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Mastering Structural Heart Disease
Mastering Structural Heart Disease
Edited by
Eduardo J. de Marchena, MD
Professor of Medicine and Surgery
Director of Eberhard Grube International Structural Heart Disease
Training Program at the University of Miami Miller School of Medicine
United States
Camilo A. Gomez, MD
Interventional Cardiologist at the Jackson Memorial Health System
and a Voluntary Assistant Professor, Department of Medicine
University of Miami Miller School of Medicine
United States
This first edition first published 2023
© 2023 John Wiley & Sons Ltd
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material
from this title is available at http://www.wiley.com/go/permissions.
The right of Eduardo J. de Marchena and Camilo A. Gomez to be identified as the authors of the editorial material in this work has been
asserted in accordance with law.
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Library of Congress Cataloging-in-Publication Data
Names: De Marchena, Eduardo, editor. | Gomez, Camilo A. (Camilo Andres),

1984- editor.
Title: Mastering structural heart disease / edited by Eduardo J. de
Marchena, Camilo A. Gomez.
Description: First edition. | Hoboken, NJ : Wiley, 2023. | Includes
bibliographical references and index.
Identifiers: LCCN 2022030845 (print) | LCCN 2022030846 (ebook) | ISBN
9781119807810 (cloth) | ISBN 9781119807827 (adobe pdf) | ISBN
9781119807834 (epub)
Subjects: MESH: Heart Diseases—therapy | Heart Diseases—physiopathology
Classification: LCC RC682 (print) | LCC RC682 (ebook) | NLM WG 210 | DDC
616.1/2—dc23/eng/20220907
LC record available at https://lccn.loc.gov/2022030845
LC ebook record available at https://lccn.loc.gov/2022030846
Cover Design and Image: Manuela Echeverri
Set in 9.5/12.5pt STIXTwoText by StraiveTM, Chennai, India

To my parents for their guidance, support and encouragement; to my teachers for their knowledge, inspiration and patience;
to my patients for their confidence; and to my wife Melanie, children and grandchildren for keeping life fun and exciting.
Eduardo J. de Marchena
To God, for all the blessings; to my parents, for their guidance and constant support; to my wife, for her love and
encouragement; to my son, for the inspiration and joy he has brought to us; and to my teachers, for their knowledge,
mentorship, and opportunities.
Camilo A. Gomez
vi
Acknowledgements
We would like to thank Julissa Gutierrez for her meticulous, untiring support during preparation of this textbook.
We would also like to thank Manuela Echeverri for her inspirational, masterful artwork in the preparation of the book
cover.
vii
Cover Design Artist Statement
Manuela Echeverri
Manuela is a renowned Colombian artist, internationally recognized for her work with hearts. Her art includes a variety of
colorful heart sculptures and paintings.
Artist Statement
“A piece of color, a piece of life”
I don’t recall a specific moment in my life when I began taking an interest in art. On the contrary, I feel that art has always
been a part of me, like small shapes that when put together create a larger puzzle full of color. Art gives a greater sense of
purpose to my days and fills my life with laughter, joy, and gratitude, knowing that every moment is unique and
unrepeatable.
Through art, I have learned things that are not taught in any academy.
My work is full nuances and techniques but always defined by the use of COLOR – driven by my understanding of the
world. Through my art, and through color, I have learned to be more human, more sensitive: to create from the HEART.
And as I create, inspired by love, I have always sought to develop artistic projects with people who give meaning to what I
do, supporting the causes and perspectives that I hold dear in my life. My art has enabled me to connect with and grow in
the company of beautiful people who continue to inspire me to create an impact through my work.
ix
Brief Contents
List of Contributors xlv

Preface lv
About the Companion Website lvii
Part I Structural Interventions for the Aortic Valve 1
1 The Natural History and Hemodynamic Assessment of Aortic Valve Disease 3
2 Pathology Insights of Aortic Valve Disease 11
3 The Top Ten Clinical Trials in Patients Undergoing Transcatheter Aortic Valve Implantation
The Evolution of a Transformative Therapy into Clinical Practice 19
4 Present and Future Generations of Transcatheter Aortic Valves 31
5 Computed Tomography for Transcatheter Aortic Valve Replacement Planning

Current Perspectives and Future Directions 39
6 Optimal Selection of TAVR Devices 51
7 Transcatheter Aortic Valve Replacement

Step-by-Step Approach 59
8 Balloon Aortic Valvuloplasty

Current Clinical Role and Technical Aspects 69
9 Challenging Anatomy Scenarios in TAVR 75
10 TAVR for Bicuspid Aortic Valve 83
11 TAVR for Pure Native Valve Aortic Regurgitation 89
12 Aortic Valve-in-Valve Interventions 95
13 Prevention and Management of Coronary Artery Obstruction in TAVR 103

x Brief Contents
14 Coronary Artery Disease and Transcatheter Aortic Valve Replacement

Timing and Patient Selection for Coronary Intervention in Patients Planned for TAVR 109
15 Conduction Disturbances Associated with TAVR

Clinical Impact and Techniques to Minimize 115
16 Management of Conduction Disturbances Post-TAVR 123
17 TAVR Mechanical Complications Prevention and Management 131
18 Pathological Insights of TAVR Degeneration and Thrombosis 139
19 Clinical Implications of Valve Thrombosis and Early Thickening

Management of Antiplatelets and Anticoagulation Post TAVI 151
20 TAVR and Stroke 155
21 Current Evidence of Neuroprotection in TAVR 163
22 Difficult Transfemoral Access for TAVR and Bailout Techniques 169
23 Alternative Access for TAVR 175
24 Vascular Access and Closure Options for TAVR 183
Part II Structural Interventions for the Mitral Valve 191
25 The Natural History of Mitral Valve Disease 193
26 Hemodynamic Assessment of the Mitral Valve 203
27 Echocardiographic Assessment Prior to Mitral Valve Edge-to-Edge Repair 211
28 Intra-procedural Transesophageal Echocardiography for Mitral Valve Structural Interventions 217
29 Surgical Trials in Mitral Valvular Disease 227
30 Surgical Techniques for Mitral Valve Repair 233
31 Structural Interventions for Mitral Stenosis 239
32 Transcatheter Edge-to-Edge Repair Trials

The EVEREST and COAPT Trials 251
33 Mitral Valve TEER

The MitraClip Procedure 257
34 TEER Challenging Anatomy and MitraClip Tips and Tricks 273
35 MitraClip Complications
Prevention and Management 281
Brief Contents xi
36 CT Imaging for TMVR 291
37 Transcatheter Mitral Valve Replacement

Transcatheter Mitral Valve-in-Valve (ViV), Valve-in-Ring (ViR), and Valve-in-MAC (ViMAC) 301
38 Transseptal Transcatheter Mitral Valve-in-Valve Replacement (TS MViV)

Technical Considerations and Step-by-Step Procedure 311
39 Transseptal Systems for TMVR and Transcatheter Devices for Mitral Annuloplasty 317

The Tendyne System 325
41 Self-Expanding Transcatheter Mitral Valve Replacement Systems

Medtronic Intrepid Valve 331
Part III Structural Interventions for the Tricuspid Valve 335
42 Natural History and Hemodynamic Assessment of Tricuspid Valve Diseases 337
43 Indications and Outcomes for Surgical Tricuspid Valve Repair 343
44 Intra-Procedural Imaging of Tricuspid Valve Edge-to-Edge Interventions 347
45 Transcatheter Tricuspid Valve Device Landscape 353
46 Progress in Transcatheter Tricuspid Valve Repair and Replacement 363
47 Tricuspid Valve-in-Valve and Valve-in-Ring 383
48 Caval Valve Implantation (CAVI) for the Treatment of Severe Tricuspid Regurgitation 391
Part IV Structural Interventions for Management of Paravalvular Leaks 395
49 Aortic Paravalvular Leak Closure

Techniques and Devices for Surgical and Transcatheter Prostheses 397
50 Mitral Paravalvular Leak: Imaging and Interventional Approaches 403
Part V Left Atrial Appendage Closure 415
51 Current Indications for Percutaneous Left Atrial Appendage Occlusion 417
52 Imaging for LAA Interventions 425
53 Devices for Left Atrial Appendage Closure 433
54 LAA Occlusion Technique and Challenging Scenarios 441
55 Preventing and Managing Complications of LAA Closure 449

xii Brief Contents
Part VI Selected Structural Interventions for Cardiomyopathies 457
56 The Natural History of Hypertrophic Cardiomyopathy 459
57 Alcohol Septal Ablation in Hypertrophic Cardiomyopathy 463
58 Transcatheter Edge-to-Edge Repair for Hypertrophic Cardiomyopathy 467
59 Interatrial Shunt Creation 471
Part VII Selected Adult Congenital Structural Interventions 475
60 Shunt Hemodynamics and Calculations 477
61 Persistent Foramen Ovale Closure

Technical Considerations 485
62 Atrial Septal Defects Closure 493
63 Ventricular Septal Defects Closure 499
64 Percutaneous Treatment of Aortic Coarctation 505
65 Percutaneous Pulmonary Valve Replacement (PPVR) 515
Part VIII Miscellaneous 523
66 Hemodynamic Pearls in Adult Structural Heart Disease 525
67 Percutaneous Closure of Coronary Artery Fistulas 535
68 Renal Denervation Therapy

Available Evidence, Catheters, and Techniques 541
69 Acute Pulmonary Embolism Interventions: Data and Indications 547
70 Acute Pulmonary Embolism Intervention: Devices and Techniques 553
71 Transseptal Puncture Technique in the ERA of Structural Heart Disease 561
72 ECMO for Structural Interventions 567
73 Best Practices for Mechanical Circulatory Support with Impella for Acute Myocardial Infarction Cardiogenic Shock
and Selected Structural Interventions 571
74 Transcatheter Interventions for Aortic Valve Insufficiency in Patients with Left Ventricular Assist Devices 585
Index 589
xiii
Contents
List of Contributors xlv

Preface lv
About the Companion Website lvii
Part I Structural Interventions for the Aortic Valve 1
1 The Natural History and Hemodynamic Assessment of Aortic Valve Disease 3

Aortic Stenosis 3
1. What are the causes of aortic stenosis (AS)? 3
2. How is AS severity graded? 3
3. What are the hemodynamic consequences of AS? 3
4. How are the hemodynamics of AS translated into symptoms? 3
5. How are the hemodynamics of AS translated into physical exam findings? 4
6. How is AS diagnosed (imaging and invasive hemodynamics)? 5
7. What is low-flow AS? 5
8. What are the indications for medical therapy of AS, and what do those therapies consist of? 6
9. What are the indications for mechanical therapy of AS, and what do those therapies consist of? 6
10. What is the prognosis for AS? 6
Aortic Regurgitation 6
11. What are the major etiologies of aortic regurgitation (AR)? 6
12. How is severe AR defined? 7
Chronic AR 7
13. What are the hemodynamics of chronic AR? 7
14. How are chronic AR hemodynamics translated into symptoms? 7
15. How are chronic AR hemodynamics translated into physical signs? 7
16. How is AR diagnosed (imaging and invasive hemodynamics)? 7
17. What are the indications for medical therapy in AR and of what do Those therapies consist? 8
18. What are the indications for mechanical therapy of AR and of what do Those therapies consist? 8
19. What is the prognosis following treatment 8
evere Acute AR
S 8
Bibliography 9
2 Pathology Insights of Aortic Valve Disease 11

Introduction 11
1. What is the normal anatomy of the aortic valve? 11
2. What are the etiologies of aortic valve diseases? 11
3. What is the epidemiology of aortic valve disease? 11
xiv Contents
4. What is the pathology of tricuspid calcific aortic stenosis? 12

5. What is the etiology of bicuspid aortic valve? 14
6. What is the classification of bicuspid aortic valves? 14
7. What are the pathologic findings of a bicuspid aortic valve? 15
8. What are the classification and pathology of the unicuspid aortic valve (UAV)? 15
9. What are the differences between the pathological findings in tricuspid vs. bicuspid vs. unicuspid aortic
valves? 15
10. What are the risk factors for calcific aortic stenosis? 16
11. What are the underlying mechanisms of aortic valve calcification? 16
onclusion 17
C
Bibliography 17
3 The Top Ten Clinical Trials in Patients Undergoing Transcatheter Aortic Valve Implantation
The Evolution of a Transformative Therapy into Clinical Practice 19
1. Who invented TAVI, and where were the early studies performed? 19
2. How was TAVI evaluated in the United States? 19
Leon, M.B., Smith, C.R., Mack, M. et al. (2010). Transcatheter aortic-valve implantation for aortic stenosis in patients
who cannot undergo surgery. N. Engl. J. Med. 363 (17): 1597–1607. 20
3. Did PARTNER B affect “clinical equipoise” for randomized trials in non-operable patients? 20
Popma, J.J., Adams, D.H., Reardon, M.J. et al. (2014). Transcatheter aortic valve replacement using a self-expanding
bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J. Am. Coll. Cardiol. 63 (19):
1972–1981. 20
4. When did the Heart Team develop, and what has it meant to TAVI decision-making? 20
Smith, C.R., Leon, M.B., Mack, M.J. et al. (2011). Transcatheter versus surgical aortic-valve replacement in high-risk
patients. N. Engl. J. Med. 364 (23): 2187–2198. 21
5. Were the initial concerns about stroke with TAVI justified? 21
Adams, D.H., Popma, J.J., Reardon, M.J. et al. (2014). Transcatheter aortic-valve replacement with a self-expanding
prosthesis. N. Engl. J. Med. 370 (19): 1790–1798. 21
6. What contributed to the differences in one-year mortality between TAVI and surgery patients? 21
Leon, M.B., Smith, C.R., Mack, M.J. et al. (2016). Transcatheter or surgical aortic-valve replacement in intermediate-
risk patients. N. Engl. J. Med. 374 (17): 1609–1620. 22
Reardon, M.J., Van Mieghem, N.M., Popma, J.J. et al. (2017). Surgical or transcatheter aortic-valve replacement
in intermediate-risk patients. N. Engl. J. Med. 376 (14): 1321–1331. 22
7. What have we learned about the assessment of valve durability? 22
Feldman, T.E., Reardon, M.J., Rajagopal, V. et al. (2018). Effect of mechanically expanded vs self-expanding
transcatheter aortic valve replacement on mortality and major adverse clinical events in high-risk patients with
aortic stenosis: the REPRISE III randomized clinical trial. J. Am. Med. Assoc. 319 (1): 27–37. 23
Mack, M.J., Leon, M.B., Thourani, V.H. et al. (2019). Transcatheter aortic-valve replacement with a balloon-
expandable valve in low-risk patients. N. Engl. J. Med. 380 (18): 1695–1705. 24
Popma, J.J., Deeb, G.M., Yakubov, S.J. et al. (2019). Transcatheter aortic-valve replacement with a self-expanding
valve in low-risk patients. N. Engl. J. Med. 380 (18): 1706–1715. 25
Makkar, R.R., Cheng, W., Waksman, R. et al. (2020). Self-expanding intra-annular versus commercially available
transcatheter heart valves in high and extreme risk patients with severe aortic stenosis (PORTICO IDE): a
randomised, controlled, non-inferiority trial. Lancet 396 (10252): 669–683. 25
8. What did we learn about subclinical leaflet thrombosis from this study? 25
9. What are other areas of improvement for TAVI? 26
10. What should be considered for the lifetime management of patients undergoing TAVI? 26
11. What patient subsets have yet to be studied? 27
Moderate Aortic Stenosis 27
Asymptomatic Aortic Stenosis 27
Aortic Insufficiency 27
onclusions 28
C
Bibliography 28
Contents xv
4 Present and Future Generations of Transcatheter Aortic Valves 31

1. What life-long management is required for patients undergoing TAVR 31
2. How is TAVR used for low-surgical-risk patients? 31
3. Describe the hemodynamics after TAVR 32
4. How durable is TAVR? 32
5. Describe coronary access after TAVR. 33
6. Describe pacemaker implantation after TAVR 33
7. What is the present generation of transcatheter valves? 33
SAPIEN 3 Ultra Valve 33
Evolut PRO+ Valve 34
ACURATE neo2 Valve 34
JenaValve 34
ALLEGRA Valve 34
8. What is the future generation of transcatheter valves? 35
Colibri Valve 35
DurAVR Valve 35
Navitor 35
Triskele UCL Valve 35
onclusions 35
C
Bibliography 36
5 Computed Tomography for Transcatheter Aortic Valve Replacement Planning

Current Perspectives and Future Directions 39
Introduction 39
1. What Is the best way to approach pre-procedural CT assessment, patient preparation, contrast administration,
scanning protocol, and data-reconstruction techniques in patients undergoing CT evaluation prior to TAVR? 39
2. What is the best way to analyze aortic valve calcium extension, scoring, and its clinical significance? 39
3. What is the best approach for aortic valve annular evaluation and sizing? 40
4. What is the best way to evaluate the aorta on CT scan prior to TAVR, and what is the evaluation’s clinical
significance? 41
Ascending Aorta 41
Coronary Ostium, Sinus of Valsalva, and Sinotubular Junction Measurements 42
5. What are the TAVR access sites, and how are they evaluated on a CT scan? 42
Transfemoral Access 43
Alternative Access 43
6. What is the importance of assessing the suitability of carotid embolic protection devices prior to TAVR? 44
7. What is the best way to evaluate coronary arteries and coronary bypass grafts using CT scan? 44
8. What is the importance of reporting the CT scan functional assessment, and what is the significance of cardiac
and non-cardiac incidental findings? 45
9. What is the best way to use myocardial extracellular volume (ECV) as a potential screening for cardiac amyloidosis
and myocardial fibrosis? 45
10. What is the best way to perform CT evaluation of valve-in-valve TAVR? 45
Sizing 46
Risk of Coronary Artery Obstruction 46
11. What are the CT assessments in patients with bicuspid aortic valve prior to TAVR? 47
Morphology 47
High-Risk Features 47
Annulus Size 48
Bibliography 48
xvi Contents
6 Optimal Selection of TAVR Devices 51

1. What types of transcatheter aortic valve replacement devices are commercially available? 51
2. Are other TAVR devices under clinical investigation? 51
3. Is there evidence to claim superiority of one type of TAVR device over the others? 51
4. Are there situations in which one valve should be considered over another? 52
5. Does annular size affect the choice of valve? 53
6. What type of valve should be chosen based on aortic valve calcification? 53
7. How does the risk of conduction abnormalities influence the choice of the TAVR device? 54
8. Why are the risk of coronary occlusion and the need to reaccess the coronaries are important? 55
9. What is the impact of aortic angulation on TAVR outcomes? 56
10. What about bicuspid aortic valves? 56
11. Should any other factors be considered for optimal selection of TAVR device? 56
linical Vignette 57
C
Bibliography 58
7 Transcatheter Aortic Valve Replacement

Step-by-Step Approach 59
1. What is transcatheter aortic valve replacement (TAVR)? 59
Patient Evaluation 59
2. What are the current indications for TAVR? 59
3. Are there any absolute contraindications to TAVR? 59
Step-By-Step TAVR Approach 59
4. What are the pre-procedural approach to and planning for successful TAVR? 59
5. What are the steps during the TAVR procedure? 60
Vascular Access 60
6. What is the approach for vascular access during TAVR? 60
7. What is the current best practice to establish femoral access safely? 61
8. For patients with inadequate femoral access, what are the potential options for alternative arterial access
for transcatheter valve delivery? 61
9. What is the approach to axillary/subclavian artery access? 62
10. What is the approach to carotid artery access? 62
11. What is the approach for transaortic access for TAVR? 62
12. What is the approach to transcaval access for TAVR? 62
13. What is the approach to antegrade, transapical access? 62
14. What is the approach to antegrade, transseptal access? 62
15. What are the optimal vascular closure techniques for large-bore vascular access during TAVR? 63
Balloon-Expandable Transcatheter Aortic Valve Replacement 63
16. What are the components of the Edwards SAPIEN balloon-expandable valve? 63
17. What are the essential considerations during balloon-expandable TAVR? 64
Self-Expanding Transcatheter Aortic Valve Replacement 65
18. What are the components of the self-expanding valve and catheter system? 65
19. What are the essential considerations during self-expandable TAVR? 66
20. Can the Evolut valve be repositioned during deployment? 67
21. After valve implantation, how is adequate valve position confirmed? 67
onclusion 67
C
Bibliography 67
8 Balloon Aortic Valvuloplasty

Current Clinical Role and Technical Aspects 69
1. What are the guideline recommended indications for aortic balloon valvuloplasty (BAV)? 69
2. What are the contra-indications to aortic balloon valvuloplasty? 69
3. What are the goals of BAV and what defines a successful BAV? 69
Contents xvii
4. What is the incidence of complications in BAV? 70

5. What are the balloon sizing considerations for BAV? 70
6. Which types of balloons are available for BAV? 70
7. What is the technique used to cross stenotic aortic valve? 70
8. How is the valvuloplasty balloon stabilized across the aortic valve during inflation? 71
9. What is the role of valvuloplasty in patients undergoing TAVR? 71
10. What is the role of BAV in patients with low-flow, low-gradient aortic stenosis? 71
11. What is the role of BAV to reduce cardiac complications of patients requiring non-cardiac surgery? 71
12. What is the post-procedure care of BAV patients? 72
13. What are the options for hemodynamically assisted aortic valvuloplasty? 72
Bibliography 72
9 Challenging Anatomy Scenarios in TAVR 75

Aortic Root 75
1. During transcatheter aortic valve replacement (TAVR), what are important principles for patients with severe
aortic leaflet and annular calcification? 75
2. What unique risks exist during TAVR when there is minimal aortic leaflet and annular calcium? 75
3. How does sinotubular junction (STJ) calcification affect valve deployment? 76
4. What does “horizontal aorta” refer to during TAVR, and what techniques are required in this situation? 76
5. How should LVOT calcification affect valve deployment? 76
6. What is the role of TAVR in patients with bicuspid aortic valve disease? 76
7. What can be done for patients with a small aortic annulus? 77
8. How should a valve be correctly sized in an extremely large annulus? 77
9. What are the options for annular sizing in patients who cannot receive computer tomography (CT) with
contrast? 77
Coronary Arteries 78
10. For what patient anatomy should you consider protecting the left main coronary artery? 78
11. How should you perform TAVR if a patient will likely need a future percutaneous coronary intervention
(PCI)? 78
Aorta 79
12. Is it possible to perform a TAVR in a patient with an ascending aortic aneurysm? 79
13. What techniques allow transfemoral access for patients with a tortuous descending aorta? 79
14. Does the presence of a bovine arch prevent the placement of a cerebral embolic protection device? 80
emoral Arterial Access 80
F
15. How can transfemoral TAVR be performed if there is significant iliac artery calcification? 80
16. How can transfemoral TAVR be performed if there is significant femoral artery calcification? 80
17. What can be done if there is only one patent iliofemoral artery? 80
18. If iliofemoral access is not feasible, what are different options for alternate access? 80
Valve-in-Valve (ViV) 81
19. When performing ViV TAVR, how do you choose the correct transcatheter valve? 81
20. What are the relevant considerations when potentially fracturing an existing surgical valve prior to ViV
implantation? 81
21. What can be done if there is a high risk of coronary artery obstruction with ViV TAVR? 81
Bibliography 82
10 TAVR for Bicuspid Aortic Valve 83

Epidemiology 83
1. What is the prevalence of bicuspid aortic valves? 83
2. How is BAV identified? 83
3. How do patients with bicuspid AS undergoing transcatheter aortic valve replacement compare to
patients with tricuspid AS? 83
xviii Contents
Bicuspid Valve Morphology 83

4. Match the illustrated valve morphologies to the correct bicuspid phenotypes according to the conventional Sievers
classification and the newly derived CT classification (see figure 10.1). 83
5. What anatomical characteristics commonly associated with BAVs may complicate TAVR? 84
Procedural Planning 84
6. What considerations should be taken into account when choosing a THV type (annular/supra-annular;
balloon-expandable/self-expanding)? 84
7. Can computer simulation complement pre-procedural TAVR planning? 85
8. What sizing strategies exist for selecting THV size in bicuspid AS? 85
9. What is recommended for pre-dilatation and post-dilatation? 86
Outcomes 86
10. How do outcomes of TAVR in bicuspid AS compare with tricuspid AS? 86
11. Describe how the different bicuspid phenotypes (see question 4) impact outcome after TAVR. 86
12. What features of the newer-generation THVs significantly improved the outcome of TAVR? 86
Bibliography 87
11 TAVR for Pure Native Valve Aortic Regurgitation 89

1. How common is aortic regurgitation (AR)? 89
2. What are the most common causes of NAVR? 89
3. What are the natural history and prognosis of AR? 89
4. What are the indications and the best timing for intervention of the aortic valve in AR? 89
5. What is the recommended therapy for patients with severe NAVR and indication for intervention? 90
6. What are the challenges of TAVR in pure NAVR? 90
7. What is the available evidence evaluating TAVR for pure NAVR? 90
8. What is the preferred type of THV for TAVR in pure NAVR? 91
9. What are some critical technical considerations? 91
Bibliography 93
12 Aortic Valve-in-Valve Interventions 95

1. Why are aortic valve-in-valve procedures needed? 95
2. Why are ViV TAVR outcomes better than native valve TAVR? 95
3. What are the primary limitations of aortic ViV TAVR? 95
4. Why does the mechanism of bioprosthetic valve failure matter? 96
5. How do you plan for a ViV procedure? 97
6. How do you avoid PPM in aortic ViV procedures? 97
upra-Annular vs. Intra-Annular Design 98
S
Implantation Technique (High vs. Low) 98
High-Pressure Post-Dilation and Balloon Valve Fracture 98
7. How do you prevent and treat coronary obstruction? 99
ASILICA Procedure 99
B
Chimney Technique 100
8. How important is adjunct pharmacology after ViV-TAVI? 100
Bibliography 101
13 Prevention and Management of Coronary Artery Obstruction in TAVR 103

1. What is the incidence of coronary artery obstruction in transcatheter aortic valve replacement (TAVR)? 103
2. What is the mechanism of coronary artery obstruction in TAVR? 103
3. Which coronary artery is most commonly obstructed during TAVR? 103
4. What is delayed coronary obstruction after TAVR? 103
Contents xix
5. What are the symptoms of coronary artery obstruction in TAVR? 104

6. What are the outcomes for patients that have coronary artery obstruction with TAVR? 104
7. What are risk factors for coronary artery obstruction with TAVR? 104
8. How do you prevent coronary artery obstruction with TAVR? 105
9. What is the treatment for coronary artery obstruction with TAVR? 105
10. What is preparatory coronary protection? 106
11. Explain the BASILICA procedure. 106
Bibliography 107
14 Coronary Artery Disease and Transcatheter Aortic Valve Replacement

Timing and Patient Selection for Coronary Intervention in Patients Planned for TAVR 109
1. How common is coronary artery disease (CAD) in patients with severe aortic stenosis (AS)? 109
2. What is the clinical impact of CAD on TAVR outcomes? 109
3. How do you assess for CAD prior to TAVR? 109
4. Can you use the instantaneous wave-free ratio (iFR) in patients with severe AS? 109
5. What is the role of percutaneous revascularization in TAVR? 110
6. What is the recommendation for the management of left main (LM) disease prior to TAVR? 111
7. What is the optimal timing for revascularization in patients being evaluated for TAVR? 111
8. What about completeness of revascularization in patients undergoing TAVR? 111
9. Are there technical considerations in patients undergoing PCI post-TAVR? 112
10. What is the current guideline for revascularization in patients undergoing TAVR? 113
Bibliography 113
15 Conduction Disturbances Associated with TAVR

Clinical Impact and Techniques to Minimize 115
1. What is the relationship between the aortic valve structures and the conduction system? 115
2. What is the incidence of conduction disturbances associated with TAVR? 115
3. What is the clinical impact of conduction disturbances after TAVR? 116
4. What are the predictors of conduction disturbances and PPI associated with TAVR? 117
5. What strategies can be implemented to prevent or minimize conduction disturbances associated with
TAVR? 117
IDAS Approach 118
M
Cusp Overlap Technique 118
Advantages of the Cusp Overlap Technique 119
Disadvantages of the Cusp Overlap View 119
High-implantation Technique for the Balloon-Expandable SAPIEN 3 Valve 119
6. Describe post-procedural monitoring and electrophysiological assessment after TAVR. 120
Bibliography 120
16 Management of Conduction Disturbances Post-TAVR 123

1. What are the components of normal conduction from sinus node to ventricular tissue? 123
2. Match the components of the conduction system to the following intervals 123
3. What components of the conduction system are susceptible to injury during transcatheter aortic valve
replacement (TAVR) implantation? 123
4. At what operative stage can AV conduction abnormalities be encountered? 124
5. What changes to the EKG can be anticipated after TAVR? 124
6. What pre-operative EKG finding is the strongest predictor of post-TAVR conduction disturbances and pacemaker
requirement? Why? 124
7. What procedural factors have been associated with higher risk of post-TAVR conduction disturbances? 124
8. At what point should a 12-lead EKG be performed to determine the duration of temporary pacing wire and
post-operative telemetry? 125
xx Contents
9. A patient with the pre-operative EKG shown here undergoes TAVR. No change in EKG is seen at the end of the
procedure. What is recommended for the duration of temporary pacing and telemetry monitoring? 125
10. What is the likelihood that a patient with this EKG will require a pacemaker implant after TAVR? 125
11. The patient in question 10 has no change in the 12-lead EKG at the end of the procedure. How long after the
TAVR procedure is temporary pacing recommended? 126
12. A patient who undergoes TAVR has the pre-operative EKG shown in (a) and the post-procedure EKG shown in
(b). What management decisions are recommended for this scenario? 126
13. The patient from question 12 develops the following EKG 10 hours after LBBB was noticed after TAVR. What
pacemaker configuration will maintain atrioventricular synchrony? 126
14. A patient with severe aortic stenosis and moderately reduced systolic function receives TAVR and develops the
rhythm shown here, associated with dizziness, post-TAVR. What kind of pacing configuration is less likely to
result in persistent systolic dysfunction? 127
15. Pre-operatively, an 88-year-old man has the EKG shown in (a); 48 hours after TAVR, he has the EKG shown in (b).
An electrophysiology study is performed. The intra-cardiac electrocardiograms are shown in (c). Does this patient
require a pacemaker? 128
Bibliography 129
17 TAVR Mechanical Complications Prevention and Management 131

Annular Rupture 131
1. What constitutes annular rupture in TAVR? 131
2. How do you classify annular rupture after TAVR? 131
3. How often does annular rupture occur? 131
4. Why does annular rupture happen with TAVR? 131
5. What are the risk factors for annular rupture with TAVR? 131
6. What are the outcomes of annular rupture? 132
7. How do you diagnose annular rupture? 132
8. How do you treat annular rupture? 132
9. How do you prevent annular rupture? 133
Perforation and Tamponade 133
10. How does cardiac tamponade occur in TAVR? 133
11. Why does ventricular perforation occur? 133
12. How common is ventricular perforation in TAVR? 133
13. How do you diagnose and manage perforation? 133
14. What are the outcomes after perforation? 133
15. How can you prevent cardiac perforations in TAVR? 134
Bioprosthetic Valve Infolding 134
16. What is prosthetic valve infolding? 134
17. What are the consequences of prosthetic valve infolding? 134
18. Why does valve infolding occur? 134
19. What are risk factors for valve infolding? 134
20. How common is valve infolding? 134
21. How can you diagnose valve infolding? 134
22. How do you treat valve infolding? 134
Valve Embolization 135
23. What is transcatheter valve embolization? 135
24. How common is valve embolization? 135
25. What is the cause of TVEM? 136
26. How do you treat TVEM? 136
27. How can you prevent TVEM? 137
Bibliography 137
Contents xxi
18 Pathological Insights of TAVR Degeneration and Thrombosis 139

Introduction 139
Bioprosthetic Valve Failure (BVF) 139
1. What types of valve failure modes are observed in TAVR bioprostheses? 139
Infective Endocarditis 139
2. What are the incidence and causative microorganisms of IE after TAVR? 139
3. What are the pathological findings of IE? 140
Leaflet Thrombosis 140
4. What are the clinical relevancies of leaflet thrombosis? 140
5. What are the pathological findings of valve thrombosis? 141
Neointimal Coverage and Pannus Formation 141
6. Is pannus formation seen in the TAVR valve? 141
7. What are the pathological findings of pannus formation and leaflet endothelialization in TAVR
bioprostheses? 141
Leaflet Calcification 142
8. What is the cause of leaflet calcification? 142
9. When is leaflet calcification seen after implantation? 143
10. What are the pathological findings of leaflet calcification? 143
Structural Changes (Non-calcific Structural Valve Deterioration) 145
11. What are the other causes of SVD besides calcification? 145
Durability of Bioprosthetic Valves 146
12. Is the durability of TAVR bioprostheses similar to that of SAVR bioprostheses? 146
13. Is the long-term durability the same in both TAVR and SAVR bioprostheses? 147
onclusion 147
C
Bibliography 147
19 Clinical Implications of Valve Thrombosis and Early Thickening

Management of Antiplatelets and Anticoagulation Post TAVI 151
1. What are the risk factors for transcatheter heart valve (THV) thrombosis? 151
2. What is the role of the routine use of anticoagulation post-transcatheter aortic valve implantation (TAVI) in the
absence and a concurrent anticoagulation indication (such as atrial fibrillation)? 151
3. For bioprosthetic TAVI patients who do not have other indications for anticoagulation, is it appropriate to use a
single antiplatelet agent, or is dual antiplatelet always necessary? 151
4. In the setting of bioprosthetic TAVI, for whom would dual antiplatelet therapy be indicated? 151
5. For bioprosthetic TAVI patients who have a stroke while on antiplatelet therapy, would it be reasonable to start on
oral anticoagulation in place of antiplatelet therapy? 152
6. For bioprosthetic TAVI patients who have suspected valve thrombosis and are clinically stable, what would be the
initial anticoagulation choice? 152
7. In the setting of bioprosthetic TAVI, what regimen would be indicated for a patient with concurrent atrial
fibrillation and a CHA2DS2-Vasc Score of 4, but no other indication for antiplatelet therapy? 152
8. In the setting of bioprosthetic TAVI, what regimen would be indicated for a patient with concurrent atrial
fibrillation and a CHA2DS2-Vasc Score of 4, as well as a recent coronary artery stent? 152
9. Which bioprosthetic TAVI patients should be on concurrent dual antiplatelet therapy as well as anticoagulation
(i.e. triple therapy)? 152
10. For bioprosthetic TAVI patients with a concurrent indication for anticoagulation, are DOACs a reasonable
alternative to VKAs? 152
11. What are the clinical implications of subclinical valve thrombosis, also called hypoattenuating leaflet thrombosis
(HALT)? 152
Bibliography 153
xxii Contents
20 TAVR and Stroke 155

Introduction 155
1. Describe the evidence for TAVR. 155
Stroke Following TAVR 156
2. What is the incidence of stroke following TAVR? 156
3. What are the predictors and impact of stroke associated with TAVR? 157
Management of TAVR-Related Stroke 157
4. How can you prevent stroke related to TAVR? 157
5. What is the best way to treat stroke related to TAVR? 158
onclusions 159
C
Bibliography 159
21 Current Evidence of Neuroprotection in TAVR 163

Peri-Procedural Stroke 163
1. Is the occurrence of peri-procedural strokes still the Achilles’ heel of TAVR? 163
2. What is the underlying mechanism of stroke in TAVR patients? 163
3. What are the consequences of debris embolizing to the brain? 163
The Rationale for Cerebral Embolic Protection Devices 163
4. How many TAVR patients are affected by embolized debris? 163
5. What kind of EPDs are currently available for TAVR? 164
6. Are other technologies in the pipeline? 164
Characteristics of Dislodged Debris 164
7. What kind of debris may embolize toward the brain? 164
8. What is the captured debris size? 165
9. Are there any predicting factors for the dislodgement of debris? 165
10. Who might benefit most from protected TAVR? 165
Clinical Evidence of Neuroprotection In TAVR 165
11. Is there a proven clinical benefit from randomized controlled trials (RCTs) to underpin the systematic use of
cerebral embolic protection in TAVR? 165
12. What will the future bring? 167
Bibliography 167
22 Difficult Transfemoral Access for TAVR and Bailout Techniques 169

1. What are the benefits of transfemoral access? 169
2. What is considered “high-risk” vascular anatomy for transfemoral TAVR? 169
3. How common is severe peripheral arterial disease in severe aortic stenosis patients? 169
4. How do you plan for a successful transfemoral TAVR procedure? 170
5. What are the most important technology developments for TF access success? 170
Size and Design of TAVR Delivery Systems 170
Ultrasound-Guided Vascular Access 170
Shockwave Intravascular Lithotripsy 171
How to Approach High-Risk Vascular Anatomies 171
6. How do you approach small vessels? 171
7. Can endovascular pretreatment of iliofemoral atherosclerotic disease be performed? 172
8. How do you approach significant calcific peripheral disease? 172
9. How do you approach severe vascular tortuosity? 172
10. Can TF TAVR be performed in patients with abdominal aortic aneurysms? 173
Bibliography 173
Contents xxiii
23 Alternative Access for TAVR 175

1. Why is TF access the gold standard for TAVR? 175
2. How are transapical and direct aortic access performed? 175
3. What are the important considerations when selecting transaxillary (TAx) access for TAVR? 176
4. How is TAx TAVR performed? 176
5. What are the advantages and important considerations of transcarotid (TC) access? 177
6. What is the physiology that allows for transcaval (TCV) access and prevents a life-threatening retroperitoneal
bleed? 178
7. How is TCV access for TAVR performed? 178
8. How is TCV access closure performed? 179
onclusion 180
C
Bibliography 181
24 Vascular Access and Closure Options for TAVR 183

1. What constitutes pre-procedural vascular access evaluation? 183
2. What is the gold standard imaging technique for the anatomic evaluation of arterial access sites before
TAVR? 183
3. What is the optimal arterial puncture technique for common femoral artery access? 183
4. What is the best technique for fluoroscopic confirmation of vascular sheath insertion in the common femoral
artery? 184
5. What are the technical considerations to obtain optimal carotid and axillary artery access? 184
6. What are the technical considerations to obtain optimal transcaval access, and what techniques are helpful
to achieve hemostasis after removal of
large-caliber sheaths following transcaval approach? 185
7. What vascular closure devices are currently recommended after transfemoral interventions with large-caliber
vascular sheaths? 185
8. What accounts for vascular access-site and access-related complications? 185
9. What is the incidence of vascular access complications? 187
10. What is the most appropriate management of an arterial dissection? 187
11. What is the most appropriate management of an arterial perforation? 187
12. What is the most appropriate management of retroperitoneal bleeding? 187
13. What is the most appropriate management of acute limb ischemia? 187
14. What methods can be used to prevent ischemic limbs when large bore access is occlusive? 188
Bibliography 188
Part II Structural Interventions for the Mitral Valve 191
25 The Natural History of Mitral Valve Disease 193

Mitral Stenosis 193
1. What are the causes of mitral stenosis (MS)? 193
2. What are the hemodynamic consequences of MS? 193
3. How are the hemodynamics of MS translated into symptoms? 193
4. How are the hemodynamics of MS translated into physical exam findings? 193
5. How is MS diagnosed (imaging and invasive hemodynamics)? 194
6. What are the indications for medical therapy of MS, and what do those therapies consist of? 195
7. What are the indications for mechanical therapy of MS, and what do those therapies consist of? 195
8. What is the prognosis of MS? 195
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Mitral Regurgitation 195

9. What are the two major classes of MR? How do they differ in prognosis and therapy? 195
rimary Mitral Regurgitation 196
P
10. What are the major etiologies of PMR? 196
11. What are the hemodynamics of PMR? 196
12. How are PMR hemodynamics translated into symptoms? 197
13. How are PMR hemodynamics translated into physical signs? 197
14. How is PMR diagnosed (imaging and invasive hemodynamics)? 197
15. What are the indications for medical therapy in PMR, and what do those therapies consist of? 198
16. What are the indications for mechanical therapy of PMR, and what do those therapies consist of? What is the
prognosis following treatment? 198
econdary Mitral Regurgitation 198
S
17. What are the major etiologies of SMR? 198
18. What are the hemodynamics of SMR? 199
19. What are common myths about the hemodynamics of SMR? 199
20. How are SMR hemodynamics translated into symptoms? 199
21. How are SMR hemodynamics translated into physical signs? 199
22. How is SMR diagnosed (imaging and invasive hemodynamics)? 199
23. What are the indications for medical therapy in SMR, and what do those therapies consist of? 199
24. What are the indications for mechanical therapy of SMR, and what do those therapies consist of? 199
25. What is the prognosis of SMR? 200
Bibliography 200
26 Hemodynamic Assessment of the Mitral Valve 203

Mitral Stenosis 203
1. Why is it important to distinguish between rheumatic and nonrheumatic calcific mitral stenosis? 203
2. What is the pathophysiology leading to the hemodynamic consequences of MS? 203
3. When is it reasonable to consider intervention for MS? 203
4. What are the findings on invasive hemodynamic assessment to suggest severe MS? 203
5. What are the pitfalls of using PCWP as surrogate for LA pressure? 204
6. What can cause an elevated transmitral gradient? 204
7. What are the expected hemodynamics before and after PMBV? 205
8. What is a dreaded immediate complication to monitor for during PMBV? 206
9. What are the common causes of primary and secondary MR? 206
10. What is the difference in pathophysiology leading to the hemodynamic consequences of acute vs.
chronic MR? 206
11. What are mimickers that lead to a prominent v wave on PCWP or LA pressure tracings? 206
12. When is it reasonable to consider percutaneous intervention for MR? 206
13. What is the concept of proportionately and disproportionately severe secondary MR? 207
14. Alternatively, what is the difference between atrial and ventricular functional MR (AFMR vs. VFMR)? 207
15. What are the percutaneous MV interventions currently available and under investigation? 208
16. What are the expected hemodynamic changes after the most common percutaneous edge-to-edge repair with
MitraClip? 208
Bibliography 208
27 Echocardiographic Assessment Prior to Mitral Valve Edge-to-Edge Repair 211

1. What is edge-to-edge mitral valve repair? 211
2. What is the role of pre-procedural transthoracic echocardiography (TTE) prior to edge-to-edge mitral valve
repair? 211
Contents xxv
3. How is MR classified? 211

4. Which patients with primary MR would benefit the most from percutaneous edge-to-edge repair? 211
5. Which patients with secondary MR would benefit the most from percutaneous edge-to-edge repair? 211
6. Which are the most important views in the pre-procedural TTE? 212
7. Why is pre-procedure transesophageal echocardiography (TEE) important? 212
8. Which are the most important pre-procedural TEE views to assess for edge-to-edge mitral valve repair? 213
9. What are the applications of 3D pre-procedural TEE for edge-to-edge repair? 213
10. What are the differences between real-time 3D and multi-beat 3D acquisition, and how does this affect edge-to-
edge mitral valve repair? 213
11. Does 3D TEE add any information to the quantification of MR? 213
12. From the EVEREST trial, which anatomy is considered suitable? 214
13. Pair the figures with the appropriate measurements: (a) coaptation length, (b) coaptation depth, (c) flail gap, and
(d) flail width. 215
14. Which is the appropriate location for transseptal puncture? 215
Bibliography 215
28 Intra-procedural Transesophageal Echocardiography for Mitral Valve Structural Interventions 217

1. Who is “qualified” to perform intra-procedural transesophageal echocardiography (TEE) for structural
interventions on the mitral valve (MV)? 217
2. Which structural mitral interventions is TEE most used for? 217
3. What are the major views in 2D TEE used for MV structural interventions? 217
4. Are there any advanced 2D imaging techniques that are useful in guiding structural heart interventions? 218
5. What are the major views in 3D TEE used for MV structural interventions? 219
6. Which 3D imaging modalities are most used in structural mitral interventions? 219
Septal Puncture 220
7. How is TEE used to guide TSP? 220
8. What are the procedural-specific considerations for the echocardiographer during TSP? 220
Edge-to-Edge Repair 220
9. What measurements are commonly made by echocardiography prior to an edge-to-edge repair? 220
10. What are the steps and imaging considerations for edge-to-edge repair? 221
11. What are the unique features of the different generations of MitraClip devices that echocardiographers should be
familiar with? 222
12. What are some common “tricks” that can be used to help with leaflet grasp during the clip procedure? 222
13. What are the key complications during MitraClip that echocardiographers need to consider? 222
TMVR 222
14. What is the role of the echocardiographer in TMVR? 222
15. How do echocardiographers assist in sizing a valve during valve-in-valve and native valve TMVR? 223
16. How do echocardiographers aid in valve deployment? 223
17. Which echocardiographic parameters can predict LVOTO in native valve TMVR? 223
Balloon Valvuloplasty 223
18. Are there any special considerations the echocardiographer should be aware of during balloon
valvuloplasty? 223
19. What echocardiographic guided procedures are on the horizon? 224
20. What are the health system implications of a growing field of structural heart interventions, as it relates
to echocardiography? 224
aravalvular Leak Closure 225
P
Bibliography 225
xxvi Contents
29 Surgical Trials in Mitral Valvular Disease 227

1. Describe the surgical therapy for acute MR. 227
2. Discuss recent publications on mitral valve reconstruction being superior to replacement in chronic
structural MR. 227
3. Discuss recent publications about MV replacement having similar and non-inferior results in patients with
secondary MR. 228
4. Describe two published randomized trials assessing the outcome of percutaneous MV repair using the MitraClip
for therapy of secondary MR. 228
5. What are the surgical indications for MV repair? 228
6. Describe the “double-orifice” surgical repair technique described by Alfieri et al. 228
7. What are the surgical details of performing mitral ring annuloplasty? 229
8. Should you resect the entire leaflet when replacing the valve? 229
9. What is the ideal vascular access for VA extracorporeal membrane oxygenation (ECMO) implantation in patients
undergoing mitral clip implantation? 229
10. What are the possible surgical complications during and/or post surgical MV insertion? 229
11. What size of surgical MV prosthesis placement enables later valve-in-valve implantation? 229
12. Is persistent MR a negative predictive factor for patients requiring left ventricular assist device (LVAD)
insertion? 229
13. Why should the Heart Team discuss structural cases in detail before the procedure? 230
14. The Heart Team is consulted on a case with persistent atrial septal defect (ASD) and a left-to-right shunt following
mitral clip placement. What is the therapeutic intervention? 230
Bibliography 230
30 Surgical Techniques for Mitral Valve Repair 233

1. What are the stages of primary mitral regurgitation (MR)? 233
2. When should patients be considered for surgical repair of their MR? 233
3. Should mitral valves (MVs) be repaired or replaced? What are the advantages? 233
4. What is SAM, and what are the risk factors for developing it? 233
5. What is the best initial step when SAM is identified while coming off cardiopulmonary bypass? 234
6. What should a surgeon do if SAM is still present after initial conservative measures to slow the heart rate and
reduce inotropic support? 234
7. Describe standard surgical approaches to the MV 234
8. Which patients should be considered for MitraClip or other transcatheter edge-to-edge repair? 235
9. When should a surgeon consider a MV replacement? What techniques should be used? 235
10. What is a papillary muscle sling, and when may it be of benefit? 235
11. How much MR is acceptable following a mitral repair? 235
12. When is the appropriate time to assess the success of MV repair? 236
13. What are the advantages of a Heart Team and center of excellence? 236
Bibliography 236
31 Structural Interventions for Mitral Stenosis 239

1. What are the current classification criteria for mitral stenosis (MS)? 239
2. What are the current indications and contraindications for percutaneous MV intervention in rheumatic MS? 239
3. What are the predictors of successful/failed PMV? 239
4. What are the techniques for PMV? 240
Mitral Balloon Valvuloplasty 242
5. What are the steps to perform PMV with the Inoue technique? 242
quipment List 242
E
Balloon Selection 242
Procedure Detail 242
6. What are the steps to perform PMV with the antegrade double-balloon technique? 244
Contents xxvii
alloon Selection 244

B
Procedure Detail 244
7. What is the follow-up protocol after PMV? 244
8. What are the potential complications of PMV? 244
emopericardium 246
H
Iatrogenic Interatrial Septal Defect 246
9. What is the role of transcatheter therapy for rheumatic MS in women who are pregnant or contemplating
pregnancy? 246
efore Pregnancy 246
B
During Pregnancy 246
10. What is the role of PMV in patients with aortic regurgitation? 246
11. What is the role of PMV in patients with concomitant severe tricuspid regurgitation? 246
12. Should PMV be attempted in patients with MV calcification? 247
13. Can PMV be done in patients with previous PMV? 247
14. What are the roles of transcatheter intervention in patients with nonrheumatic calcific MS? 247
15. What are the current and future transcatheter therapies for nonrheumatic MS? 247
ranscatheter Mitral Valve Replacement (TMVR) Using Balloon-Expandable Transcatheter Aortic Valves in
T
Mitral Position 247
Future Directions of TMVR in Non-rheumatic MS 248
Bibliography 248
32 Transcatheter Edge-to-Edge Repair Trials

The EVEREST and COAPT Trials 251
Edge-to-Edge Mitral Valve Repair (EVEREST Trials) 251
1. What is the difference between primary and secondary mitral regurgitation? 251
2. What is the basis of edge-to-edge mitral valve (MV) repair? 251
3. What was the purpose of the EVEREST Phase I clinical trial? 251
4. What were the results of EVEREST Phase 1? 251
5. What was the basis of the EVEREST II trial? 253
6. Describe the patient population in EVEREST II 253
7. What were the endpoints for comparison used in EVEREST II? 253
8. What were the results of EVEREST II? 253
9. What are the takeaway messages of EVEREST II? 253
Secondary MR and Transcatheter Repair (COAPT Trial) 253
10. What was the purpose of the COAPT trial? 253
11. Describe the patient population of the COAPT trial. 254
12. What were the endpoints of the COAPT trial? 254
13. What were the results of the COAPT trial? 254
14. What are the takeaway messages from the COAPT trial? 255
15. What are the guidelines for transcatheter MV repair in secondary MR? 255
Bibliography 255
33 Mitral Valve TEER

The MitraClip Procedure 257
Introduction 257
1. What are the anatomical and pathophysiologic considerations of the mitral valve in evaluating patients for
TEER? 257
2. What is the difference between primary mitral valve insufficiency related to degenerative mitral valve disease and
secondary functional mitral insufficiency? 258
xxviii Contents
3. What is the Heart Team approach to evaluation for mitral valve therapies? 258
4. What patients are appropriate to consider for surgical mitral valve repair vs. the TEER procedure using the
MitraClip device? 259
5. What are the current indications for the TEER procedure using the MitraClip device? 259
6. Are there any absolute contraindications to TEER? 259
7. Aside from the absolute contraindications, what are the relative contraindications to be aware of for TEER? 259
8. Is the presence of a transcatheter atrial septal defect (ASD) occlusion device a contraindication for TEER? 259
9. What are the important aspects and key questions in the pre-procedural imaging during the pre-operative
evaluation for TEER? 259
10. In degenerative valve disease including mitral valve prolapse and/or flail mitral valve leaflets, what are the
important aspects to assess during the pre-procedural TEE? 260
11. What are the anatomical considerations for percutaneous TEER? 260
12. What are the minimal MVA requirements for TEER? 260
13. What are the important aspects in the assessment of the atrial septum for adequate transseptal access? 260
14. What are the current literature and trial results using TEER for the treatment of degenerative mitral valve
insufficiency? 260
15. What are the current data for the treatment of functional mitral valve insufficiency? 261
16. Why do the results from the MITRA-FR and COAPT studies differ so significantly? 261
17. What are the real-world experience and outcomes using the MitraClip for TEER? 262
The MitraClip Device 262
18. What are the components of the MitraClip catheter system? 262
19. What are the differences between the currently available clips? 262
20. Are there any evidence-based recommendations for using the NTR vs. XTR clips? 262
Echocardiographic Imaging 263
21. What is the role of echocardiography and TEE during TEER? 263
22. What are the essential TEE views to obtain during TEER? 263
Procedure 263
23. What are the steps involved in TEER? 263
24. What are the preferred access site and vascular closure approaches during TEER? 263
25. What equipment is necessary for transseptal puncture for TEER? 264
26. What is the procedure for transseptal puncture for TEER? 264
27. What are the optimal TEE views during transseptal puncture? 264
28. What is the optimal positioning for transseptal puncture for TEER? 264
29. How is the delivery system advanced into the LA? 265
30. How is the delivery system advanced into the LA and directed toward the mitral valve leaflets? 265
31. What are the steps for grasping the leaflets with the MitraClip? 266
32. Prior to deployment, how is the MitraClip assessed to ensure adequate position, grasp, and results? 266
33. How do you assess mitral valve stenosis during clip deployment? 266
34. What should you do if the device becomes entrapped in the chordal apparatus during TEER? 266
35. After deployment, how is the adequacy of the edge-to-edge repair assessed? 266
36. If there is residual MR after the initial MitraClip, can additional clips be placed? How does the operator decide
when and how to deliver additional clips during TEER? 269
Special Patient Subgroups and Considerations 269
37. Can TEER still be used in patients with complex mitral valve pathology? 269
38. Can TEER still be used in patients with mitral valve and/or mitral annular calcification? 270
39. What are the applications and limitations of TEER in patients with restricted posterior mitral valves, mitral valve
clefts, and/or flail mitral valve leaflets? 270
onclusion 270
C
Bibliography 270
Contents xxix
34 TEER Challenging Anatomy and MitraClip Tips and Tricks 273

Introduction 273
1. What are the Alfieri stitch and transcatheter edge-to-edge repair techniques? 273
2. What is the MitraClip system? 273
MitraClip for the Myxomatous Mitral Valve 273
3. What are the anatomical findings of myxomatous mitral valve disease? 273
4. Where are some key strategies to increase success in TEER treatment of DMD? 274
5. When should an additional clip be placed? 275
MitraClip for Wide Flail Leaflets 276
6. What is considered a wide flail MV prolapse? 276
7. What are the technical considerations when treating wide flail mitral leaflets? 276
Noncentral and Commissural Lesions 276
8. How common is noncentral MR, and can it be treated using TEER? 276
9. Where should the transseptal puncture be positioned for medial mitral regurgitant lesions? 276
10. How is the optimal MitraClip arm angle determined? 277
11. What are the strategies to avoid and deal with entanglement? 277
12. How can vascular plugs and cardiac occluders be used to treat commissural lesions? 277
Calcified Mitral Valve 277
13. Did the EVEREST and COAPT trials include patients with calcification of the MV? 277
14. Is TEER feasible in patients with calcified MV apparatus? 277
econdary Mitral Regurgitation 278
S
15. What are the anatomical considerations of secondary MR? 278
16. What are the key strategies to success in treating secondary MR? 278
17. When should an additional clip be placed? 278
Bibliography 279
35 MitraClip Complications
Prevention and Management 281
Introduction 281
1. What is the incidence of vascular complications from the MitraClip procedure? 281
2. How can you prevent vascular complications during the MitraClip procedure? 282
Transseptal Puncture Complications 282
3. What are the complications of a transseptal puncture during the MitraClip procedure? 282
Complications from Device Navigation in the Left Atrium: Air Embolism and Thrombus Formation 283
4. What are the complications of device navigation in the LA? 283
Complications from Leaflet Grasping 284
5. What complications may occur during leaflet grasping? 284
6. What is a single leaflet device attachment? 284
7. How is SLDA treated? 285
8. How is SLDA prevented? 286
9. What is the incidence of MitraClip embolization? 286
10. How can you manage clip embolization? 286
Complications from Device Deployment 286
11. What is the incidence of residual MR after the MitraClip procedure? 286
12. How is residual MR treated? 287
13. What is the incidence of iatrogenic MS after MitraClip implantation? 287
14. What are the complications of elevated mean MV gradients post-MitraClip implantation? 288
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15. How can you prevent iatrogenic MS? 288

16. What is the incidence of iatrogenic atrial septal defects post-MitraClip procedure? 288
17. What are the clinical implications of persistent iASD? 288
18. What are the indications for device closure of persistent iASD? 288
Bibliography 289
36 CT Imaging for TMVR 291

1. What are the important components of the mitral valve apparatus that are important to know for TMVR
planning? 291
2. What is the role of echocardiography in TMVR? 291
3. What are the advantages of utilizing multi-detector computed tomography (MDCT) in TMVR planning? 292
4. What are the basic CT scanner image acquisition concepts and technical protocols required for obtaining a usable
mitral CT? 293
5. How is the TMVR landing zone sized and evaluated? 294
6. What is the neo-LVOT? 294
7. How can neo-LVOT be predicted? 295
8. What factors make neo-LVOT prediction modeling complex? 295
9. Which type of TMVR is at greatest risk of LVOT obstruction: valve-in-valve, valve-in-ring, or valve-in-MAC? 297
10. How can CT imaging estimate the coplanar fluoroscopic angle? 297
11. What are other relevant adjacent structures to consider in CT planning for TMVR? 298
12. What are the important measurements and characteristics to define prior to the transseptal approach for
TMVR? 298
13. What are the important measurements and characteristics to define prior to the transapical approach for
TMVR? 299
14. What is the role of CT in post-procedural imaging? 299
onclusion 300
C
Bibliography 300

Transcatheter Mitral Valve-in-Valve (ViV), Valve-in-Ring (ViR), and Valve-in-MAC (ViMAC) 301
1. What is the best way to approach a patient with a failing bioprosthetic mitral valve? 301
2. What are the important anatomic variables on cardiac computerized tomography to consider when evaluating a
patient for TMVR suitability? 302
3. What is the best way to approach and evaluate a patient with a failing mitral ring in preparation for a ViR
procedure? 302
4. What are the ideal rings in the market for ViR procedures? 303
5. What fluoroscopic landmarks are important for positioning THVs for ViV and ViR procedures? 303
6. What are the available treatment options for severe mitral annular calcification? 303
7. What are favorable characteristics for transcatheter valve anchoring in severe mitral annular calcification? 303
8. What is the ideal location for a transseptal puncture for TMVR? 304
9. What are the indications to close the transseptal septostomy site after TMVR? 304
10. What are the steps taken to perform the procedure? 304
11. What are potential complications associated with TMVR and the solutions to managing them? 304
12. What are the contraindications for ViV or ViR procedures? 305
13. What are the procedural success rates and complications associated with TMVR? 305
14. What factors are responsible for left ventricular outflow tract obstruction (LVOTO) after ViV and ViR? 305
15. What is the anticoagulation/antiplatelet strategy after TMVR? 306
16. What cases are better performed transseptal vs transapical? 307
onclusion 308
C
Bibliography 308
Contents xxxi
38 Transseptal Transcatheter Mitral Valve-in-Valve Replacement (TS MViV)

Technical Considerations and Step-by-Step Procedure 311
1. What are the important pre-procedural considerations in transseptal mitral valve-in-valve replacement ? 311
2. What are the important recommendations for patient preparation and the room setting for the TS MViV
procedure? 311
3. What steps should be followed for a successful TS MViV procedure? 311
4. What is important for vascular access during TS MViV? 311
5. Should the femoral vein access be pre-closed? 311
6. How do you obtain baseline LVOT hemodynamics during TS MViV? 312
7. How do you perform a safe transseptal puncture at an optimal location for TS MViV? 312
8. When do you insert the Edwards E sheath? 312
9. How do you cross the surgical mitral valve into the LV? 312
10. How do you perform atrial septostomy dilation? 312
11. How do you prepare the transcatheter valve for the TS MViV? 313
12. Should the surgical mitral valve be pre-dilated? 314
13. How do you advance and position the delivery system? 314
14. How do you cross the septum and the mitral valve with the delivery system and THV? 314
15. How do you position and implant the THV during TS MViV? 314
16. What is important in the post–valve deployment assessment? 314
17. When should atrial septostomy closure be considered? 314
18. How do you obtain adequate hemostasis at the vascular access site? 315
Potential Obstacles and Bailout Strategies 315
19. What can be done if the THV is not crossing the septum? 315
20. What can be done if the THV is not crossing the mitral orifice? 315
Bibliography 315
39 Transseptal Systems for TMVR and Transcatheter Devices for Mitral Annuloplasty 317
1. Is there any role for percutaneous treatment of mitral valve disease? 317
2. What are the different transcatheter MV techniques? 317
3. What is transcatheter mitral valve replacement (TMVR), and how does it differ from transcatheter aortic valve
replacement (TAVR)? 318
4. What TMVR devices are available? 319
5. What is transcatheter MV repair? 320
6. What is transcatheter MV annuloplasty? 320
7. What are some devices for transcatheter indirect MV annuloplasty? 321
8. What are some devices for transcatheter direct MV annuloplasty? 322
9. What are some other devices for transcatheter MV repair? 323
10. What is the future of transcatheter treatment of MV disease? 323
Bibliography 324

The Tendyne System 325
1. What is the rationale for the Tendyne transcatheter mitral valve replacement system? 325
2. What are the indications and contraindications for considering TMVR with the Tendyne system? 327
3. What are the anatomic variables to consider on pre-operative imaging when evaluating a patient for TMVR using
Tendyne? 327
4. What is the approach to Tendyne valve implantation, and what are the unique features? 327
5. What are specific challenges and potential complications of TMVR with the Tendyne system? 328
onclusions 329
C
Acknowledgments 329
Bibliography 329
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41 Self-Expanding Transcatheter Mitral Valve Replacement Systems

Medtronic Intrepid Valve 331
1. What are the key features of the Medtronic Intrepid transcatheter mitral valve replacement (TMVR) valve? 331
2. How does the Medtronic Intrepid valve achieve fixation and sealing? 331
3. How does the Medtronic Intrepid valve heal in the heart? 331
4. What are the available delivery systems for the Medtronic Intrepid valve? 332
5. How is the Medtronic Intrepid valve deployed via transapical delivery? 332
6. What has been the experience with the Medtronic Intrepid transapical delivery system? 332
7. What has been the experience with the Medtronic Intrepid transseptal delivery system? 333
onclusions 334
C
Bibliography 334
Part III Structural Interventions for the Tricuspid Valve 335
42 Natural History and Hemodynamic Assessment of Tricuspid Valve Diseases 337

Epidemiology, Natural History, and Prognosis 337
1. How prevalent is tricuspid regurgitation? 337
2. What is the significance of TR? 337
Anatomy 337
3. What are the four components of the tricuspid valve? 337
4. How do we classify TR, and what diseases fall into each category? 337
5. What are the signs and symptoms of TR? 338
Evaluation/Diagnosis 338
6. What are the major imaging modalities used to assess the tricuspid valve? 338
7. What are the advantages of each of these imaging modalities? 338
8. How is the tricuspid valve evaluated with echocardiography? 339
9. What are the characteristics of severe TR? 339
Management 340
10. What are the broad categories of TR management? 340
11. When is surgery considered the preferred option? 340
12. What are the surgical methods for TR management? 340
13. Which patients are considered for TTVI? 340
14. What challenges are associated with TTVI? 340
15. What are the major categories of TTVI? 340
Bibliography 340
43 Indications and Outcomes for Surgical Tricuspid Valve Repair 343

Tricuspid Regurgitation (Tricuspid Valve Insufficiency) 343
1. What are known etiologies associated with TR? 343
2. What is the reported mortality rate for surgical repair of TR? 343
3. Are there better clinical results using transcatheter tricuspid valve intervention (TTVI)? 343
4. Describe a surgical assessment and repair technique to repair a tricuspid valve 344
5. Which transcatheter annuloplasty technique resembles the surgical DeVega and Kay techniques? 345
6. What are some of the most frequently described surgical annuloplasty systems in the literature? 345
7. What is the outcome of TR repair and LVAD implantation in patients not responding to advanced medical heart
failure therapy? 345
Bibliography 345
Contents xxxiii
44 Intra-Procedural Imaging of Tricuspid Valve Edge-to-Edge Interventions 347

Introduction 347
1. Is it important to understand the structures adjacent to the tricuspid valve? 348
2. What should the transesophageal imaging protocol be? 348
3. Why is Tricuspid valve imaging challenging? 349
4. What are the steps in TV imaging? 349
5. How is TR graded? 350
6. How should post-procedural imaging be graded? 351
Bibliography 352
45 Transcatheter Tricuspid Valve Device Landscape 353

1. What is the magnitude of tricuspid regurgitation disease and its impact on patient outcomes? 353
2. What is the pathophysiology of TR? 353
3. What are the current medical and surgical recommendations for managing TR? 353
4. What are the main surgical TV repair techniques? 354
5. What are the main challenges associated with transcatheter TV interventions? 354
6. What transcatheter repair and replacement options are available? 354
eaflet-Directed Therapies 355
L
Annular-Reshaping Therapies 357
Direct Ring Annuloplasty Therapies 357
Indirect Ring Annuloplasty Therapies 358
Direct Suture Annuloplasty Therapies 358
Heterotopic Caval Valve Implantation (CAVI) 359
Bibliography 359
46 Progress in Transcatheter Tricuspid Valve Repair and Replacement 363

1. Describe the anatomy of the tricuspid valve. 363
2. What are the causes and pathophysiology of tricuspid regurgitation? 363
3. What are the signs and symptoms of TR? 364
4. What are the indications of treatment of TR in the current guidelines? 365
5. What constitutes the pre-procedural planning for tricuspid valve intervention? 365
Echocardiography 365
Multi-detector Computed Tomography 367
6. What are the indications of transcatheter tricuspid valve replacement? 368
7. What are different types, outcomes, and complications of transcatheter tricuspid valve replacement devices? 370
Coaptation Devices 370
Suture Annuloplasty Systems 371
Ring Annuloplasty Systems 372
Heterotopic Devices 373
Orthotopic Devices 373
Complications 374
Future Development of Devices 374
8. What are the limitations of transcatheter tricuspid valve replacement? 374
Bibliography 379
47 Tricuspid Valve-in-Valve and Valve-in-Ring 383

Tricuspid Regurgitation 383
1. How is tricuspid regurgitation classified? 383
2. When should TR be treated? 383
xxxiv Contents
Surgical TV Annuloplasty 383

3. What is the rationale behind TV annuloplasty? 383
4. What are the most common suture-based annuloplasty techniques? 384
5. What are the properties of prosthetic rings? 384
6. What are the outcomes of TV annuloplasty? 384
7. How can the results of TV annuloplasty be predicted? 384
8. What is the role of imaging after a failed surgical TV annuloplasty? 385
9. What information can be obtained from computed tomography? 385
10. How do you manage a failed tricuspid annuloplasty? 385
ranscatheter Tricuspid Valve-in-Ring Procedure 386
T
11. Can you always perform a TTViR? 386
12. What does the literature say about TTViR procedures? 386
Transcatheter Tricuspid Valve-In-Valve Procedure 387
13. What is the rate of bioprosthetic TV failure? 387
14. What does the literature say about TTViV procedures? 387
onclusions 387
C
Bibliography 388
48 Caval Valve Implantation (CAVI) for the Treatment of Severe Tricuspid Regurgitation 391
1. What is the concept behind caval valve implantation (CAVI)? 391
2. What is the initial data to support CAVI as a treatment for TR? 391
3. Who is a candidate for CAVI? 391
4. What information is needed to perform CAVI? 391
5. What are the steps in CAVI? 391
6. What are the current data with CAVI? 392
7. What is the future of CAVI? 393
8. What are the unknowns of CAVI? 393
Bibliography 393
Part IV Structural Interventions for Management of Paravalvular Leaks 395
49 Aortic Paravalvular Leak Closure

Techniques and Devices for Surgical and Transcatheter Prostheses 397
1. What are the indications for percutaneous aortic paravalvular leak (PVL) closure? 397
2. What are the contraindications for percutaneous aortic PVL closure? 397
3. How do you plan an aortic PVL closure procedure? 397
4. How do you cross the aortic PVL defect? 397
5. What are the techniques to deliver occluder devices? 397
6. How to negotiate an uncrossable defect? 399
7. What are the device choices for aortic PVL closure? 399
8. What are the mechanisms and treatments for post-transcatheter aortic valve replacement (TAVR) PVL? 399
9. What are the specific anatomical challenges to close post-transcatheter aortic valve PVLs? 399
10. What are some tips and tricks while closing post-TAVR PVLs? 399
11. What are the potential complications of aortic PVL closure? 400
Bibliography 400
50 Mitral Paravalvular Leak: Imaging and Interventional Approaches 403

Imaging 403
Echocardiography 403
1. What imaging modality should be considered first with suspicion of mitral PVL following repair? 403
Contents xxxv
2. What are the limitations of TTE in assessing mitral PVL? What are adjunctive quantitative measures used to
ascertain mitral PVL? 403
3. What is the next study considered after screening TTE for better visualization of the MV? 403
4. What nomenclature is used to anatomically define the PVL location? Where are severe mitral PVLs most often
found? 404
5. What echocardiographic parameters exist for grading the severity of mitral PVLs? 404
6. What role does 3D TEE play in evaluating mitral PVLs? 406
7. What role does cardiac MRI play in evaluating mitral PVLs? 406
8. What role does cardiac CT play in evaluating mitral PVLs? What are some of its limitations? 407
9. What are the potential benefits of using intracardiac echocardiography in percutaneous leak closure? 407
10. What combination imaging modalities are useful when evaluating and intervening in mitral PVLs? 408
Transcatheter Closure of Mitral PVLs 408
11. What is the most common approach to mitral PVL closure? 408
Anterograde Transseptal Approach 408
Transseptal Puncture 408
12. Describe the approach an interventionalist should take with transseptal puncture. How does this change
with (a) posterior defects, (b) anterior defects, and (c) medial defects? 408
13. In what position should the fluoroscopic gantries be oriented for transseptal puncture? What techniques
or equipment should be considered when performing transseptal puncture? 409
14. Describe the retrograde transapical approach to mitral PVL closure 410
15. Describe the retrograde femoral approach to mitral PVL closure 411
Retrograde Femoral Approach 411
Hybrid Anterograde-Retrograde Approach 411
Defect Crossing and Telescoping Catheters 411
16. Describe the steps required to cross a mitral PVL 411
17. Describe the concept of telescoping catheters for mitral PVL closure 412
Device Selection 412
18. What are common devices used for mitral PVL closure? 412
Device Deployment 413
19. What technique should be used for single-device deployment? 413
20. What techniques should be considered with multiple-device deployment? 413
Simultaneous Deployment Technique (Double Wire) 413
Sequential Deployment Technique (Anchor Wire) 413
21. What technique can be used to increase stability for catheter passage across a serpiginous defect that is difficult
to cross? 413
Sequential Deployment Technique Using Arteriovenoous or Transapical Rail 413
onclusion 413
C
Bibliography 414
Part V Left Atrial Appendage Closure 415
51 Current Indications for Percutaneous Left Atrial Appendage Occlusion 417

1. Is there a rationale for left atrial appendage occlusion (LAAO)? 417
2. Left atrial appendage occlusion: why percutaneous? 418
3. What is the level of evidence supporting percutaneous LAAO? 418
CTs for Percutaneous LAAO 418
R
Registries for Percutaneous Left Atrial Occlusion 418
4. What are the current US society recommendations for percutaneous LAAO? 420
5. Are there additional considerations related to LAAO? 420
Bibliography 421
xxxvi Contents
52 Imaging for LAA Interventions 425

Cardiac CT Pre-procedural Planning 425
1. What are the main objectives of pre-procedural cardiac tomography in left atrium appendage occlusion? 425
2. How should the patient be prepared before CT? 425
3. What is the technical protocol for imaging acquisition? 425
4. Explain how to exclude the presence of thrombus in the LAA with CT 426
5. How is anatomic feasibility of LAAO assessed by CT? 426
TEE Pre-procedural Planning 427
6. What is the role of transthoracic echocardiography (TTE) before LAA closure procedure? 427
7. What are the objectives of TEE in pre-procedural planning for LAAO? 427
8. How should the measurements of the LAA be performed during pre-procedural TEE? 427
9. What is the advantage of using 3D TEE compared with 2D TEE? 427
10. Apart from LAA sizing, what other information is relevant during pre-procedural planning with TEE? 427
11. Which imaging technique is preferred for pre-procedural planning for LAAO? 427
Intra-procedural TEE and ICE Guided Intervention 428
12. Which imaging modalities can be used for intra-procedural guidance in LAA closure? 428
13. What are the main objectives of intra-procedural TEE during LAAO? 428
14. What are the best perspectives for each of the steps of the procedure? 429
15. Explain how transseptal puncture is guided with TEE 429
16. When is the device considered to be correctly placed within the LAA? 430
17. When intracardiac echocardiography is used to guide TEE, where should the probe be placed? 430
18. What are the advantages of double transseptal puncture for ICE probe transseptal crossing? 431
19. Is ICE a safe and effective alternative to TEE for intra-procedural LAAO guidance? 431
Bibliography 431
53 Devices for Left Atrial Appendage Closure 433

1. LAA occlusion: does one device fit all? 433
2. What are the main differences among LAA occlusion device designs? 433
3. What are the characteristic of the WATCHMAN FLX device? 434
4. What are the characteristics of the Amulet device? 435
5. What are the characteristic of the LAmbre device? 436
6. Lobe and disc vs. plug: is one approach superior to the other? 436
7. What is in the pipeline? 437
Bibliography 438
54 LAA Occlusion Technique and Challenging Scenarios 441

1. What are the main prerequisites for left atrial appendage occlusion (LAAO)? 441
2. What are the main imaging techniques employed to guide LAAO? 441
3. What are the mains steps of LAAO? 441
4. What features of femoral venous access are most relevant for LAAO? 441
5. What are the keys steps for TSP? 441
6. Can LAAO be performed through a patent foramen oval (PFO) or atrial septum defect (ASD)? 443
7. What steps are required to position the delivery system at the LAA? 443
8. How is device sizing performed? 443
9. What are the anatomical landmarks for LAAO device implantation? 444
Device Deployment 444
10. What specific considerations must be taken into account with each dedicated LAAO device? 444
WATCHMAN FLX 444
Amulet 445
LAmbre 446
Contents xxxvii
ltraseal 446
U
11. What are the main steps to perform a “sandwich technique”? 446
12. What other LAA anatomies can pose a challenge for LAAO? 447
13. Can LAAO be performed in the presence of LAA thrombus? 447
References 447
55 Preventing and Managing Complications of LAA Closure 449

1. What is the relevance of this topic? 449
Pericardial Effusion (PE) 449
2. What is the current incidence of PE? 449
3. What are the causes of PE, and how can they be prevented? 449
4. How do you manage a LAAC-related PE? 450
Device Embolization 450
5. What is the current incidence of device embolization (DE)? 450
6. What are the causes of DE, and how can it be prevented? 450
7. What can be clinical manifestations of DE? 450
8. How can you perform a device retrieval? 450
Air Embolism (AE) 451
9. What are the manifestations of AE? 451
10. What are the causes of AE, and how can it be prevented? 451
11. How do you treat AE? 451
Periprocedural Ischemic Stroke 451
12. What is the current incidence of periprocedural ischemic stroke (PIS)? 451
13. What are the causes of PIS, and how can it be prevented? 451
Complications Related to Vascular Access 452
14. What are the complications related to access, and how can they be prevented? 452
Peri-device Leaks (PDLs) 452
15. What are the clinical relevance and incidence of PDLs? 452
16. What are the related factors or mechanisms? 452
17. What are the treatment options for PDL? 452
Device-Related Thrombus (DRT) 452
18. What are the incidence and clinical relevance of DRT? 452
19. What factors predispose patients to DRT, and how can it be prevented? 452
20. How do you diagnose DRTs? 453
21. How do you treat DRTs? 453
22. What other complications have been described? 454
Bibliography 454
Part VI Selected Structural Interventions for Cardiomyopathies 457
56 The Natural History of Hypertrophic Cardiomyopathy 459

1. What is hypertrophic cardiomyopathy? 459
2. What is the prevalence of HCM? 459
3. Is left ventricular outflow tract obstruction a common occurrence in patients with HCM? 459
4. What is the prognosis of an individual with HCM? 459
5. Are there predictors of sudden cardiac death? 459
6. How is a diagnosis of HCM made? 459
7. Is genetic testing helpful? 460
xxxviii Contents
8. Are there multiple HCM-related genes? 460

9. Are all individuals with HCM affected similarly? 460
10. What kind of symptoms does HCM cause? 460
11. Are there measures that should be undertaken in all individuals with HCM, even those with no symptoms? 460
12. What treatment is available for individuals with symptoms? 460
13. What medical therapy is recommended? 460
14. Does medical therapy “cure” the problem of HCM? 461
15. What is alcohol septal ablation? 461
16. What is septal myectomy? 461
17. What is permanent pacing, and how is it helpful to the symptomatic HCM patient? 461
Bibliography 461
57 Alcohol Septal Ablation in Hypertrophic Cardiomyopathy 463

1. In the group of patients with hypertrophic cardiomyopathy (HCM) who fail medical therapy, what proportion are
candidates for alcohol septal ablation? 463
2. Are there patients with drug-refractory obstructive HCM who are not excellent candidates for alcohol
ablation? 463
3. What specific baseline conduction system abnormalities are a problem, and why? 463
4. Are there other conduction system abnormalities that are caused by alcohol septal ablation? 463
5. What is the time interval for which patients who developed procedural-related conduction system abnormalities
must be observed to avoid unnecessary permanent pacemaker insertion? 463
6. Did the European group reporting AV block with alcohol ablation have a recommendation regarding the length of
time patients should be observed before inserting a permanent pacemaker? 464
7. Are there strategies that may reduce the rate of occurrence of AV block? 464
8. What complications can be expected in patients undergoing alcohol septal ablation? 464
9. Subsequently, have long-term studies been reported? 464
10. What is the first step that the operator takes in performing alcohol ablation? 464
11. Does this arterial branch always originate from the LAD? 464
12. Must the septal artery selected for alcohol ablation be of a certain size? 464
13. How does the operator confirm that the septal artery selected is the correct one? 464
14. Describe how the proper size of the balloon catheter is determined. 465
15. What is the consequence of alcohol being injected into the LAD? 465
16. Is the usual contrast media suitable for alcohol septal ablation? 465
17. How does the operator determine when the procedure has been successful and should be terminated? 465
18. Is reduction of LVOT pressure gradient to <20 mm Hg a reliable indicator of a “successful” alcohol ablation
procedure? 466
Bibliography 466
58 Transcatheter Edge-to-Edge Repair for Hypertrophic Cardiomyopathy 467

1. Why is the mitral valve important in hypertrophic cardiomyopathy? 467
2. Are mitral valve abnormalities in HCM a primary or secondary phenomenon, or is there primary mitral valve
pathology? 467
3. What are the options for treatment of patients with HCM who fail medical therapy? 467
4. Is percutaneous mitral valve repair with the MitraClip an option in HCM? 468
5. What are the potential benefits of percutaneous mitral valve repair compared to traditional techniques used in
HCM? 468
6. What are the technical considerations if the MitraClip is selected as therapy for HCM? 469
7. What are future venues for the percutaneous treatment and repair of the mitral valve with the MitraClip or other
technologies in HCM? 470
Bibliography 470
Contents xxxix
59 Interatrial Shunt Creation 471

1. What is the rationale for the creation of interatrial shunts? 471
2. Which populations may benefit from interatrial shunt devices? 471
3. How is net shunt volume quantified? 471
4. What is the role of shunt creation via atrial septostomy for patients with refractory cardiogenic shock? 471
5. What are the principal steps in performing bedside AS? 471
6. What are the primary interatrial shunt devices currently under investigation? 472
7. Outline the steps involved in atrial shunt device implantation 472
8. Do interatrial shunt devices increase PA pressure and the risk of RV overload? 472
9. What are other long-term concerns with interatrial shunt devices? 472
10. What is the recommended antithrombotic therapy after implantation? 473
11. What are shunt devices that do not create an ASD? 473
Bibliography 473
Part VII Selected Adult Congenital Structural Interventions 475
60 Shunt Hemodynamics and Calculations 477

1. What is a shunt, and how do we classify shunts? 477
2. What is a diagnostic shunt study? 477
3. During a routine left- or right-heart catheterization, what should prompt an interventional cardiologist to look
for an intracardiac shunt? 478
4. Does it matter if the patient is on oxygen while doing a diagnostic shunt study in the catheterization
laboratory? 478
5. What are the basic principles and equations required for shunt hemodynamics calculation? 479
6. How does right-heart catheterization (RHC) data help in the decision-making for ASD closure? 479
7. What are the criteria for a significant step up to diagnose a left-to-right shunt (assuming QS = 3L/min/m2)? 480
8. What are the criteria for a significant step up to diagnose a right-to-left shunt, and how do you localize it? 480
9. What is a bidirectional shunt, and how do you calculate it? 481
10. What are the implications of peripheral AV shunts like an AV fistula (AVF) for dialysis access? 482
11. How can you differentiate between high-output heart failure and other types of heart failure? 482
12. What is Nicoladoni-Branham sign? 482
Bibliography 482
61 Persistent Foramen Ovale Closure

Technical Considerations 485
Devices and Techniques 485
1. What is the rationale behind the closure of a patent foramen ovale (PFO)? 485
2. What devices are available in the United States for the closure of PFOs? 485
3. What is the appropriate technique for crossing the PFO? 486
4. Are there differences in technique for PFO closure between both approved devices? 486
5. What is the technique for device retrieval? 488
6. What is the goal of anticoagulation throughout the procedure? 488
7. How do you size the device? 488
8. How should multiple shunts associated with a PFO be approached? 488
9. Should the device size be modified in the presence of an atrial septal aneurysm? 489
10. Should transseptal puncture be considered when negotiating difficult anatomies? 489
11. Are there special considerations when closing a PFO associated with a lipomatous atrial septum? 489
12. Can the PFO closure be performed in the presence of an inferior vena cava (IVC) filter? 489
13. Can the procedure be performed from other access sites if the femoral access cannot be used? 489
xl Contents
omplication Prevention and Management 489

C
14. Are there complications related to device preparation? 489
15. How should you manage a device migration? 490
16. What types of complications can you encounter when treating a PFO in association with multiple atrial septal
defects? 490
17. How can device thrombosis be prevented? 490
18. Are there any electrical complications from PFO closure? 490
Bibliography 490
62 Atrial Septal Defects Closure 493

1. What are the indications to close an atrial septal defect (ASD)? 493
2. What are the contraindications to close ASD? 493
3. What kind of occluding devices are there? 493
Self-Centering Devices 493
Non-self-Centering Devices 494
4. What imaging tests should be done before the procedure? 494
5. What are the steps in a conventional procedure? 495
6. What can you do if you cannot get a proper device orientation in relation to the IAS? 496
7. What should you do when there is more than one defect? 497
8. What should you do when the device embolizes? When should you try to remove it percutaneously, and when
should you send the patient to the operating room? 497
9. What late complications may occur? 498
Bibliography 498
63 Ventricular Septal Defects Closure 499

Muscular VSDs 499
1. What muscular ventricular septal defects (MVSD) patients should you think about closing percutaneously? 499
2. What are the contraindications for percutaneous closure of MVSDs? 499
3. What devices are available? 499
4. What are the steps during the procedure? 500
5. What are the possible complications of percutaneous closure of MVSDs? 501
Perimembranous VSDs (PMVSDs) 501
6. In which patients is percutaneous closure of PMVSDs indicated? 501
7. What types of devices can be used to close PMVSDs? 502
8. What are the steps of the procedure? 502
9. What complications may occur in the closure of PMVSDs? 503
Bibliography 503
64 Percutaneous Treatment of Aortic Coarctation 505

1. What is coarctation of the aorta? 505
2. What other conditions is coarctation of the aorta associated with? 505
3. What is the clinical presentation? 505
4. What diagnostic imaging is recommended? 505
5. What are the types of transcatheter interventions in a patient with coarctation? 506
6. How is balloon angioplasty performed? 508
7. Should a low-pressure balloon or high-pressure balloon be used? 509
8. How is stent implantation performed? 509
9. Should a bare-metal or covered stent be used? 511
10. What are the most common complications? 512
Contents xli
11. What is the follow-up for patients who undergo percutaneous intervention? 512
12. What are the short- and long-term results? 513
Conclusion 513
Bibliography 513
65 Percutaneous Pulmonary Valve Replacement (PPVR) 515

1. In what anatomical settings can we perform percutaneous pulmonic valve replacement (PPVR)? 515
2. When is PPVR indicated? 516
3. What diagnostic tests should be performed before doing the PPRV? 516
4. What kind of valves are available? 516
5. How is the procedure performed? 517
6. What technical differences do you have to consider depending on the type of dysfunctional RVOT? 519
PPVR in Dysfunctional Prosthetic Conduits 519
PPVR in Dysfunctional Native RVOT 519
PPVR in Dysfunctional Biological Valves 519
7. What do you do if you cannot advance the prosthesis to the implant area? 519
8. What complications are associated with the procedure? 520
9. What is the result of PPVR during follow-up? 520
10. What technical innovations in PPVR are available in clinical practice? 520
Bibliography 522
Part VIII Miscellaneous 523
66 Hemodynamic Pearls in Adult Structural Heart Disease 525

Hemodynamic Assessment of the Aortic Valve 525
1. When is an invasive hemodynamic assessment required? 525
2. How do you calculate the aortic valve area using invasive hemodynamics? 525
3. Does the Hakki formula accurately estimate the valve area when compared to the more complex Gorlin
formula? 525
4. How do you accurately measure cardiac output? 525
5. How do you appropriately measure the transvalvular gradient? 526
6. How do you assess the transvalvular aortic valve gradient in atrial fibrillation? 526
7. Can a single-catheter pullback from the LV into the aorta be used to assess the transvalvular gradient? 526
8. Can the left ventricular and femoral pressures be used to evaluate the gradient? 526
9. How can you use the pressure waveforms to better understand the degree of aortic valve stenosis? 527
10. What other features suggest that the pressure gradient is due to a static or dynamic obstruction? 527
11. What is low-flow, low-gradient AS? 527
12. How do you differentiate true low-flow AS from pseudo-AS or a severe cardiomyopathy without contractile
reserve? 528
13. How does hypertension affect the invasive hemodynamic assessment of AS? 528
14. What are the expected hemodynamic changes that occur post-transcatheter aortic valve replacement? 529
15. What hemodynamic findings are concerning post-TAVR? 529
Hemodynamics of the Mitral Valve 529
16. What are the main hemodynamic principles of the left atrium (LA)? 529
17. How do you adequately evaluate the pressure across the mitral valve (MV)? 530
18. Can you use the pulmonary capillary wedge pressure (PCWP) to measure the left atrial pressure and transmitral
gradient? 530
19. How do you correct the phase lag between the LV pressure tracing and PCWP tracing? 530
xlii Contents
itral Stenosis 530

M
20. When should you do invasive hemodynamic measurements for MS? 530
21. What invasive hemodynamic findings are suggestive of severe MS? 531
22. How are the hemodynamics affected in patients with atrial fibrillation? 531
23. What is considered a successful percutaneous mitral balloon valvuloplasty (PMBV) via hemodynamic
measurements? 531
24. How can you detect worsening MR during the procedure if you cannot get an adequate echocardiographic
assessment? 531
25. How can you differentiate between acute and chronic MR? 531
26. What else can cause an elevated v wave on PCWP or LA pressure tracings? 531
27. How does atrial fibrillation affect the hemodynamics of MR? 531
28. How does the MitraClip affect LA pressure, and should continuous pressure measurement be used? 532
Hypertrophic Cardiomyopathy and Septal Ablation 532
29. What is the adequate way to measure gradient in patients with left ventricular outflow tract (LVOT)
obstruction? 532
30. The gradient of LVOT obstruction remains <50 mmHg at rest. What should you do next? 532
31. How does atrial fibrillation affect the gradient in hypertrophic cardiomyopathy? 532
32. How do you determine success after alcohol septal ablation? 532
33. There was intra-procedural relief of obstruction after septal ablation, but the echocardiogram two days post-
procedure showed an increase in the LVOT gradient. Does this mean the procedure was a failure? 532
Bibliography 533
67 Percutaneous Closure of Coronary Artery Fistulas 535

1. What is the incidence of coronary artery fistulas? 535
2. Describe how coronary artery fistulas are currently classified 535
3. What is the coronary steal phenomenon? 535
4. What diagnostic modalities are used in establishing the diagnosis of CAF? 535
5. Describe the clinical presentation of hemodynamically significant CAFs 536
6. What are the indications and contraindications for device closure of a CAF? 536
7. Describe the devices currently available for occlusion of CAF 536
8. Describe the technical principles for device occlusion of CAFs: surgical vs. percutaneous approach 536
9. Describe the technical principles for device occlusion of CAFs: retrograde arterial vs. antegrade venous
approach 537
10. What are the results of device closure of CAFs? 537
11. What other coronary problems involving a steal flow phenomenon can be treated using these occlusion
devices? 537
Bibliography 538
68 Renal Denervation Therapy

Available Evidence, Catheters, and Techniques 541
1. What is renal denervation? 541
2. What did first-generation trials on RDN show? 541
3. What did second-generation trials on RDN show? 541
4. What are other RDN ablation systems? 542
RDN Procedure: Technique and Steps 544
5. Describe the use of antiplatelet thereapy and anticoagulation 544
6. What is the preferred vascular access? 544
7. How do you engage the renal artery? 544
Contents xliii
8. Should you use vasodilators before RDN? 544

9. What additional medication may be needed? 544
10. How do you deliver the RDN catheter? 544
11. How do you deliver the RDN therapy? 544
12. What are some of the potential complications of RF RDN? 545
Bibliography 545
69 Acute Pulmonary Embolism Interventions: Data and Indications 547

1. How do you risk-stratify patients with acute pulmonary embolism? 547
2. Is anticoagulation alone enough for patients with high-risk submassive PE? 547
3. What is the role of catheter-directed thrombolysis in submassive PE? 548
4. Does CDL-US improve outcomes compared to standard CDL? 548
5. What is the role of mechanical thrombectomy in patients with submassive PE? 550
6. What is the role of catheter-directed therapy in massive PE? 550
7. What is the role of PE response teams in the interventional management of patients with acute PE? 551
Bibliography 551
70 Acute Pulmonary Embolism Intervention: Devices and Techniques 553

1. What devices are currently available to treat acute pulmonary embolism? 553
2. How do you choose between the different treatment options? 554
3. Is acute PE treatment similar to chronic PE treatment? 554
4. How safe is the interventional treatment of acute PE? 555
5. What patient and what artery do you treat? 555
6. What is the most efficient technique for catheter placement for directed thrombolysis? 555
7. How long do you infuse TPA? 556
8. What are the safe techniques to perform large-bore aspiration? 556
9. What are the endpoints for percutaneous thrombectomy? 557
10. How do you manage hemodynamically unstable patients? 557
11. How do you manage thrombus in transit? 558
12. How do you manage anticoagulation around treatment? 558
13. What outpatient follow-up is needed? 558
Bibliography 559
71 Transseptal Puncture Technique in the ERA of Structural Heart Disease 561

Introduction 561
1. What constitutes the fossa ovalis and the interatrial septum? 561
2. What are the current indications for accessing the left atrium 561
3. Why is it relevant to access specific locations of the interatrial septum? 562
4. What are the typical site-specific locations for the most common procedures requiring transseptal puncture? 562
5. How is a site-specific transseptal puncture performed? 562
6. What transseptal needles are commercially available? 564
7. What recent advances in imaging can assist with transseptal puncture? 565
8. What are the most common complications associated with transseptal puncture? 565
9. What is the stitch puncture complication? 566
10. Is it always required to close the interatrial communication after every transseptal procedure? 566
11. Is it feasible to cross the interatrial septum in the presence of a percutaneous septal occluder (PFO/ASD)? 566
Bibliography 566
72 ECMO for Structural Interventions 567

1. What is the ideal access strategy to initiate VA-ECMO in TAVR patients? 567
Another random document with
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to work well; so that Andy was now able to attend strictly to
business, and not spend most of his time trying to keep an
equilibrium.
The biplane had kept on rising, even after Frank brought his craft on
an even keel. He wondered what the meaning of this movement
could be. At the moment all he could think of was that Puss believed
he would be able to make better direct time if he kept just fifty feet
above the line of flight adopted by his rival.
The shouts became dimmer as they left the aviation field further in
their wake. Still they knew that every eye was focused on their
movements, and hundreds of glasses brought into use to note every
little movement of the two rival craft.
Frank seemed just as calm and collected as though he had been
going off on an ordinary little trip, to give the engine a warming-up.
From where he sat he could watch the working of the wonderful little
Kinkaid engine; for in a monoplane it is always secured before the
pilot. Some aviators incline to call this an advantage, because with a
biplane the engine must of necessity be back of the navigator.
He and Andy could converse without trouble, should the spirit move
them. True, with the little engine doing its liveliest, and the muffler
not throttled in the least, there arose a necessity for raising the voice
a trifle in order to be heard even a foot away; but Andy had good
lungs.
“Frank, they’re holding the advantage!” he exclaimed, when they had
been moving along for another minute, and heading almost straight
for the summit of the high mountain.
Looking down, Andy could see the trees of the forest far below. A
thousand feet, yes, possibly twelve hundred, they had risen without
making use of the usual method of “boring” for altitude. It was really
higher than as yet they had dared venture. Still, strange to say, Andy
did not feel the least particle of fear in connection with any possible
tumble.
His anxiety was concentrated upon the chances of the biplane
leading them all the way along the journey, just as though it were a
procession, and Puss the grand marshal.
“I know it,” replied Frank, without showing any concern.
“But we must break into their pace better than this, if we hope to
win!” declared Andy, who had taken a look upward, to see the
grinning face of Sandy Hollingshead turned down toward them, just
as though he already scented victory in the air.
“Don’t you worry, Andy!” Frank simply said.
“Are you holding back anything?” demanded the other, eagerly.
“A little. We can do better. Just wait, and trust me!”
Andy breathed more easily. When Frank spoke like that it always
gave him a new lease on hope. That came of knowing his cousin so
well, and having such perfect confidence in his sterling abilities.
When Frank Bird said “Have faith, and trust me to pull through,”
Andy was ready to believe almost anything could happen.
So he once more turned his eyes on the cap of the great mountain
which they were approaching at a rapid rate.
Old Thunder Top was indeed an imposing spectacle as seen from a
level. Of course, in the eyes of real mountaineers, the elevation
would have been a trifle, and they might have spoken of it as a mere
“foothill”; but to all loyal Bloomsbury boys it was always referred to
with respect, as the “Mountain”! Perhaps the fact of those queer cliffs
preventing any one from reaching the summit added to the
admiration with which it was gazed upon. Had the boys been
accustomed to picnicking upon that top whenever they pleased, it
must have lost much of its grandeur.
Frank had judged wisely.
“We are on a direct line with the top, don’t you think?” he asked
presently.
“As near as I can say, we are,” replied the other, as the monoplane
veered just a trifle when a gust of wind, coming from beyond the
peak, met her, and Frank manipulated his aerial steed after a clever
fashion he had inaugurated.
“If anything, a little higher,” continued Frank.
“Yes, that’s a fact,” assented Andy, with another keen look.
“That’s what I wanted. Sure you’ve got that flag handy, are you?”
went on the pilot of the speeding monoplane.
“Just you get there, and you’ll see how soon I jump out and wave it!”
declared Andy, with a vim.
Frank looked up.
The biplane still led, though by a narrow margin. At the same time, if
the relative distance were maintained to the close of the race, Puss
and Sandy would be able to land on the level plateau of the
mountain top a few seconds before them, and that would win out.
And Frank had now to decide in his active mind whether the vital
second had not arrived when he meant to release the little extra
speed he had been so jealously husbanding ever since they started.
He believed that Puss had opened his throttle to its widest extent
from the beginning, and would not have any reserve force left.
Knowing the reckless nature of his rival gave him this idea. If it
proved true, there was nothing to be feared, and they could
outdistance the biplane without difficulty.
The mountain top was now near enough for them to see the
formation of the rock. It was a matter of considerable moment
whether there was a level space large enough to allow of a landing
in safety; for an aeroplane cannot stop in twenty feet of clear ground
when going at speed.
The sun was now starting down its western journey, and
unfortunately it interfered to some extent with a clear view. Frank had
even thought of this. It was of tremendous importance to him that he
knew just what he had to expect when he attempted to land on top of
that pile of rock; and in order to assist his eyesight he had fastened a
pair of good field glasses, so that he could glue his eyes to them for
a couple of seconds, while the monoplane was shooting along in a
direct course.
The result satisfied him that his little scheme had paid, for he made a
mental photograph of the plateau, and noted just which side offered
the better advantage in the way of a landing place.
But now the decisive second was at hand when he must release his
little reserve speed, and send the monoplane on a trifle faster.
Much depended on the result. If Puss had been wise enough to do
the same thing he would be able to retain the advantage which he
now possessed, perhaps even add to the gap between them.
And so it was with more or less trepidation that Frank gave his
throttle its very last push.
“Oh!” exclaimed Andy, who of course felt the little jump which this
new impetus gave the already drumming motor.
Of course the ever watchful Sandy, from his eyrie above, would
immediately discover this maneuver on the part of the rival
aeroplane, and communicate the news to his companion.
What then? Would the pilot of the biplane simply follow suit, and thus
increase the speed of his craft? That would be the logical deduction,
if only Puss had any surplus in reserve.
Andy was on the watch, for that was a part of his business. Having
little else to do, since Frank managed the engine and the tail rudder
entirely, he was expected to discover, and report, everything that
might bear in the least on their chances.
And Andy immediately gave utterance to a low cry of delight. Even
had he not spoken a single word Frank would have known full well
that they were now rapidly closing the little gap that up to now had
stood between the monoplane and its larger rival.
“We’re going to run past them, Frank!” exclaimed Andy, doubtless
quivering with concentrated nervousness and delight. “Already we’ve
cut their lead down by half! Oh! don’t poor old Sandy looked scared
now! We’ve got them on the run, Frank, as sure as you live!”
But Frank made no answer. Perhaps a slight smile, as of pleasure,
may have crossed his set face. Only too well did he know that when
Puss Carberry was concerned, a fellow could never be positive of
having won until the line were actually crossed; and even then it was
his favorite stunt to claim “foul!”
To tell the truth, Frank would be very much easier in his mind when
once they were clear of that hovering biplane, whose Gnome engine
was banging away just above them as though scores of guns were
being discharged in rapid succession.
The suspicion that had flashed athwart his mind earlier in the race
now returned in double force; he feared lest those reckless rivals,
ready to take the most desperate chances rather than confess to
defeat, would attempt one of their customary mean tricks.
That may have been why, in the very beginning, Puss had insisted
upon keeping at a higher level than the other aeroplane! It gave him
the privilege of seeing how his rival might be coming on, without
craning his neck. It also opened up an opportunity for something to
drop, of course accidentally, just when the smaller air craft was
forging ahead!
Frank drew a long breath. He knew that the crisis of the race was
now upon him. The speed of the biplane had not increased by even
a fraction, which fact proved plainly that Puss had not held anything
in reserve.
Then it looked very much as though Puss and his chum were bound
to be beaten, unless they adopted some underhand tactics, trusting
to the distance, and the little haze encountered at this height, to
screen their despicable action from the eyes of those who looked
through all those glasses.
And Andy too must have feared something of the sort, for he was
keeping his eyes fastened on the biplane, now almost directly
overhead. Frank knew that he must meet the sudden emergency, if
one arose, with quickness, if he meant to prevent a catastrophe. He
was resolutely determined not to slow down, and allow the others to
gain a victory they had not earned; that was not Frank Bird’s way.
“Oh! he’s going to drop something on us, Frank!” cried Andy,
suddenly.
“Who is—Sandy?” demanded the other. “Give me a push as it leaves
his hand!”
Andy did not understand, but he was in the habit of minding what
Frank said; and three seconds later he brought his elbow sharply
against the pilot’s side.
Sandy had let go above, allowing the bulky object to fall through
space!
CHAPTER XXII.
WELL WON!
Instantly Frank closed the throttle, and shut off all power!
It was taking a big chance; but there was nothing else to be done.
No matter what it was Sandy had let slip, expecting that it would fall
upon the monoplane, to at least cause consternation, and in some
way lessen the speed of the smaller craft, Frank did not mean that it
should strike them, if he knew it.
Of course their speed instantly slackened; not much, perhaps, but
just enough to allow of a miss in the calculations of the unscrupulous
Sandy.
Some object whizzed past, just in advance of the now descending
monoplane. Immediately it went by, Frank, under the belief that the
danger was now over, once more carefully opened the throttle.
Joy! the faithful little Kinkaid answered to the call, and began to
renew its former volleying. Once more they were going along swiftly,
though a bit lower than when the sudden emergency had caused
such prompt work on the part of the wide-awake pilot.
Frank shot a look upward.
The biplane had not diminished its speed an iota all this while. Puss
was attending to his part of the business, leaving all other matters in
the care of his well groomed assistant.
Both of them were leaning forward, staring down and backward at
the monoplane. Even at that distance Frank could see that their
faces were as white as chalk, as though the enormity of what they
had done now burst upon them. Perhaps they may even have felt a
spasm of relief at that moment, because the sand bag which had
been dropped had missed its intended target, thanks to Frank’s
ready wit.
Now the monoplane seemed to be pushing forward with more speed
than ever, as if bent on making up for lost time. And Frank was
rising, too, for he knew he must of necessity find himself above the
crown of the mountain, when ready to alight.
“What was that they dropped?” he asked of Andy.
“Looked like a sand bag,” replied the other; “but whatever would they
be doing with such a thing in a biplane?”
“That was what I wanted to know,” replied Frank, “when I saw it tied
there with a cord; and Puss explained that he and Sandy were not
quite heavy enough. Said their experiments had proved the biplane
could make faster time with a little more weight!”
“He just lied!” burst out the indignant Andy. “A hundred to one they
took that sand bag up with them on purpose to drop it on us if we
tried to pass. And look how he kept hovering up there. That gives
him away, I tell you!”
“Perhaps he got the idea from hearing how that other sand bag
came down on our lumber pile, nearly squashing us while we slept!”
observed Frank.
“Well, he only had one, didn’t he?” questioned Andy, showing
considerable nervousness; for they were now once more directly
under the biplane.
“Only one, so the trick can’t be duplicated,” answered Frank,
confidently.
“I wouldn’t put it past that sneak Sandy, to let a monkey wrench drop
on us, if he could lay hands on one,” cried Andy; and then raising his
voice he shouted: “Hey! don’t you dare try that trick again! Accidents
don’t happen twice in succession; and they’ll hang you for murder if
anything knocks us out. They can see everything that goes on up
here!”
Possibly this was stretching it pretty lively; but all the same Andy
meant to frighten Sandy, so that he would not dream of following up
a blunder by a second miserable attempt.
“It’s too late, anyhow!” said Frank, with a vibration in his voice that
might be caused by anticipated triumph.
“Yes, we’re passing them, as sure as you live! Look at the poor old
biplane dropping out of the race, Frank! Why, it might just as well
stand still as try to keep up with this dandy little airship, once you pull
the throttle wide open! We’ve got ’em beat to a frazzle, I tell you!
Goodbye, fellows. We’ll wait for you on top of old Blitzen and
Thunder! Sorry, but somebody’s got to eat the drumsticks of the
turkey!”
Andy was feeling immensely relieved. The monoplane no longer
ranged under its larger opponent. Superior speed, backed by careful
management, had given them the lead. And as Andy declared, it
looked as though the race might end in a real Garrison finish, the
one behind shooting to the front when on the home stretch.
No matter what they would have liked to do, Puss and Sandy were
now helpless to hinder the triumphal arrival of their rivals on top of
the mountain. Everything depended on the success that might attend
Frank, when making his drop. Should he make a bad job of it, and
shoot beyond the other edge of the plateau, possibly after all the
others might be the first to land. It was their only hope.
Frank knew what he had before him. He was keenly alive to the
chances of making a poor landing. And like a wise general he had
anticipated all such things before now, even practicing stopping
within a certain limited space when going at full speed.
“We’re high enough, all right, Frank!” cried Andy reassuringly, as
they swooped down toward the top of the ominous cliffs that had
always barred their gaining lodgment on the crown of Old Thunder
Top.
“Yes, no doubt about that, Andy,” returned the other, confidently.
“Now, be ready for your part. Remember, not to blunder, or we may
lose out yet. They are coming hotfooted after us, you know!”
“I’ll remember. You can trust me, Frank!”
Really, Andy was showing commendable grit and steadiness as the
termination of the fierce race through the upper currents of the air
drew nearer and nearer its termination. There was hope that in time
he might conquer that nervousness of his, and play his part as a
worthy successor to his famous father, the professor.
Like a great bird they sailed straight for the plateau marking the flat
top of the elevation. Frank could even see the nest of sticks and
grass that marked the home of the two great kings of the air, the bald
eagles, now circling around overhead, and evidently greatly excited
at the coming of these astonishing creatures, with their loud
crackling voices.
“Say, you don’t think they’ll tackle us, and knock us off the rocks?”
cried Andy, who had also been taking notice of the wheeling birds,
now swooping down, and anon rising higher on outspread pinions.
“Keep an eye on ’em!” was all Frank could say; for just then they
were close to the outer edge of the plateau, and his entire attention
had to be focused upon what was before him, since one little
misjudgment might bring about the ruination of his plans, however
admirably fashioned.
Andy had already clutched the little pole to which the National
emblem was fastened, so that not a second might be lost in giving it
to the breeze, once his feet touched the plateau. But his anxiety was
sufficient to cause him to reach to the tool box, and extract a rather
long alligator-jaw wrench, which he had in his mind as the most
suitable weapon of defense, in case of an emergency, in which one
of those old pirates of the air figured.
Angry shouts came from the rear. Of course it was the very last
despicable little scheme of the baffled plotters, by which they hoped
to disconcert Frank enough to cause him to make a bad landing, so
that they might come swinging along in time to fly the flag first.
But Frank was not built that way. It would have to be something
much greater than a few harmless hoots, to cause him to lose his
head, especially when so very important a result depended on his
nice judgment.
He had calculated to a fraction of a foot just how far above the
plateau the monoplane was situated, so that when he shut off the
engine they would drop lightly just where he figured.
And Andy knew how to apply the drag brake, so as to haul up in a
short distance.
All the same it must have been a moment of extreme anxiety to both
of the daring young aviators. They had victory within their grasp, and
in another few seconds it would be clinched and riveted, when their
flag flew from the crown of the now conquered Old Thunder Top, that
had so long defied all attempts at mastery.
Just as Frank had figured the monoplane glided down after the
engine was stopped, and touched the rocks as gently as ever he had
come to earth, running along on the three bicycle wheels, jolting over
the rough surface, yet gradually coming to a standstill, as the brake
got in its work.
Indeed, the aeroplane had not actually come to a stop before Andy
was out of his seat, and wildly flaunting the flag that had been given
him by the head of the sports committee. He knew that every eye far
away was riveted on the spot, and that since the biplane was still
afloat, those who had glasses could readily see how the other air
craft had landed first, and hence won the race.
Of course Andy shouted like a young cowboy; he would hardly have
been human not to have found some such outlet for the pent-up
emotions that were threatening to suffocate him.
And naturally enough, those victorious whoops must have been so
like gall and worm-wood to the disheartened pair just about to alight
on the plateau, a quarter of a minute after the victors had taken
possession.
Frank knew too that there must be the added consciousness of
having attempted a nasty trick, and failed! There is possibly no
meaner feeling that can overwhelm a boy than to realize that he has
tried to down a rival through trickery, that must have been apparent
to many eyes, and failed.
But Frank’s was a generous nature. Even then he was resolved not
to press the charge against his defeated rivals. No harm had
resulted from the contemptible endeavor to delay or injure them; and
doubtless already Puss must regret that he had ever allowed himself
to conspire with Sandy to carry it out. Surely he could not have
realized what a terrible thing it was they had attempted. Let it go as
an accident then; but all the same Frank was bound to make sure
that he did not again sail the upper currents under any sort of an air
craft which either Puss Carberry or Sandy Hollingshead piloted.
The others managed to alight on the plateau, though their
momentum was enough to have carried them over the other edge
had not Frank, who had left his own machine, laid hold and held the
biplane back.
Puss looked white and confused. Sandy, on the other hand, scowled,
and clenched his hands menacingly, as though so sore over his
defeat that he was almost tempted to rush on the cheering bearer of
the flag, and have it out with him there on the very apex of Old
Thunder Top.
Possibly the sight of that long alligator-jaw wrench which Andy still
clutched in his right hand may have deterred the belligerent Sandy,
though his face continued to work spasmodically, as though he might
be saying things not at all complimentary to the object of his
aversion.
Suddenly Frank gave utterance to a shout. Faintly on the air came
the uproarious cheering of the tremendous throng, away down
yonder on the aviation field, as they saw the humiliation of the once
proud Thunder Top; but it was not in connection with this that Frank
gave tongue.
“Look out!” he cried, “the eagle!”
Sandy Hollingshead happened to be the one picked out by the angry
bird, upon whom to first try his claws and beak. The boy turned at
Frank’s cry, and just managed to throw his arm up to screen his face
from the attack. But the heavy bird struck him with tremendous force
so that Sandy was hurled over upon the rocks, and more or less
bruised and cut.
Andy ran toward him, bent on defending the prostrate lad from any
further attack on the part of the enraged feathered king of the air.
Then he stopped short, gaped at something that lay there on the
rocks, having fallen undoubtedly from one of Sandy’s coat pockets
when he was sent sprawling; and with a shrill laugh Andy snatched
the object up in his hand.
“Frank, looky here would you! Just think of me finding it up on Old
Thunder Top!”
And Frank stared, as well he might, for his chum was holding up the
missing little aluminum monkey wrench for which he had so long
searched everywhere.
CHAPTER XXIII.
PROVEN GUILTY—CONCLUSION.
“Hurrah! found at last! Didn’t I tell you I’d run it down sooner or later,
Frank? And just to think that this sneak had it all the while; grabbed it
some time when perhaps it fell out of my pocket. It’s the greatest
thing ever! I’m glad I came up here!”
So Andy kept on crying, to the secret amusement of his cousin.
Evidently the other found more real joy in the sudden and
unexpected recovery of his missing monkey wrench, than in the
great victory which the little monoplane had won.
“Look out! There come both of them, Andy! Drop flat!” he yelled, as
he saw the circling eagles start to swoop down again.
Andy just saved himself by following directions, for one of the eagles
barely missed him. Sandy was sitting up, and rubbing the back of his
head, where it had come in contact with the hard rock. He appeared
half dazed, and evidently there was little use demanding any
explanation as to how the precious tool chanced to be in his
possession. Truth to tell, Andy never did find out, and had to jump at
conclusions.
The great birds continued to wheel and dart at the intruders, so that
all of the boys were soon engaged in defending themselves.
“They think we mean to rob their nest of the two eaglets you can see
there,” was Frank’s explanation. “Perhaps if we go over to the other
side of the plateau they may haul off, and let us embark again. I
wouldn’t like to hurt them, boys.”
“And I’d kill the whole outfit, if I had my way,” grumbled Sandy,
whose clothes were torn and marked with blood, where the sharp
talons of the furious bird had clawed along his person.
“Oh! well, we’ll leave you here to clean ’em out, if you say so,”
remarked Puss, who was himself anxious to get down from that
dizzy height as soon as possible, and feeling ugly toward all
creation, as fellows who make a bad mess of things usually are.
“Not much you don’t,” said Sandy quickly. “I’m going when you get
good and ready, bet your life on it. Wouldn’t ketch me staying up
here alone. Wow! even if I had a rope long enough to reach down,
I’d be afraid to chance it. Come along, Puss, we ain’t got no call to
stay here any longer. Let’s vamose.”
The biplane was the first to start off, and Frank was a little nervous
as to whether the thing could be successfully navigated in so short a
space. But nothing went wrong, and presently those who manned
the other aeroplane also took their places and made the trial.
The flag had been left fluttering in the breeze, Andy having fixed the
short pole in a crevice of the rocks, where he could wedge it fast.
With the aid of any fairly decent glasses it could be seen from town;
and would doubtless serve to stimulate many boys in the endeavor
to accomplish some similar feat of daring.
The eagles were still soaring in great circles, now rising, and again
swooping down on their broad pinions. Frank even feared that they
might take a notion to strike the strange bird that had dared invade
their eyrie home; but evidently the eagles had come to the wise
conclusion that they need fear nothing from the visit of the two
aeroplanes, for they followed them but a short distance, to return,
and perching on a crag give utterance to what might be called a
victorious scream.
“Say, what d’ye think of that?” demanded Andy, laughing as the
sound floated to them while speeding along. “They reckon they’ve
licked us, good and plenty.”
“Well,” said Frank, quickly, “so they have in one sense, for we gave
up the field to them. But looks to me as though Puss and Sandy
somehow don’t want to return to the aviation field. They’re veering
off as if they meant to go home.”
“Humph! guess that’s the best thing they could do anyhow, after
what happened!” grunted Andy.
“Meaning that sand bag they let drop?” remarked his cousin. “If I
were you, Andy, I wouldn’t say anything about that, unless asked.
Perhaps it was an accident, and they didn’t mean to do us any
harm.”
“Accident! You know just as well as I do, Frank Bird, that it was
meant, every time,” exploded the impulsive Andy. “It’s just the kind of
dirty trick Puss and his cowardly shadow are always playing on
those they don’t like.”
“Well, could you swear to it?” asked Frank.
“On general principles, yes I could,” answered the other, shaking his
head in an obstinate fashion.
“Then you saw Sandy unfasten the cord, or cut it loose?” Frank went
on.
“No—no, I can hardly go as far as that. He seemed to be handling
the bag, and I just guessed what he had in mind,” Andy admitted.
“Well, since we couldn’t prove our assertion it would be better to
keep mum on the subject. They’ll hatch up a story, and swear they
were just going to cast the bag over-board, thinking they might hit up
a faster pace, and didn’t see us below. You ought to know Puss
Carberry by this time; did you ever see him wanting a good excuse
for anything he did? And he can put on such an innocent face, too.
Let it drop, Andy. We won, and can afford to be generous, you
know.”
Andy could never stand out against this convincing tone of Frank’s.
“Oh! all right, if you say so, Frank, though I think you’re by long odds
too easy on the skunks. Why, if that bag had struck us in a certain
way, we might be as dead as herrings long before now. Makes me
shiver every time I look down. And after a fall of more than a
thousand feet, a fellow wouldn’t look good at his own funeral. But
since you say forget it, I’ll try to.”
When they hovered over the big field there was a whirlwind of shouts
that must have been pleasant music to these two young victorious
air voyagers returning from their recent exploit.
The next half hour was filled with plenty of excitement all around.
Frank had to guard his precious little monoplane from the crowds of
curious and applauding people who had witnessed their plucky race.
And the silver cup was indeed a beauty, well worth all the effort they
had put into their work. No one was more extravagant in praise than
Colonel Josiah Whympers, who toddled around with crutch and
cane, telling everybody he met what wonderful things Andy and
Frank were going to do some day. While most people were of the
opinion that he “put the cart before the horse” when using those two
names in that fashion, still they could forgive him, because Andy was
naturally everything to the doting old man.
Of course after that it was demanded that the Bird boys give a few
exhibition flights, just to let the gaping crowd see to what an
astonishing degree the modern aviator could guide his novel craft
through the air.
So Frank ascended to a height of nearly fifteen hundred feet, boring
his way upward after a fashion much in vogue among these pilots
who lead the world in aerial navigation; after which he descended in
spirals, being averse to attempting the risky stunt known as
volplaning, until he had learned the ropes better.
But it was all a grand circus for the thousands who viewed these
wonderful feats for the first time. And great was the uproarious
applause that greeted the young aviators after they had landed
again.
Before evening came the Bird boys once more went up, and headed
for the home field, tired but satisfied.
Dr. Bird had insisted that Frank come home for the night, since he
had been away so very long now.
“I guess there’s no danger about the monoplane,” Frank remarked,
as they locked the doors, and Andy for the twentieth time drew out
his recovered little monkey wrench to examine it carefully. “You know
Chief Waller nabbed those two men, Jules and Jean, and has them
locked up tight. Besides, now that the race is over, Puss and Sandy
will have no reason to want to injure our machine.”
“Perhaps not,” said Andy, “but Colonel Josiah ain’t going to take any
risks. He told me he had hired a watchman to sleep here in the shed
every night, just as long as we want. I’m going to hang around and
wait for him. I don’t trust Puss or his crony one little bit.”
“Well,” said Frank, as he prepared to depart on his wheel, “we’ve
had a grand day of it, old fellow; and I doubt if we ever see such a
great time again.”
“Just what I was thinking,” replied Andy, half regretfully, as though he
felt badly because all pleasant things must have an end. “There’ll be
no more races for us to win, and things will get mighty humdrum,
unless something turns up shortly.”
Little did either of the Bird boys, fresh from their victory of the air,
dream of the astonishing adventures that were soon to fall to their
portion, beside which those they had experienced, as narrated
between the covers of this book, would appear almost insignificant.
In good time the reader may be taken into our confidence, and
allowed to share in the knowledge of those stirring times that is in
our possession.
A few days later Frank and Andy happened to be among a group of
boys gathered on the campus in front of the high school building.
Although school had long since been dismissed for the summer
vacation, still the boys often congregated here by the famous
Bloomsbury school fence, to talk over things in general, such as
interested lads in a country town.
Baseball matters were being discussed, and the possibilities of a
good football season in the Fall. Frank and Andy were not so deeply
interested in these matters as usual though they did not see fit to tell
their friends just why.
Frank had been watching for an opportunity to carry out a little
scheme he had in mind, and which he had talked over with Andy,
Elephant Small, Larry Geohegan, and one or two other good fellows.
“Here he comes, Frank!” said Andy finally, as Puss Carberry and his
eternal shadow, Sandy Hollingshead, were seen approaching from
the direction of town.
Just as they were passing Larry stepped forward.
“I say, Puss, does this belong to you?” and he held out a card—none
other than the one which had been found in the hangar of the
monoplane the day after that trick of cutting the canvas of the planes
had been accomplished.
Puss was for once taken off his guard.
“Why, yes, I believe it does, Larry,” he said, immediately pulling out a
pack of fine cards. “You know I brought these up with me from the
city. See, it has the Indian on the back, and the words ‘Red Hunter.’
I’ll run them over, and see if the jack of spades is missing.”
He did so in an adept manner that told how accustomed he was to
handling such things.
“You see, it is missing,” he said triumphantly, “so I’ll thank you for
returning my black jack to me. Where did you pick it up, Larry?”
“Oh! you’re not indebted to me for its return,” declared Larry, turning
up his nose in disgust. “Frank here found it; he can tell you just
where.”
And Puss grew fairly scarlet, he hardly knew why himself, as he
turned his gaze upon the accusing face on the one whom he had
done so much to injure.
“You dropped it out of your pocket the night you visited our hangar,
and cut the canvas of our monoplane wings to flinders. I have been
saving it for you. Thank you, Puss, for admitting that you were the
author of that dirty trick,” and Frank turned his back on the confused
rogue.
Unable to frame a reply, Puss and his crony walked hastily away.
And before night the whole of Bloomsbury knew of what they had
been guilty; because Larry and Elephant refused to keep it to
themselves.
But it was not to be expected that this would cause such fellows as
Puss Carberry or Sandy Hollingshead to see the error of their ways.
On the contrary, it was only apt to make them the more bitter against
the Bird boys; and in time to come they would wish more than ever
that they could find some way by means of which they might injure
those who had so skillfully guided their little air craft to victory in the
race to the crest of Old Thunder Top.
Whether that opportunity would ever come, as well as many other
things in the line of adventure which were fated to befall the Bird
boys, must be left to another volume, which the reader, who has
followed our venturesome young aviators thus far, will be pleased to
know has already been issued under the title of “The Bird Boys on
the Wing; or, Aeroplane Chums in the Tropics.”
The End.

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Mastering Structural Heart Disease 1st

Edition Eduardo J. De Marchena

Tratado de obstetrícia Febrasgo 1st Edition César

Handbook of Structural Heart Interventions 1st Edition

Chronic Coronary Artery Disease. A Companion to

Valvular Heart Disease: A Companion to Braunwald's

Heart Failure: A Companion to Braunwald's Heart Disease

Heart Failure: A Companion to Braunwald’s Heart Disease

Lifestyle in Heart Health and Disease Watson

Hypertension: A Companion to Braunwald's Heart Disease

Limit of Liability/Disclaimer of Warranty

Library of Congress Cataloging-in-Publication Data

Names: De Marchena, Eduardo, editor. | Gomez, Camilo A. (Camilo Andres),

Cover Design and Image: Manuela Echeverri

Set in 9.5/12.5pt STIXTwoText by StraiveTM, Chennai, India

Cover Design Artist Statement

List of Contributors xlv

Part I Structural Interventions for the Aortic Valve 1

1 The Natural History and Hemodynamic Assessment of Aortic Valve Disease 3

2 Pathology Insights of Aortic Valve Disease 11

4 Present and Future Generations of Transcatheter Aortic Valves 31

5 Computed Tomography for Transcatheter Aortic Valve Replacement Planning

6 Optimal Selection of TAVR Devices 51

7 Transcatheter Aortic Valve Replacement

8 Balloon Aortic Valvuloplasty

9 Challenging Anatomy Scenarios in TAVR 75

10 TAVR for Bicuspid Aortic Valve 83

11 TAVR for Pure Native Valve Aortic Regurgitation 89

12 Aortic Valve-in-Valve Interventions 95

13 Prevention and Management of Coronary Artery Obstruction in TAVR 103

14 Coronary Artery Disease and Transcatheter Aortic Valve Replacement

15 Conduction Disturbances Associated with TAVR

16 Management of Conduction Disturbances Post-TAVR 123

17 TAVR Mechanical Complications Prevention and Management 131

18 Pathological Insights of TAVR Degeneration and Thrombosis 139

19 Clinical Implications of Valve Thrombosis and Early Thickening

20 TAVR and Stroke 155

21 Current Evidence of Neuroprotection in TAVR 163

22 Difficult Transfemoral Access for TAVR and Bailout Techniques 169

23 Alternative Access for TAVR 175

24 Vascular Access and Closure Options for TAVR 183

Part II Structural Interventions for the Mitral Valve 191

25 The Natural History of Mitral Valve Disease 193

26 Hemodynamic Assessment of the Mitral Valve 203

27 Echocardiographic Assessment Prior to Mitral Valve Edge-to-Edge Repair 211

28 Intra-procedural Transesophageal Echocardiography for Mitral Valve Structural Interventions 217

29 Surgical Trials in Mitral Valvular Disease 227

30 Surgical Techniques for Mitral Valve Repair 233

31 Structural Interventions for Mitral Stenosis 239

32 Transcatheter Edge-to-Edge Repair Trials

33 Mitral Valve TEER

34 TEER Challenging Anatomy and MitraClip Tips and Tricks 273

36 CT Imaging for TMVR 291

37 Transcatheter Mitral Valve Replacement

38 Transseptal Transcatheter Mitral Valve-in-Valve Replacement (TS MViV)

40 Transcatheter Mitral Valve Replacement

41 Self-Expanding Transcatheter Mitral Valve Replacement Systems

Part III Structural Interventions for the Tricuspid Valve 335

42 Natural History and Hemodynamic Assessment of Tricuspid Valve Diseases 337

4. What is the pathology of tricuspid calcific aortic stenosis? 12

4. What is the incidence of complications in BAV? 70

Bicuspid Valve Morphology 83

5. What are the symptoms of coronary artery obstruction in TAVR? 104

Mitral Regurgitation 195

3. How is MR classified? 211