Real-Time Three-Dimensional Transesophageal Echocardiography Adds Value to Transcatheter Aortic Valve Implantation

TY - JOUR

T1 - Real-Time Three-Dimensional Transesophageal Echocardiography Adds Value to Transcatheter Aortic Valve Implantation

AU - Smith, Lindsay A.

AU - Dworakowski, Rafal

AU - Bhan, Amit

AU - Delithanasis, Ioannis

AU - Hancock, Jane

AU - MacCarthy, Philip A.

AU - Wendler, Olaf

AU - Thomas, Martyn R.

AU - Monaghan, Mark J.

PY - 2013/4

Y1 - 2013/4

N2 - Background: Successful transcatheter aortic valve implantation (TAVI) mandates comprehensive, accurate multimodality imaging. Echocardiography is involved at all key stages and, with the advent of real-time three-dimensional (3D) transesophageal echocardiography, is uniquely placed to enable periprocedural monitoring. The investigators describe a comprehensive two-dimensional (2D) and 3D echocardiographic protocol, and the additional benefits of 3D TEE, within a high-volume TAVI program. Methods: TAVI was performed with 2D and 3D transesophageal echocardiographic and fluoroscopic guidance in consecutive high-risk patients with symptomatic severe aortic stenosis. The role of TEE, including the additive value of 3D TEE, was examined, and procedural and echocardiographic outcomes were evaluated. A 3D sizing transcatheter heart valve (THV) strategy was used, except as mandated by study protocol. Results: Procedural success was achieved in 99% of 256 patients (mean age, 82.9 +/- 7.1 years, mean logistic European System for Cardiac Operative Risk Evaluation score, 21.6 +/- 11.2%; mean aortic valve area, 0.63 +/- 0.19 cm(2)), with no procedural deaths. Acceptable 2D and 3D transesophageal echocardiographic images were achieved in all patients. Aortic valve annular dimensions by 2D transthoracic echocardiography, 2D TEE, and 3D TEE were 21.6 +/- 1.9 mm, 22.5 +/- 2.2 mm (P < .001), and 23.0 +/- 2.0 mm (P = .004 vs 2D TEE), respectively. The 2D THV sizing strategy would have changed THV selection in 23% of patients, downsizing in most. Three-dimensional TEE provided superior spatial visualization and anatomic orientation and optimized procedural performance. Postprocedural mild, moderate, and severe paravalvular aortic regurgitation was observed in 24%, 3%, and 0% of patients, respectively, with no or trace transvalvular aortic regurgitation in 95%. A second valve was successfully deployed in five patients, and TEE detected five other periprocedural complications. Conclusions: A systematic, comprehensive echocardiographic protocol, incorporating the additional benefits of 3D TEE, has a vital role within a TAVI program and, combined with a 3D THV sizing strategy, contributes to excellent outcomes.

AB - Background: Successful transcatheter aortic valve implantation (TAVI) mandates comprehensive, accurate multimodality imaging. Echocardiography is involved at all key stages and, with the advent of real-time three-dimensional (3D) transesophageal echocardiography, is uniquely placed to enable periprocedural monitoring. The investigators describe a comprehensive two-dimensional (2D) and 3D echocardiographic protocol, and the additional benefits of 3D TEE, within a high-volume TAVI program. Methods: TAVI was performed with 2D and 3D transesophageal echocardiographic and fluoroscopic guidance in consecutive high-risk patients with symptomatic severe aortic stenosis. The role of TEE, including the additive value of 3D TEE, was examined, and procedural and echocardiographic outcomes were evaluated. A 3D sizing transcatheter heart valve (THV) strategy was used, except as mandated by study protocol. Results: Procedural success was achieved in 99% of 256 patients (mean age, 82.9 +/- 7.1 years, mean logistic European System for Cardiac Operative Risk Evaluation score, 21.6 +/- 11.2%; mean aortic valve area, 0.63 +/- 0.19 cm(2)), with no procedural deaths. Acceptable 2D and 3D transesophageal echocardiographic images were achieved in all patients. Aortic valve annular dimensions by 2D transthoracic echocardiography, 2D TEE, and 3D TEE were 21.6 +/- 1.9 mm, 22.5 +/- 2.2 mm (P < .001), and 23.0 +/- 2.0 mm (P = .004 vs 2D TEE), respectively. The 2D THV sizing strategy would have changed THV selection in 23% of patients, downsizing in most. Three-dimensional TEE provided superior spatial visualization and anatomic orientation and optimized procedural performance. Postprocedural mild, moderate, and severe paravalvular aortic regurgitation was observed in 24%, 3%, and 0% of patients, respectively, with no or trace transvalvular aortic regurgitation in 95%. A second valve was successfully deployed in five patients, and TEE detected five other periprocedural complications. Conclusions: A systematic, comprehensive echocardiographic protocol, incorporating the additional benefits of 3D TEE, has a vital role within a TAVI program and, combined with a 3D THV sizing strategy, contributes to excellent outcomes.

KW - Transesophageal echocardiography

KW - 3-dimensional echocardiography

KW - Valvular heart disease

KW - Aortic stenosis

KW - Transcatheter aortic valve implantation

KW - HIGH-RISK PATIENTS

KW - EUROPEAN-ASSOCIATION

KW - STENOSIS

KW - REPLACEMENT

KW - INTERVENTIONS

KW - EXPERIENCE

KW - REGURGITATION

KW - FEASIBILITY

KW - CARDIOLOGY

KW - RECOMMENDATIONS

U2 - 10.1016/j.echo.2013.01.014

DO - 10.1016/j.echo.2013.01.014

M3 - Article

SN - 0894-7317

VL - 26

SP - 359

EP - 369

JO - Journal of The American Society of Echocardiography

JF - Journal of The American Society of Echocardiography

IS - 4

ER -