15.2 Percutaneous Valve Interventions

15.2 Percutaneous Valve Interventions

Quick Answer: Percutaneous valve work includes valvuloplasty (high-pressure balloon dilation), TAVR (transcatheter aortic valve replacement via transfemoral or alternate access), annuloplasty bands/rings delivered by catheter where applicable, PVL closure after TAVR, and TEER (MitraClip-class leaflet repair). RCIS staff manage large-bore access, rapid pacing, hemodynamic crashes, and post-deployment imaging checkpoints.

Valve interventions carry higher morbidity than routine PCI. CCI expects invasive specialists to understand platform differences, deployment sequences, and complication pathways—even when the interventional cardiologist drives every decision. This section maps Domain C tasks 13–14 valve content to cath lab practice.

Balloon Valvuloplasty

Valvuloplasty splits a stenotic valve with a high-pressure balloon without leaving a permanent prosthesis.

Mitral Valvuloplasty (PMV)

Percutaneous mitral valvuloplasty (PMV)—often with an Inoue balloon—remains the reference treatment for severe symptomatic mitral stenosis from rheumatic disease when echo scores (Wilkins score ≤8 in classic teaching) favor success.

RCIS responsibilities:

• Prepare Inoue balloon components (stylet, dilator, balloon sizes 24–30 mm typical range).
• Support transseptal puncture (TEE or fluoroscopic landmark) and wire exchanges.
• Monitor hemodynamics pre/post: transmitral gradient reduction, new MR (complication).
• Heparinize per protocol; ACT targets align with structural cases (250–300 s common).

Complications: Severe mitral regurgitation (split leaflet or chordal tear), atrial septal tear, embolism, tamponade.

Aortic Valvuloplasty (BAV)

Balloon aortic valvuloplasty (BAV) provides palliation in severe aortic stenosis when TAVR/SAVR is not immediately available—or as bridge therapy. Restenosis within 6–12 months is common; BAV is not durable definitive therapy in most adults.

RCIS prepares large non-compliant balloons, often 18–25 mm range depending on annulus (physician measurement). Rapid ventricular pacing at 180–220 bpm for 10–20 seconds reduces cardiac output and stabilizes the balloon during inflation—coordinate with anesthesia and have atropine/epinephrine ready for pacing exit asystole.

Transcatheter Aortic Valve Replacement (TAVR)

TAVR delivers a bioprosthetic valve (bovine/porcine leaflets on a nitinol or cobalt frame) across the native stenotic aortic valve without sternotomy.

Patient Selection (Context for RCIS Items)

Modern trials (PARTNER, Evolut Low Risk) extended TAVR to low, intermediate, and high surgical risk patients with severe symptomatic aortic stenosis. RCIS may see vignettes on STS score, frailty, coronary obstruction risk, and bicuspid anatomy—recognize these as physician decision inputs, not tech tasks.

Access Routes

Pre-procedure CT angiography defines annulus size, coronary heights, iliofemoral diameter, and angulation—RCIS verifies CT is in chart before bringing valves to the room.

Valve Platforms: Balloon-Expandable vs Self-Expanding

RCIS must know which valve is on the field: pacing pad placement, saline flush of balloon, and deployment pressure differ by IFU.

TAVR Deployment Sequence (Transfemoral Teaching Flow)

1. Vascular access — femoral artery (often ultrasound-guided); place closure sutures/devices per plan.
2. Valve crimping/loading — occurs in prep area; verify serial number and size (e.g., 23, 26, 29 mm annulus fit).
3. Cross native valve — stiff wire in LV; deliver sheath across aortic valve.
4. Position prosthesis — align radiopaque markers with annulus plane on fluoroscopy (coplanar view from CT).
5. Rapid ventricular pacing (balloon-expandable) — inflate deployment balloon; release valve.
6. Assess — aortic regurgitation, mean gradient, coronary flow, conduction block (new LBBB, need for pacemaker).
7. Large-bore closure — deploy pre-placed sutures, confirm hemostasis, watch for retroperitoneal bleed.

Antithrombotic Therapy After TAVR

Protocols vary; exam stems often reference single antiplatelet (aspirin) or DAPT for 1–6 months plus longer aspirin, or OAC if AF is present. Avoid guessing in real patients—follow institutional order sets. Know that antithrombotics reduce valve thrombosis but balance bleeding on large-bore access.

Annuloplasty (Percutaneous Context)

Surgical annuloplasty uses rings to reduce annular dilation in functional MR. Percutaneous indirect annuloplasty devices (e.g., Carillon mitral contour system, PASCAL/Cardioband-class systems in evolution) cinch the annulus or remodel the ventricle via coronary sinus or transventricular anchors.

RCIS exposure may be limited, but RCIS items can test the concept: annuloplasty complements leaflet repair or replacement by addressing dilated annulus or functional MR from ventricular remodeling—not the same as TAVR.

Paravalvular Leak (PVL) After TAVR

Paravalvular leak—regurgitation around the prosthesis frame—is more common with incomplete annular seal, heavy calcification, or undersized valves.

Severity assessment: TEE/ICE color Doppler; circumferential extent and jet width guide intervention.

Management ladder:

1. Post-dilatation of the valve (if frame allows) to improve apposition.
2. Percutaneous PVL closure with plug devices (Amplatzer Vascular Plug variants, dedicated PVL occluders) delivered via transfemoral or transapical approach—RCIS prepares plug sizes, guidewires, and snares.
3. Valve-in-valve (ViV) if regurgitation is severe and not amenable to plugs.
4. Surgical conversion for refractory hemolysis or heart failure.

Hemolysis clue: Severe PVL may cause anemia, schistocytes, elevated LDH—recognize for exam vignettes.

Transcatheter Edge-to-Edge Repair (TEER / MitraClip-Class)

MitraClip (Abbott) and PASCAL (Edwards) represent TEER: a clip grasps anterior and posterior mitral leaflets, creating a double-orifice valve that reduces mitral regurgitation without excision.

Indications (Teaching Level)

• Primary (degenerative) MR when surgery is high risk.
• Secondary (functional) MR in selected heart failure patients (COAPT trial context for reduced EF with moderate-severe MR despite GDMT).

Procedural Highlights for RCIS

• Transseptal access with steerable guide catheter into the left atrium.
• TEE mandatory for clip alignment, grasping, and MR reduction assessment (≥ 1+ grade reduction often targeted).
• Multiple clips may deploy (Clip ≥2 in complex MR).
• Complications: single-leaflet detachment, residual MR, perforation, SAM (systolic anterior motion) if MR undertreated asymmetrically.

Do not confuse MitraClip with Watchman: MitraClip treats mitral regurgitation; Watchman occludes LAA for AF.

Conduction and Hemodynamic Emergencies

Valve Repair vs Replacement Summary

RCIS Pre-Case Setup: TAVR Table

• Valve size confirmed against CT annulus measurements
• Rapid pacing generator tested; pads applied
• Large-bore closure devices and rescue covered stent available
• Temporary pacing wire kit and EP contact confirmed
• TEE probe / sonographer scheduled
• Blood type and crossmatch if high-risk anatomy
• Post-TAVR ICU bed and conduction monitoring ordered

Percutaneous valve questions on RCIS test platform identification, pacing requirements, access complications, and TEER vs TAVR vs LAAO indication matching. Master those distinctions and you cover the highest-yield structural valve items in the Interventional domain.