transfemoral Corevalve Evolut TAVR

Lauren Christine Kane, MD, FACC
Texas Children’s
The history and evidence base for transcatheter pulmonic valve replacement

Michael Kayatta, MD
Emory University
Current controversies, active trials, and future directions

James N. Kirkpatrick, MD, FACC
University of Washington
Palliative care and TAVR

Ajay J. Kirtane, MD, FACC
Columbia University Medical Center
The evidence base for TAVR: landmark trials

Neal S. Kleiman, MD, FACC
Houston Methodist
Step-by-step guide: transfemoral Corevalve Evolut TAVR

Sandeep Krishnan, MD
University of Washington
Other alternate access options: trans-carotid, trans-caval, direct aortic

Vishesh Kumar, MD
Dartmouth-Hitchcock
Valve-in-valve TAVR

Catalin Loghin, MD
UT Houston
Basics of echocardiography for transcatheter interventions

Michael J. Mack, MD, FACC
Baylor Scott and White Health
Current controversies, ongoing trials, new valves, and future directions

S. Chris Malaisrie, MD, FACC
Northwestern Memorial Hospital
Transfemoral/Transseptal Mitral Valve-in-Valve using Sapien 3

Moses Mathur, MD, FACC
University of Washington
Other alternate access options: trans-carotid, trans-caval, direct aortic

James M. McCabe, MD, FACC
University of Washington
Other alternate access options: trans-carotid, trans-caval, direct aortic

Doff McElhinney, MD
Stanford Cardiovascular Institute
Cardiac imaging for TPVr: evaluation, planning, and intra-procedural use

Serguei Melnitchouk, MD
Massachusetts General Hospital
The role of the heart team

Bibhu D. Mohanty, MD
USF Health
Valve-in-valve TAVR

Brian Morray, MD
University of Washington
Step-by-step guide: Melody valve implantation

Ashwin Nathan, MD
Hospital of the University of Pennsylvania
Diagnostic workup and evaluation: eligibility, risk assessment, FDA guidelines

Tom Nguyen, MD
UT Houston
Step-by-step guide: transfemoral Sapien S3 TAVR

Ramon Partida, MD, FACC
Massachusetts General Hospital
Step-by-step guide: Transseptal MitraClip

Jonathan J. Passeri, MD
Massachusetts General Hospital
Cardiac imaging for TAVR: CTA, TTE, TEE, and valve sizing The role of the heart team

Gregory Pattakos, MD
Texas Heart Institute and Baylor College of Medicine
Post-procedure management: complications; anticoagulation, standard pathways, discharge instructions and follow-up

Amit Pawale, MD
Mount Sinai Medical Center
Management of procedural complications in the cath lab/hybrid OR

Jennifer L. Perri, MD, MBA
Dartmouth-Hitchcock Medical Center
Cost-effective Analysis of TAVR

Bryan Piccirillo, MD
Brigham and Women’s Hospital
History of TAVR

Athar Qureshi, MD
Texas Children’s
The history and evidence base for transcatheter pulmonic valve replacement

Michael J. Reardon, MD, FACC
Houston Methodist
Step-by-step guide: transfemoral Corevalve Evolut TAVR

Iliana Hurtado Rendon, MD
Akron City Hospital
Diagnostic workup and evaluation: eligibility, risk assessment, FDA guidelines

Manuel M. Reyes, MD
Houston Methodist
Step-by-step guide: transfemoral Corevalve Evolut TAVR

Mark J. Ricciardi, MD, FACC
Northwestern Memorial Hospital
Transfemoral/Transseptal Mitral Valve-in-Valve using Sapien 3

Lucy M. Safi, DO, FACC
Massachusetts General Hospital
Cardiac imaging for TAVR: CTA, TTE, TEE, and valve sizing

Rahul Sakhuja, MD, FACC
Massaschusetts General Hospital
Step-by-step guide: Transseptal MitraClip

Pinak Bipin Shah, MD, FACC
Brigham and Women’s Hospital
History of TAVR

Vikas Singh, MD
Massachusetts General Hospital
The role of the heart team

Zachary Steinberg, MD
University of Washington
Cardiac imaging for TPVr: evaluation, planning, and intra-procedural use
Step-by-step guide: Melody valve implantation

Jill M. Steiner, MD
University of Washington
Palliative Care and TAVR

Gibert Tang, MD, MSC, MBA, FACC
Mount Sinai Medical Center
Management of procedural complications in the cath lab/hybrid OR
Future transcatheter mitral valve repair/replacement technology

Manoj Thangam, MD
McGovern Medical School
Standard wires and balloons used in TAVR

Rose Tompkins, MD
Stanford University
Cardiac imaging for TPVr: evaluation, planning, and intra-procedural use

Vinod Thourani, MD, FACC
Medstar
Current controversies, active trials, and future directions

Frans van Wagenberg, MD
UT Southwestern
Other alternate access options: trans-carotid, trans-caval, direct aortic

Adam R. Williams, MD
Duke University School of Medicine
Step-by-step guide: Subclavian Corevalve Evolut TAVR

Moritz C. Wyler von Ballmoos, MD, PhD, MPH, FACC
Duke University
The history of transcatheter mitral valve technology

Michael Young, MD
Massachusetts General Hospital
The role of the heart team

Evin Yucel, MD, FACC
Massachusetts General Hospital
Cardiac imaging for TMVr - TTE and TEE

Firas E. Zahr, MD, FACC
Oregon Health & Sciences University
Fluoroscopy and contrast: angles, doses, and radiation safety

Syed Zaid, MD
Mount Sinai Medical Center
Management of procedural complications in the cath lab/hybrid OR
Future transcatheter mitral valve repair/replacement technology


Peer reviewers

Joaquin E. Cigarroa, MD, FACC
Oregon Health & Sciences University

Joseph C. Cleveland, Jr., MD, FACC
University of Colorado

Laura Flannery, MD
Massachusetts General Hospital

Lloyd W. Klein, MD
Rush University

Gautam Kumar, MD, FACC
Emory University

S. Chris Malaisrie, MD, FACC
Northwestern Memorial Hospital

James B. McClurken, MD, FACC
Doylestown Hospital/Temple University School of Medicine

Perwaiz Meraj, MD, FACC
Cohen Children’s Medical Center of New York

Harish Ramakrishna, MD, FACC
Mayo Clinic

Matthew A. Romano, MD, FACC
University of Michigan Health System

Vinod Thourani, MD, FACC
Medstar

Table of Contents

  Part I - Essential Concepts in Structural Interventions
  Part I - Essential Concepts in Structural Interventions
  1. Surgical anatomy of the aortic and mitral valves
    • Jordan Hoffman, MD and David Fullerton, MD, FACC
      UC Denver
  2. Standard wires and balloons used in TAVR
    • Manoj Thangam, MD and Prakash Balan, MD, FACC
      McGovern Medical School
  3. Fluoroscopy and contrast: angles, doses, and radiation safety
    • Firas Zahr, MD, FACC and Joaquin E. Cigarroa, MD, FACC
      Oregon Health & Sciences University
  4. Basics of echocardiography for transcatheter interventions
    • Adrian DaSilva-DeAbreu, MD and Catalin Loghin, MD
      UT Houston
  5. The role of the heart team
    • Michael N. Young, MD; Vikas Singh, MD; Amy Fiedler, MD; Serguei Melnitchouk, MD; Igor Palacios, MD; Ignacio Inglessis, MD; Michael G. Fitzsimons, MD, Jonathan J. Passeri, MD
      Massachusetts General Hospital
  Part II - Transcatheter Aortic Valve Replacement
  Part II - Transcatheter Aortic Valve Replacement
  1. History of TAVR
    • Bryan Piccirillo, MD and Pinak Bipin Shah, MD, FACC
      Brigham and Women’s Hospital
  2. The evidence base for TAVR: landmark trials
    • Rachel Easterwood, MD and Ajay Kirtane, MD, FACC
      Columbia University Medical Center
  3. Diagnostic workup and evaluation: eligibility, risk assessment, FDA guidelines
    • Iliana Hurtado Rendon, MD, Peter Bittenbender, MD, Justin M. Dunn, MD, MPH, and Michael S. Firstenberg, MD, FACC
      Summa Health and The Medical Center of Aurora
  4. Cardiac imaging for TAVR: CTA, TTE, TEE, and valve sizing
    • Lucy M. Safi, DO, FACC, Brian Ghoshhajra, MD, MBA and Jonathan J. Passeri, MD
      Massachusetts General Hospital
  5. Step-by-step guide: transfemoral Sapien S3 TAVR
    • Omar Hadidi, MD and Tom C. Nguyen, MD, FACC
      UT Houston
  6. Step-by-step guide: transfemoral Corevalve Evolut TAVR
    • Ankur Kalra, MBBS, FACC, Michael Reardon, MD, FACC, Colin Barker, MD, FACC, Neal Kleiman, MD, FACC, and Manuel Reyes, MD
      Houston Methodist
  7. Step-by-step guide: Transapical Sapien S3 TAVR
    • Chase Brown, MD and Nimesh Desai, MD, PhD
      Penn Medicine
  8. Step-by-step guide: Subclavian Corevalve Evolut TAVR
    • Adam Williams, MD and Jeffrey Gaca, MD
      Duke University School of Medicine
  9. Step-by-step guide: Percutaneous Transaxillary TAVR with S3
    • Sankeep K. Krishnan, MD, Moses Mathur, MD, FACC, and James McCabe, MD, FACC
      University of Washington
  10. Step-by-step guide: Trans-carotid, trans-caval, and direct aortic
    • Frans van Wagenberg, MD and Michael Jessen, MD, FACC
      UT Southwestern
  11. Valve-in-valve TAVR
    • Bibhu Mohanty, MD, Vishesh Kumar, MD, and James T. Devries, MD, FACC
      USF Health and Dartmouth-Hitchcock
  12. Management of procedural complications in the cath lab/hybrid OR
    • Amit Pawale, MD, Syed Zaid, MD, and Gilbert Tang, MD, MSC, MBA, FACC
      Mount Sinai Medical Center
  13. Post-procedure management: complications; anticoagulation, standard pathways, discharge instructions and follow-up
    • Gregory Pattakos, MD and Joseph Coselli, MD, FACC
      Texas Heart Institute and Baylor College of Medicine
  14. Current controversies, ongoing trials, new valves, and future directions
    • Sukhdeep S. Basra, MD, MPH and Michael J. Mack, MD, FACC
      The Heart Hospital Baylor Plano, Texas
  15. Cost-effective Analysis of TAVR
    • Jennifer L. Perri, MD, MBA and Alexander Iribarne, MD, MS
      Dartmouth-Hitchcock Medical Center
  16. Palliative care and TAVR
    • Jill Steiner, MD and James Kirkpatrick, MD, FACC
      University of Washington
  Part III - Transcatheter Mitral Valve Repair
  Part III - Transcatheter Mitral Valve Repair
  1. The history of transcatheter mitral valve technology
    • Moritz C. Wyler von Ballmoos, MD, PhD, MPH, FACC and Vinay Badhwar, MD, FACC
      Duke University and West Virginia University
  2. The evidence base for TMVr: the EVEREST Trials
    • Muath Bishawi, MD and Donald Glower, MD, FACC
      Duke University
  3. Diagnostic workup and evaluation: eligibility, risk assessment, FDA guidelines
    • Ashwin Nathan, MD and Saif Anwaruddin, MD, FACC
      Hospital of the University of Pennsylvania
  4. Cardiac imaging for TMVr - TTE and TEE
    • Evin Yucel, MD, FACC and Jacob Dal-Bianco, MD, FACC
      Massachusetts General Hospital
  5. Step-by-step guide: Transseptal MitraClip
    • Amy Gin, MD, FACC, Ramon Partida, MD, FACC, Sammy Elmariah, MD, MPH, FACC, and Rahul Sakhuja, MD, MPP, MSc FACC
      Massachusetts General Hospital
  6. Transfemoral/Transseptal Mitral Valve-in-Valve using Sapien 3
    • S. Chris Malaisrie, MD, FACC, Mark J. Ricciardi, MD, FACC, and Charles Davidson, MD, FACC
      Northwestern Memorial Hospital
  7. Future transcatheter mitral valve repair/replacement technology
    • Syed Zaid, MD, Gilbert Tang, MD, MSC, MBA, FACC and Ahmed El-Eshmawi, MD
      Mount Sinai Medical Center
  8. Current controversies, active trials, and future directions
    • Michael Kayatta, MD and Vinod Thourani, MD, FACC
      Emory University and Medstar
  Part IV - Transcatheter Pulmonic Valve Repair
  Part IV - Transcatheter Pulmonic Valve Repair
  1. The history and evidence base for transcatheter pulmonic valve replacement
    • Varun Aggarwal, MD, Athar Quershi, MD, and Lauren Christine Kane, MD, FACC
      Texas Children’s
  2. Cardiac imaging for TPVr: evaluation, planning, and intra-procedural use
    • Zachary Steinberg, MD, Rose Tompkins, MD, and Doff McElhinney, MD
      University of Washington and Stanford University
  3. Step-by-step guide: Melody valve implantation
    • Brian Morray, MD, Zachary Steinberg, MD, and Thomas Jones, MD, FACC
      University of Washington

Copyright © 2018 by the American College of Cardiology, Washington, DC