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TAVI TEE.pdf
1. Hani Mahmoud-Elsayed MD, FSEC, FASE
EACVI/ Education – HIT Committee Member
Consultant Echo-Cardiologist, Aswan Heart Centre
Magdi Yacoub Foundation
2D/3D-TEE role during TAVI
4. Role of Echocardiography in TAVI
Imaging plays a central role in successfully implementing TAVI as it is
needed at each step of the procedure including:
Patient selection.
Choice of procedural access.
Prosthetic choice and sizing.
Procedural guidance.
Detection of early and late complications.
15. Valve sizing
Annular dimension is a key measurement as this determines eligibility for TAVI and guides
the selection of valve type and size.
Undersizing the prosthesis can result in:
- Device migration
- Significant paravalvular aortic regurgitation
- Prosthesis mismatch may result
Oversizing predisposes to:
- Complications related to vascular access
- Difficulties when crossing the native aortic valve with the delivery system.
Risk of under-expansion with consequent redundancy of leaflet tissue, creating folds that
will generate regions of compressive and tensile stress that may cause central aortic
regurgitation or reduction in valve durability.
Piazza N, et al. Circ Cardiovasc Interv 2008;1:74–81
28. Role of TEE during the procedure
➢ Get baseline images & gradients
➢ Aid balloon positioning during vlavuloplasty
➢ Detect post-valvuloplasty aortic regurgitation
➢ Aid prosthesis positioning during implantation
➢ Confirm prosthesis function immediately post-implantation
➢ Detect complications
29. Baseline images
➢ The long-axis view (usually around 110–130°), the LVOT and upper septum should be
assessed since the presence of a sub-aortic septal bulge may create an obstacle to
proper seating of the aortic prosthesis.
30. Baselines images
➢ The short-axis view (usually around 40-60°), the opening of the aortic valve should be
classified as central or eccentric and the severity, location, and symmetry of aortic
valve calcification accurately described
36. Balloon migration
❑ Although balloon inflation is normally performed during rapid right ventricular pacing
to reduce cardiac output, the balloon may still migrate during inflation, particularly in
patients with:
➢ Extensive subaortic septal hypertrophy
➢ A small sinotubular junction
➢ Loss of right ventricular capture and premature restoration of the native rhythm may
also result in balloon migration
41. The Optimal Position
➢ For the Edwards SAPIEN valve is with the ventricular side of the prosthesis positioned
2–4 mm below the annulus in the LVOT.
➢ Since the CoreValve TM has a different structure, the ventricular edge of the
prosthesis should be placed 5–10 mm below the aortic valve annular plane.
42. Improper positioning
Too low:
➢ It may impinge on the mitral valve apparatus
➢ It may be difficult to stabilize in patients with marked subaortic septal hypertrophy.
➢ The native valve cusps may also fold over the top of the prosthesis and impede its
function.
Too high:
➢ It may migrate up the aorta
➢ It may obstruct the coronary ostia
➢ It can result in significant PVR.
Jose L. Zamorano et. al. European J of Echocardiography (2011) 12, 557–584
54. Prosthetic Regurgitation
❑ PVR, not infrequently with multiple jets, is common following TAVI, though trace to
mild and with a benign stable course in the majority of patients.
❑ severe aortic regurgitation may occur as a consequence of:
➢ Incomplete expansion
➢ Incorrect positioning of the device
➢ Restricted cusp motion
➢ Inappropriate prosthetic size
❑ An undersized prosthesis is expected to be associated with paravalvular aortic
regurgitation.
❑ An oversized prosthesis may result in suboptimal stent expansion, impaired cusp
mobility, and central aortic regurgitation.
Rallidis LS et. al. Am Heart J 1999;138:351–7
68. Mitral regurgitation
❑ MR can be seen as a complication of TAVI due to:
➢ Lower deployment of the prosthesis with impingement on the AML.
➢ Disruption of the mitral sub-valvular apparatus (Trans-Apical approach).
84. Conclusion
❑ Echocardiography plays a central role in successfully implementing TAVI as it is
needed at each step of the procedure including:
✓ Patient selection
✓ Choice of procedural access
✓ Prosthetic choice and sizing
✓ Procedural guidance
✓ Detection of complications
