Recommendations for Comprehensive Intraprocedural Echocardiographic Imaging During TAVR

Abstract

Recent multicenter trials have shown that transcatheter aortic valve replacement is an alternative to surgery in a high risk population of patients with severe, symptomatic aortic stenosis. Echocardiography and multislice computed tomographic imaging are accepted tools in the pre-procedural imaging of the aortic valve complex and vascular access. Transesophageal echocardiography can be valuable for intraprocedural confirmation of the landing zone morphology and measurements, positioning of the valve and post-procedural evaluation of complications. The current paper provides recommendations for pre-procedural and intraprocedural imaging used in assessing patients for transcatheter aortic valve replacement with either balloon-expandable or self-expanding transcatheter heart valves.

Surgical as Opposed to Transcatheter Aortic Valve Replacement Improves Basal Interventricular Septal Hypertrophy

“…Aortic valvular stenosis (AS) develops mainly in aged population [2], therefore BSH is also common in patients with AS. BSH may potentially contribute to left ventricular (LV) outflow tract obstruction following surgical or transcatheter aortic valve replacement (SAVR and TAVR, respectively) with unfavorable outcome [3–5] and may increase the difficulty in accurate positioning and implantation of the prosthetic valve by confounding coaxial alignment of the guide wire and/or the valve or by resulting in superior displacement of the prosthetic valve during deployment [6]. Therefore, BSH is especially important in patients with AS.…”

ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease

“…Tables 9, 10, 11 cover preprocedural, intraprocedural, and postprocedural imaging for transcatheter aortic valve replacement (TAVR) for AS. 27,28 Table 9 catalogues all of the necessary measurements in the pre-TAVR evaluation. It is worth noting that this table covers the imaging support needed and not whether the procedure should be done.…”

Transcathether Valve Replacement and Valve Repair

“…Recommendations for intraprocedural TEE imaging throughout TAVR have been extensively reviewed and are summarized in Table 1. 60 It is important to remember that the imaging planes on TEE and fluoroscopy are different. The optimal imaging plane of fluoroscopy typically cannot be obtained from a TEE imaging position in the esophagus.…”

“…The American Society of Echocardiography guidelines for a comprehensive TEE examination includes 8 additional imaging views, many of which focus on the right heart and tricuspid valve. 60 Although from the midesophageal views the tricuspid valve is in the far-field, the tricuspid valve becomes near-field in both deep esophageal (gastroesophageal junction) and deep transgastric views, allowing for optimal imaging of this valve for procedures (Figure 4). The following discussion of some of the tricuspid valve devices in development or early trials relies on TEE intraprocedural imaging guidance, and protocols for each device are currently being developed.…”