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

Abstract

BackgroundWhile transcatheter aortic valve implantation (TAVI) has traditionally been supported intraprocedurally by transoesophageal echocardiography (TOE), transthoracic echocardiography (TTE) is increasingly being used. We evaluated echocardiographic imaging characteristics and clinical outcomes in patients who underwent TTE during TAVI (TTE-TAVI).Methods and resultsA select team of dedicated sonographers and interventional echocardiographers performed TTE-TAVI in 278 patients, all of whom underwent TAVI through transfemoral access. We implanted the Medtronic EVOLUT R valve in 258 patients (92.8%). TTE images were acquired immediately pre-procedure by a dedicated sonographer in the cardiac catheterization laboratory with the patient in the supine position. TTE was then performed post deployment of TAVI. In the procedure, TTE image quality was fair or better in 249 (89.6%) cases. Color-flow Doppler was adequate or better in 275 (98.9%) cases. In 2 cases, paravalvular regurgitation (PVL) could not be assessed confidently by echocardiography due to poor image quality; in those cases, PVL was assessed by fluoroscopy, aortic root injection and invasive hemodynamics. Both TTE and invasive hemodynamics were used in the assessment of need for post-deployment stent ballooning (n = 23, 8.3%). TTE adequately recognized new pericardial effusion in 3 cases. No case required TOE conversion for image quality. There was only 1 case of intraprocedural TTE failing to recognize moderate PVL, without clinical implication. In 99% of patients, TTE-TAVI adequately assessed PVL compared with 24-h and 1-month follow-up TTE.ConclusionsWith the current generation of TAVI, TTE-TAVI is adequate intraprocedurally when performed by specialized sonographers and dedicated cardiologists in a highly experienced TAVI center.

Transcatheter Aortic Valve Implantation (TAVI): Is General Anaesthesia a Necessity?

“…Poor image quality was not associated with moderate PVL. [14] Zaouter et al observed the outcomes echocardiography findings of patients receiving TAVI with either CS or GA. With the degree of PVL being assessed in GA patients via TOE and in CS patients via haemodynamics measure and fluoroscopy. Procedural success was similar between groups.…”

Minimalist approach for transcatheter aortic valve replacement

“…4,10 In another report investigating procedural TTE performance, intra-procedural TTE was able to properly obtain the information of procedural complications and PVL with sufficient image quality (fair or better in 89.6%), when performed by specialized echocardiographers. 34 With the current evidence, no consensus has been reached regarding TTE safety during a procedure. TTE image quality can be suboptimal, especially for obese patients, and those with lung disease or chest deformities.…”

The Role of the Cardiac Sonographer in Structural Heart Disease Procedures

“…Studies have found that with specialized (advanced) cardiac sonographers and dedicated cardiologists in highly experienced surgical centers, intra-procedural TTE is adequate in identifying complications such as paravalvular leaks. 8,9 It is now apparent that TTE plays a seminal role in the assessment of SHD -from the pre-procedural assessment that assists in the selection of candidates and procedural planning, to the TTE for intraprocedural guidance followed by the post-procedural serial echoes. The echocardiographic evaluation of patients undergoing transcatheter interventions places demands on cardiac sonographers that differ from those of the routine assessment of patients with native or prosthetic valvular disease.…”