Clinical and Technical Challenges of Prosthesis–Patient Mismatch After Transcatheter Aortic Valve Implantation

Figures

• 

  Figure 1. Proposed flowchart for differential diagnosis between high-flow states, transcatheter heart valve (THV) stenosis, and prosthesis-patient mismatch (PPM). 3D, three-dimensional; AT, acceleration time; CMR, cardiac magnetic resonance; CT, computed tomography; Δ, variation; ΔP, pressure gradient; DVI, Doppler velocity index; EOA, effective orifice area; EOAi, indexed effective orifice area; EOAip, predicted indexed effective orifice area; ELCo, energy loss coefficient; ET, ejection time; LVOT, left ventricular outflow tract; PPM, prosthesis-patient mismatch; PVL, paravalvular leak; TEE, transesophageal echocardiography; THV, transcatheter heart valve; TTE, transthoracic echocardiography; V, velocity.

• 

  Figure 2. Multimodality imaging for differential diagnosis of high trans-prosthetic gradients in patients with THV. Case 1. TEE showing an isoechoic mobile mass (*) adherent to THV (arrows) cusps, causing valve obstruction; blood cultures confirmed infective endocarditis (A,B). Case 2. TEE revealing severe paravalvular (arrows) leak (C, arrowheads); the regurgitant jet is also shown during CMR cine sequences (D, arrowheads), and can be quantified using phase contrast sequences. Case 3. TEE in a patient known for valve-in-valve procedure showing an isoechoic mass (E, white star) in left coronary sinus, affecting cusp motion (arrowhead). CT (F), confirmed the mass (white star) arising between the two valves, and whose features and density were consistent with thrombus.

• 

  Figure 3. Aortic annulus sizing with CT and 3D TEE. Transverse CT plane aligned at the lowest insertion points of aortic leaflets (A) and orthogonal planes oriented along the main axis of LVOT in short (B) and long axis (C) views. TEE long-axis mid-esophageal view (D), view of the aortic annulus perpendicular to the mid-esophageal view (E), aortic annulus sizing (F), and 3D visualization and measurement of aortic annulus (G).

• 

  Figure 4. Proposed algorithm for prevention of PPM according to chosen approach of aortic valve replacement. BAV, bicuspid aortic valve; EOAip, predicted indexed effective orifice area; LVOT, left ventricular outflow tract; TF, transfemoral; THV, transcatheter heart valve.