Positionnement de la valve

Dominique Himbert

Hôpital Bichat, AP-HP

The « Check List »

Hemodynamic condition Quality of pacing Position of the guide wire in the apex of LV Perpendicularity to the aortic plane Positioning Deployment

« The 3 Cusps View »

C-THVPerpendicular View

+ =

Segmented Dyna CT

The « Check List »

Hemodynamic condition Quality of pacing Position of the guide wire in the apex of LV Perpendicularity to the aortic plane Positioning Deployment

Final Positioning ES

Rapid pacing to Help Positioning

Search for a Good Alignment

C-THV Positioning

C-THV RT Positioning

CT overlay on live fluoroscopy

2D TEE Guidance

3D TEE Guidance

ICE Guidance

The « Check List »

Hemodynamic condition Quality of pacing Position of the guide wire in the apex of LV Perpendicularity to the aortic plane Positioning Deployment

Pacing Protocol for Valve Deployment

Operator Sequence Verbal

Primary Operator “Pacemaker ready?”

Pacemaker Operator “Pacemaker ready.”

Primary Operator Valve in position “Pacemaker on”

Pacemaker Operator Initiate Pacing “Pacemaker on”

Secondary Operator Verify SBP < 50 mmHg and

Verify Pulse Pressure < 10 mmHg

Inflate “Inflating”

Hold for 3 seconds

Deflate “Deflating”

Primary Operator Balloon fully deflated “Pacemaker off”

Pacemaker Operator Turn pacemaker off “Pacemaker off”

Deployment of ES Prosthesis

Angiography during Deployment of ES Prosthesis

Slow Deployment for « Valve in a Valve »

Final Result

3D TEE During Deployment

Conclusions

Hemodynamic condition Quality of pacing Position of the guide wire in the apex of LV Perpendicularity to the aortic plane Positioning Deployment

The « Key to Success » is to have a well structured team who follow these steps

Thank you!Thank you!

Percutaneous Aortic Valve Implantation

Pacing of the right ventricle (200/min)

Cribier et al J Am Coll Cardiol 2006; 47: 1216

Rapid Ventricular Pacing

1:1 capture, SBP of 50 mmHg or below , and pulse pressure < 10 mmHg.

220 bpm → 200 bpm → 180 bpm → 160 bpm

New Systems for Navigation

and Positioning during TAVI