0:00

Next we're gonna talk about post-procedural complications after tavr. And,

0:04

and the biggie is this thing called halts halt stands for hypo attenuating

0:09

leaflet thickening. And what that is,

0:11

I think it's easiest to see on these images.

0:14

You get thrombus that forms on the aortic side of the valve cusps

0:19

and really just sort of fills in those cusps. Um,

0:23

with thrombus, you can have it on one or multiple of these cupps.

0:27

Here's a nice view in the short axis dimension,

0:30

looking down the barrel of those cusps. Uh, and you can see that, um,

0:34

area of hypot leaflet thickening depicted below. Um,

0:38

what it does, um,

0:39

what you can see really nicely on this VR imaging is it restricts the amount of

0:43

opening that you can get from these leaflets.

0:45

And so the patients will often get increased gradients. So, um,

0:49

the normal low gradient across the valve,

0:52

which is what you'd like to see for a successful valve replacement,

0:55

then jumps up, um, because of this, um, hypot annuating leaflet thickening.

1:01

So this halt has an unknown impact on valve durability,

1:04

and it's actually pretty common. We're still learning a lot about it. It's a,

1:08

a fairly new concept. Um, but the, you know,

1:12

studies have shown that's it present in roughly 10 to 20% of patients.

1:16

And just of noted,

1:17

it's been found out that not only does it exist in TAVR valves,

1:20

but also happens in surgical valves, we just never really looked for it before.

1:24

Um,

1:24

so we can see halt in all the different types of prosthetic valves that are put,

1:28

uh, in patients to, to treat aortic stenosis. Um,

1:32

usually it's associated with increased gradients. And like I said,

1:35

patients may be symptomatic, although they don't have to be. Um,

1:38

and thankfully though, if we see the hypot leaflet thickening, um,

1:42

it is treatable by anticoagulation if and when detected.

1:46

So what do we want to report for patients who have halts? Um, well, uh,

1:50

we wanna report the degree of halt,

1:52

and this is a figure taken from these guidelines that I've mentioned in previous

1:56

videos from the, um, journal of Cardiovascular ct. Um,

1:59

and this is a qualitative assessment of the percentage of the leaflet that's

2:03

involved by that, uh, thrombus that I have mentioned, um, in the previous slide.

2:08

And then we also wanna report the amount of restriction of the leaflet

2:13

motion. Uh, and this is a really handy figure that comes from, uh,

2:17

this review article from JAK Cardiovascular Imaging,

2:19

which I would highly recommend on this topic, um,

2:22

because it has some really great, uh, uh, figures, um,

2:26

that help really explain what's going on. But basically, the, uh,

2:29

restriction of the leaflet motion is how much of the leaflet motion, you know,

2:34

is, is, um, abnormal. Um,

2:37

and you can measure it insistently, uh,

2:40

basically by looking at the diameter of the, the hole of the, um,

2:45

aortic valve compared to the width of the,

2:47

of amount of restriction that you see here. Um, you divide by two, right?

2:52

You basically just take the radius, so it's the percent of restriction, uh,

2:55

of that particular cusp. Um, and if the restriction

2:58

Is in the 50 to 70% range, that's considered moderate and over 70 severe.

3:02

And then obviously if the CUSP doesn't move at all,

3:05

then it's con considered a hundred percent. Now,

3:08

another type of complication, much less common is infection, um,

3:13

and endocarditis.

3:14

So it turns out there's similar rates of endocarditis between savr and tavr.

3:18

The reported rates are around two to 7%. Um,

3:22

and the problem that can happen with endocarditis is that it may result in valve

3:26

failure and require surgery, um, to take the TAVR valve,

3:30

the infected TAVR valve out and replace it with a, uh,

3:33

non-infected surgical valve.

3:35

This is an example of a patient with infection of the TAVR device. Um,

3:40

this patient's actually five years out from tavr and they saw an increased

3:43

gradients and progressive heart failure symptoms.

3:46

They actually didn't have really significant infection, uh, symptoms.

3:50

They didn't have a fever at the time. But when you looked at the device,

3:53

the evaluation was performed actually to look for halt.

3:56

We saw this really nodular thickening of the actual valve leaflets. Um,

4:00

you can see here, um, which, uh, prolapsed, uh,

4:04

above and below the valve, um, so different from halt. We see these, um,

4:09

actual vegetations on the valve in the setting of infection. This patient, uh,

4:14

was unlucky enough to also have infection all along the mitral annulus. Um,

4:18

and we're gonna actually review this case so we can actually see the, uh,

4:21

cene images, um, in, in real time. Um, when I, uh, go separately to,

4:25

to do the case review.