Role of Echocardiography in transcatheter aortic valve implantation

1. Ahmed Mohsen
Department of Cardiovascular Medicine
Cairo University
Role of Echocardiography in TAVI

2. • Transcatheter aortic valve implantation (TAVI) has
dramatically changed the care of patients with severe
aortic stenosis (AS)
• Echocardiography plays an important role in Pre-procedural
planning, intraprocedural implantation guidance, and long-
term follow-up of patients undergoing TAVI
• Preprocedural TEE with utilization of 3D Echo provide a
good alternative in patients with a contraindication for CT
such as renal dysfunction and known iodinated contrast
allergies

3. Role of Echocardiography in
pre-procedural planning in
patients undergoing TAVI

4. Role of Echocardiography in pre-procedural
planning in patients undergoing TAVI
• 1-To confirm severity of
aortic stenosis

5. Role of Echocardiography in pre-procedural
planning in patients undergoing TAVI
• 2-To exclude
presence of sigmoid
septum(basal septal
hypertrophy) which may
lead to balloon migration
when using balloon
expandable valve

6. Left ventricular outflow tract and
septum
• Prominent septal hypertrophy has also been
associated with atrioventricular (AV) block and
need for pacemaker implantation post-TAVI
• Hemodynamically significant LVOT obstruction
due to septal hypertrophy is a contraindication to
TAVI; however, there are reports of successful
implantations performed with modifications of
the THV for such patients .

7. Role of Echocardiography in pre-procedural
planning in patients undergoing TAVI
3-Aortic calcification
• Severe, asymmetric
calcification of the aortic
valve leaflets may result in
incomplete expansion of
the valve and result in
paravalvular regurgitation.

8. Role of Echocardiography in pre-procedural
planning in patients undergoing TAVI
4-To exclude bicuspid aortic
valve
• BAV not preferred with
TAVI for two reasons:
• I-Higher incidence of PVL
due to elliptical opening
leaving two holes on either
side of the prosthesis
• II-Its association with
aortopathy, more
incidence of vascular
complication

9. Role of Echocardiography in pre-procedural
planning in patients undergoing TAVI
5-Mitral valve assessment
• The aortic annulus is in
close proximity to the mitral
valve apparatus
• Placement of the valve too
low in the LVOT can
encroach upon AMVL

10. Role of Echocardiography in pre-procedural
planning in patients undergoing TAVI
5-Mitral valve assessment
• Moreover, dense
calcification within the
aortomitral curtain or
mitral annular calcification
may increase the risk of
paravalvular regurgitation
due to asymmetric
expansion of the valve .

11. Role of Echocardiography in pre-procedural
planning in patients undergoing TAVI
• Moderate or severe MR is seen in up to 48 % of
patients undergoing TAVI
• During implantation, the guidewire or delivery
catheter may interfere with the mitral subvalvular
apparatus and worsen the degree of MR.
• Worsening MR is included in the differential diagnosis
of acute hemodynamic instability during implantation,
and, as such, the operator should be aware of any
baseline mitral insufficiency.

12. 6-To exclude LV thrombus
• Left ventricular thrombus is
a contraindication to TAVI
and thus should be
excluded prior to the
procedure.

13. The role of TEE in assessment of Aorta
and aortic valve before TAVI
7-Coronary ostia
• To measure distance from
both coronary ostia to
aortic annulus by utilization
of Q-lab soft ware in 3D
• Echocardiography can
identify the risk for possible
coronary obstruction.

14. The role of TEE in assessment of Aorta
and aortic valve before TAVI
8-Aortic annulus
• 5-For accurate
measurement of aortic
annulus(minimum and
maximum) for choice of proper
size of prosthesis
Undersized prosthesis leads to
mismatch or paravalvular leak
• Oversized prosthesis leads to
vascular complication and
central regurgitation due to
improper leaflet excursion

15. The role of TEE in assessment of Aorta
and aortic valve before TAVI
9-Choice of Access
• 1-TEE help to choose the
proper access;
presence of mobile plaques
or thrombi in descending
aorta or aortic arch is a
contraindication for femoral
access

16. So with assessment of the access, you must obtain 2
perpendicular views of DA and arch to exclude mobile thrombi
Descending aorta Aortic arch

17. The role of TEE in TAVI;
Intra-procedural guidance

18. The role of TEE in TAVI; Intra-
procedural guidance
• Proper valve selection(sizing)
• Assessment of the valve position and function
immediately after deployment
• Identification of intraprocedural complications

19. After deployment of the valve, if there is PVL,
Echocardiography-guided balloon dilatation can used to
decrease the paravalvular regurgitation

20. The role of TEE in TAVI; Intra-
procedural guidance
TEE can unmask the reason for hemodynamic
decompensation during TAVI implantation
• Confirm proper device deployment,
• Coronary artery obstruction,
• Pericardial tamponade,
• Severe mitral regurgitation,
• Aortic injury or dissection,
• Left ventricular perforation,
• Embolization of the valve

21. The role of TEE in TAVI;
Post-procedural Evaluation

22. The role of TEE in TAVI; Post-
procedural Evaluation
• Echocardiography remains the standard for
long-term follow up for
• 1- Evaluation of prosthetic valve structure and
function
• 2-Evaluation the effects of TAVI on myocardial
function
• 3-Detection of late complication

24. Take home message
• Echocardiography is a key aspect of care in
patients undergoing transcatheter aortic
valve implantation (TAVI).
• Goals of preprocedural multimodality
imaging for TAVI include ensuring patient
suitability, assessment of the access site,
selection of the proper valve, and developing
a procedural plan.

25. • Goals of imaging during the TAVI procedure
include proper valve sizing, providing
immediate assessment of the valve position
and function, and immediate identification of
complications.
• Echocardiography is essential for long term
follow up after TAVI

26. Thank You