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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.
- 6. Patient selection Bicuspid Aortic Valve
- 7. Patient selection Significant basal septal hypertrophy
- 14. Valve sizing
- 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
- 31. Wiring
- 32. Sheath
- 33. Balloon
- 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
- 40. Positioning of the prosthesis
- 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
- 43. Pacing
- 44. Deployment
- 45. Deployment
- 46. Assessment
- 47. 3DTEE
- 48. Assessment
- 49. Assessment
- 53. Complications
- 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
- 55. Aortic Regurgitation Barbara E. Stähli et al. Journal of cardiovascular diagnosis & therapy. Vol 3, No 1 (March 2013)
- 62. Grading of PVR after TAVI
- 63. Moderate PVR
- 64. Moderate PVR
- 65. Mild PVR
- 66. No PVR
- 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