Intraprocedural echocardiographic guidance in transcatheter aortic valve implantation

Figures

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  Fig. 1. Assessment of paravalvular aortic regurgitation on transesophageal echocardiography. A Initial mid-esophageal long-axis (LAX) view showing no paravalvular leak (PVL), simultaneous biplane imaging with cut-plane at the level of inflow edge of the transcatheter valve to locate the PVL, at 2 o’clock of B the corresponding short-axis (SAX) view. C Further rotation of the probe confirming the eccentric PVL jet, in the off-axis mid-esophageal LAX view. Severity of PVL is graded by its circumferential extent: less than 10% is considered mild, 10% to 29% is moderate, and greater than 30% is severe; or based on the planimetered 3D vena contracta area (VCA) of the PVL jets. (D–F) For multiple PVL jets, summation of all their respective 3D VCA may be employed

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  Fig. 2. Paravalvular and transvalvular aortic regurgitation (AR) on echocardiography. A A posteriorly located paravalvular AR jet is best visualized in the mid-esophageal long-axis (LAX) view on transesophageal echocardiography (TEE) images acquired using the standard adult-TEE probe. Based on the short-axis (SAX) view in 3D TEE, the severity of the paravalvular AR is graded as moderate, involving 20% of its circumferential extent. B Transvalvular AR jet confirmed on the corresponding short-axis view, using biplane imaging in the mid-esophageal LAX view on mini-TEE. C Micro-TEE detected mild paravalvular leak (PVL) in the LAX view, confirmed on the SAX views, at 2 o’clock. D An anteriorly located paravalvular AR is best visualized on the transthoracic echocardiography, in the apical three- or five-chamber view. Due to the acoustic shadowing of the prosthetic valve, it is important to tilt the ultrasound probe in multiple directions (upward or sideways) and in unconventional planes to detect and localize the paravalvular AR. Arrows indicate PVL

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  Fig. 3. The 3D multiplanar imaging for the aortic annulus on transesophageal echocardiography (TEE). Left panel shows annular dimension obtained on 3D TEE via direct planimetry method using user-defined multiplanar approach, whereby the annular plane is a virtual plane at the level of the lowest attachment site of the three aortic cusps. As the aortic annulus is oval in shape, the long-axis plane diameter (from 2D TEE) typical represents its minor dimension (white arrow), while its maximal dimension is derived from the coronal plane obtained using multiplanar reconstruction of the acquired 3D volume dataset (red arrow). From 3D TEE, the annular area and perimeter were 410 mm2 and 74 mm, respectively. The right panel shows a computed tomography–derived aortic annular dimensions in the same patient. SAX, short axis

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  Fig. 4. Indirect planimetry and semi-automated measurements of the aortic annulus on transesophageal echocardiography. A An example of indirect planimetry using mitral valve quantification software that uses the orthogonal long-axis view to identify the annular plane in its corresponding short-axis view, followed by provision of its planimetered area and circumference without hand-tracing. B New semiautomated aortic valve quantification software is available on cart that can automatically provide the annular dimension in terms of its diameter (maximal, minimal and averaged), area and circumference, after verification of the annular plane on 3D multiplanar reconstruction

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  Fig. 5. Multiplanar imaging for coronary height measurements with aid of markers on 3D transesophageal echocardiography (TEE). Left and right coronary artery ostia are marked as the yellow and red circles, respectively on 3D TEE dataset. Using 3D multiplanar reconstruction and the markers, the height of both coronary artery ostia are easily identified on the volume rendering view. In this case, the left coronary ostium is measured at 11 mm, while that of the right coronary ostium is 16 mm above the annular plane, respectively

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  Fig. 6. Potentially life-threatening complications detected by intraprocedural transesophageal echocardiography (TEE) during transcatheter aortic valve implantation (TAVI) procedure. A Pre-TAVI TEE at baseline showing minimal pericardial effusion. B Post-TAVI TEE showing a moderate size pericardial effusion (yellow arrow) caused by right ventricular perforation from pacing wire, that was promptly identified and timely drained without any hemodynamic compromise. C Aortic dissection demonstrated on biplane TEE imaging in a patient who developed hypotension. Dissection flap was visualized in the descending aorta (red arrow)

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  Fig. 7. Transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve. A Real-time guidance using mini-transesophageal echocardiography (TEE) is highly valuable in challenging valve anatomy such as bicuspid AV with severe calcification. Under direct 3D TEE guidance, using (volume rendered) (B) en face and (C) lateral views of the aortic valve (AV), the guidewire (arrow) is directed towards the narrowed valve orifice that helps in visualizing wire crossing (arrow) of the severely calcified bicuspid AV. D A case of underexpanded transcatheter heart valve in a type 0 bicuspid AV with severe paravalvular leak (PVL) post TAVI on adult-TEE imaging, E which requires reballooning under fluoroscopy guidance. F Final residual mild PVL with circularization of the CoreValve (Medtronic) at the annular level. LAX, long axis; SAX, short axis

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  Fig. 8. Detection of new or worsening mitral regurgitation (MR) during transcatheter aortic valve implantation (TAVI) procedure. A Significant MR jet due to guidewire (arrow) interfering with subvalvular apparatus and mitral leaflet motion. B Systolic anterior motion of anterior mitral leaflet giving rise to MR and dynamic left ventricular outflow tract obstruction post TAVI due to thick basal (sigmoid) septum (arrow) confirmed on intraprocedural transesophageal echocardiography imaging

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  Fig. 9. Balloon aortic valvuloplasty (BAV) in transcatheter aortic valve implantation (TAVI). A Real-time mini-transesophageal echocardiography (TEE) imaging of a severely calcified valve undergoing BAV. Red arrows point to the expanded balloon in 3D multiview (short axis [SAX], long axis [LAX], and 3D en face rendering views). B Mild aortic regurgitation (AR) was demonstrated post BAV. C In another example, acute severe AR occurred due to split noncoronary cusp (NCC) following BAV. Red arrows depict the split NCC commissure with resultant severe AR jet, that may cause acute hemodynamic compromise in patients with stiff and hypertrophied left ventricle. LCC, left coronary cusp; RCC, right coronary cusp

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  Fig. 10. Echocardiographic and fluoroscopic appearance of the various transcatheter aortic valve implantation (TAVI) valves. Examples of commercially available TAVI valves (from balloon-expandable to self-expanding platforms) with normal valve function. First row, transesophageal echocardiography imaging; middle row, transthoracic echocardiography imaging; bottom row, fluoroscopy. LAX, long-axis; SAX, short-axis

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  Fig. 11. Underexpansion and malpositioning of transcatheter heart valve (THV). A Underexpanded THV (CoreValve, Medtronic) due to severe calcification causing moderate PVL (red arrow). B A case of aortic migration of the THV after following valve deployment with the final THV position above the annular plane. Native aortic leaflet (depicted in white arrow in midline) and the lower edge of the THV (depicted in red arrows) which is just above the native annulus. Guidewire in the left ventricle (LV) shown in yellow arrow. C Embolization of the THV into the LV (yellow arrow) in a patient with severely calcified and narrow aortic root after SAPIEN valve deployment. Red line denotes the annular plane

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  Fig. 12. Practical decision pathway for use of echocardiography modality during transcatheter aortic valve implantation (TAVI). AF, atrial fibrillation; AFL, atrial flutter; AT, atrial tachycardia; CKD, chronic kidney disease; GA, general anesthesia; CT, computed tomography; ICE, intracardiac echocardiography; LACS, local anesthesia and conscious sedation; LV, left ventricle; LVOT, left ventricular outflow tract; OSA, obstructive sleep apnea; RV, right ventricle; TEE, transesophageal echocardiography; TTE, transthoracic echocardiography