Transjugular intracardiac echocardiography-guided transcatheter aortic valve implantation

An 85-year-old Japanese female presented with New York Heart Association Class II heart failure symptom despite maximum medical therapy. Echocardiography showed severe aortic stenosis (peak velocity of 5.1 m/s, mean pressure gradient 64 mmHg, aortic valve area 0.4 cm2) and computed tomography showed severe calcified leaflets. Patient has been treated with oral corticosteroids for interstitial pneumonia; therefore, heart team decision was to perform transcatheter aortic valve implantation (TAVI) under conscious sedation. AcuNav (Biosense Webster, Irvine, CA, USA) intracardiac echocardiography (ICE) catheter is inserted via 8 Fr sheath from right jugular vein and can be observed under fluoroscopy (Panels A and B). Baseline long-axis views and stiff wire in the left ventricle are shown (Panels C and D and Supplementary material online, Videos S1 and S2). After pre-dilatation, CoreValve Evolut PRO 23 mm (Medtronic Inc., Galway, Ireland) was implanted. At the point of no recapture, ICE showed appropriate depth with minimal paravalvular leakage (PVL) (Panels E and F and Supplementary material online, Video S3), therefore, the valve was fully released. Final angiography and ICE showed trivial PVL (Panels G and H and Supplementary material online, Video S4). Post-procedural echocardiography showed excellent haemodynamics (mean pressure gradient 8.3 mmHg, effective orifice area 1.6 cm2) with trivial PVL. Patient was discharged 3 days after the procedure and clinically remains asymptomatic 1 year after the procedure. Intra-procedural imaging during TAVI is of extreme importance in order to guide accurate positioning of the valve and quickly detect complication. Intracardiac echocardiography is a useful tool which could be used under conscious sedation and usually provides better imaging quality than transthoracic echocardiography (TTE). In addition, real-time monitoring is possible without interrupting the procedure. We have developed user-friendly transjugular ICE-guided TAVI which enables more stable and higher quality acquisition of the key images of this procedure, i.e. aortic and mitral valve, intraventricular septum including membranous septum, left ventricular outflow tract, left ventricle, compared to TTE or transfemoral ICE guidance. This transjugular ICE system provides high-quality imaging which facilitates safe and effective TAVI by real-time monitoring without interruption of the procedure. Y.O. is a proctor for Medtronic. All other authors have no relationships relevant to the contents of this paper to disclose. Supplementary material is available at European Heart Journal online.