Transthoracic echocardiography is adequate for intraprocedural guidance of transcatheter aortic valve implantation

Figures

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  Figure 1. Stacked bar graph of overall image quality in pre-TAVI transthoracic echocardiograms (n = 240), procedural echocardiograms (n = 278) and 24-h post-TAVI echocardiograms (n = 278). There were no significant differences between pre-TAVI and procedural image quality (P = 0.15) and pre-TAVI and post-TAVI image quality (P = 0.08). There was a significant difference between procedural and post-TAVI echo (P < 0.001).

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  Figure 2. Transthoracic echocardiography during transcatheter aortic valve implantation procedure – excellent image quality. (A) Transthoracic parasternal short-axis view demonstrating severe calcific aortic valve stenosis. (B) Parasternal long-axis transthoracic view demonstrating normal depth, expansion and appearance immediately after transcatheter aortic valve implantation. Leaflets can be seen to move normally in these views. (C and D) Immediate post-implantation short-axis parasternal view and apical 5-chamber view demonstrating mild paravalvular regurgitation. In the short-axis view, normal Doppler interference from the transcatheter stent is visualized and the paravalvular regurgitation is turbulent. (E and F) Using a 4-dimensional (4D) transthoracic echocardiography probe, real-time 4D images were acquired that demonstrated the normal appearance of transcatheter aortic valve implantation immediately after the procedure, an en-face view from the aorta (E), and an en-face view from the left ventricular outflow tract (F).

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  Figure 3. Stacked bar graph of imaging characteristics of procedural echocardiography (n = 278).

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  Figure 4. Transthoracic echocardiography visualized intraprocedural pericardial effusion and tamponade – fair image quality. (A) Transthoracic parasternal long-axis view demonstrating severe calcific aortic stenosis and no pericardial effusion. (B) Immediately after transcatheter aortic valve implantation, pericardial effusion was visualized (orange arrow). (C) This pericardial effusion was redemonstrated on parasternal short-axis view and appeared larger; the left ventricle was demonstrated to be underfilled. This combined with hypotension required emergency endotracheal intubation and sternotomy. A pericardiocentesis was performed and a wire perforation was identified in the left ventricle and repaired. Despite fair image quality, trace paravalvular regurgitation was identified on TTE. (D and E) This same jet of paravalvular regurgitation was also noted on TOE images in short-axis and long-axis (F) esophageal views (green arrows).

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  Figure 5. Assessment of paravalvular regurgitation in transthoracic TAVI (n = 278 patients) at procedural echocardiography, 24-h echocardiography (n = 278) and 1-month echocardiography (n = 236). Echo = echocardiography; TAVI = transcatheter aortic valve implantation.