Transcatheter aortic valve implantation (TAVI) was initially proven as an alternative to valve replacement therapy in those beyond established risk thresholds for conventional surgery. With time the technique has been methodically refined and offered to a progressively lower risk cohort, and with this evolution has come that of the significant imaging requirements of valve implantation. This review discusses the role of transoesophageal echocardiography (TOE) in the current TAVI arena, aligning it with that of cardiac computed tomography, and outlining how TOE can be used most effectively both prior to and during TAVI in order to optimise outcomes.
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3D transoesophageal echocardiography in the TAVI sizing arena: should we do it and how do we do it?
Caroline Bleakley, Mehdi Eskandari, and Mark Monaghan
Preoperative aortic annulus size assessment by transthoracic echocardiography compared to the size of surgically implanted aortic prostheses
I J Ingimarsdóttir, L Hellgren Johansson, and F A Flachskampf
The aortic annulus diameter measured by transthoracic echocardiography yields lower values than by computed tomography, and echo-based selection of transcatheter aortic valve prosthesis size has been implied to result in more frequent paravalvular leakage. We investigated the relation of preoperative annulus diameter by echo with the ring size of the aortic prosthesis chosen by direct assessment during open-heart aortic valve replacement.
Preoperative annulus diameter by echo (from parasternal long-axis cross-sections of the left ventricular outflow tract and aortic valve) and implanted prosthetic diameter (tissue annulus diameter, determined intraoperatively using a sizing instrument) were compared retrospectively in 285 consecutive patients undergoing open-heart aortic valve replacement.
A total of 285 prostheses (240 biologic and 45 mechanical) were implanted, with prosthetic diameter ranging between 19 and 27 mm. There was a significant linear correlation (P < 0.0001) with r = 0.51, between preoperative annulus diameter by echo (mean 21.8 ± 2.8 mm) and prosthetic diameter (22.9 ± 1.7 mm). Preoperative annulus diameter of patients receiving prostheses no. 21, 23 and 25 mm aortic prostheses (the most frequent prosthesis sizes) were significantly different (P < 0.001) from each other. On average, preoperative annulus diameter by echo underestimated prosthetic diameter by a bias of 1.07 mm.
Our data confirm that preoperative echo assessment of the aortic valve may slightly underestimates the optimal surgical prosthesis diameter for the aortic valve annulus.
When echo gets in the way: physiological factors affecting Doppler data
J Jose, K Randall, J Baron, and J Khoo
Transthoracic echocardiography (TTE) is widely used as a pre-operative screening tool. It can provide extensive information about cardiac function and underlying pathology, which could influence decisions regarding surgery. This patient was referred for TTE as part of pre-op screening, as he had a biological prosthetic aortic valve. This was a rare case where misleading TTE measurements inadvertently led to the patient being referred for transcatheter aortic valve implantation (TAVI), which delayed non-cardiac surgery.
Echocardiographers and referrers should be familiar with physiological and haemodynamic conditions that can affect measurements.
Echocardiographic results should be interpreted in wider clinical context, particularly when it changes management.
Lack of clinical information on the referral form limits echocardiographer’s ability to interpret results in clinical context.
Referring non-cardiologists may not be aware of haemodynamic factors that could affect echocardiographic measurements.
Left ventricular speckle tracking echocardiographic evaluation before and after TAVI
Vasiliki Tsampasian, Vasileios Panoulas, Richard J Jabbour, Neil Ruparelia, Iqbal S Malik, Nearchos Hadjiloizou, Angela Frame MSc, Sayan Sen, Nilesh Sutaria, Ghada W Mikhail, and Petros Nihoyannopoulos
To assess left ventricular (LV) function before and after transcatheter aortic valve implantation (TAVI) using conventional echocardiographic parameters and global longitudinal LV strain (GLS) and compare outcomes between Edwards S3 and Evolut R valves.
Methods and results:
Data were collected for consecutive patients undergoing TAVI at Hammersmith hospital between 2015 and 2018. Of the 303 patients, those with coronary artery disease and atrial fibrillation were excluded leading to a total of 85 patients, which constituted our study group. The mean follow-up was 49 ± 39 days. In total, 60% of patients were treated with Edwards S3 and 40% Evolut R. TAVI resulted in an early improvement of GLS (−13.96 to −15.25%, P = 0.01) but not ejection fraction (EF) (47.6 to 50.1%, P = 0.09). LV mass also improved, especially in patients with marked baseline LV hypertrophy (P < 0.001). There were no appreciable differences of LV function improvement and overall LV remodelling after TAVI between the two types of valves used (P = 0.14).
TAVI results in reverse remodelling and improvement of GLS, especially in patients with impaired baseline LV function. There were no differences in the extent of LV function improvement between Edwards S3 and Evolut R valves but there was a greater incidence of aortic regurgitation with Evolut R.
Impact of mitral geometry and global afterload on improvement of mitral regurgitation after trans-catheter aortic valve implantation
Y Tayyareci, R Dworakowski, P Kogoj, J Reiken, C Kenny, P MacCarthy, O Wendler, and M J Monaghan
To assess the impact of mitral geometry, left ventricular (LV) remodelling and global LV afterload on mitral regurgitation (MR) after trans-catheter aortic valve implantation (TAVI).
In this study, 60 patients who underwent TAVI were evaluated by 3D echocardiography at baseline, 1 month and 6 months after procedure. The proportional change in MR following TAVI was determined by examining the percentage change in vena contracta (VC) at 6 months. Patients having a significant reduction of at least 30% in VC were defined as good responders (GR) and the remaining patients were defined as poor responders (PR).
After 6 months of TAVI, 27 (45%) patients were GR and 33 (55%) were PR. There was a significant decrease in 3DE-derived mitral annular diameter and area (P = 0.001), mitral valve tenting area (TA) (P = 0.05), and mitral papillary muscle dyssynchrony index (DSI) (P = 0.05) in the GR group. 3DE-derived LVESV (P = 0.016), LV mass (P = 0.001) and LV DSI, (P = 0.001) were also improved 6 months after TAVI. In addition, valvulo-arterial impedance (ZVA) was significantly higher at baseline in patients with PR (P = 0.028). 3DE-derived mitral annular area (β: 0.47, P = 0.04), mitral papillary DSI (β: −0.65, P = 0.012) and ZVA (β: 0.45, P = 0.028) were the strongest independent parameters that could predict the reduction of functional MR after TAVI.
GR patients demonstrate more regression in mitral annulus area and diameter after significant decrease in high LVEDP and trans-aortic gradients with TAVI. PR patients appear to have increased baseline ZVA, mitral valve tenting and restriction in mitral valve coaptation. These factors are important for predicting the impact of TAVI on pre-existing MR.
Transthoracic echocardiography is adequate for intraprocedural guidance of transcatheter aortic valve implantation
Renuka Jain, Daniel P O’Hair, Tanvir K Bajwa, Denise Ignatowski, Daniel Harland, Amanda M Kirby, Tracy Hammonds, Suhail Q Allaqaband, Jonathan Kay, and Bijoy K Khandheria
While transcatheter aortic valve implantation (TAVI) has traditionally been supported intraprocedurally by transoesophageal echocardiography (TOE), transthoracic echocardiography (TTE) is increasingly being used. We evaluated echocardiographic imaging characteristics and clinical outcomes in patients who underwent TTE during TAVI (TTE-TAVI).
Methods and results
A select team of dedicated sonographers and interventional echocardiographers performed TTE-TAVI in 278 patients, all of whom underwent TAVI through transfemoral access. We implanted the Medtronic EVOLUT R valve in 258 patients (92.8%). TTE images were acquired immediately pre-procedure by a dedicated sonographer in the cardiac catheterization laboratory with the patient in the supine position. TTE was then performed post deployment of TAVI. In the procedure, TTE image quality was fair or better in 249 (89.6%) cases. Color-flow Doppler was adequate or better in 275 (98.9%) cases. In 2 cases, paravalvular regurgitation (PVL) could not be assessed confidently by echocardiography due to poor image quality; in those cases, PVL was assessed by fluoroscopy, aortic root injection and invasive hemodynamics. Both TTE and invasive hemodynamics were used in the assessment of need for post-deployment stent ballooning (n = 23, 8.3%). TTE adequately recognized new pericardial effusion in 3 cases. No case required TOE conversion for image quality. There was only 1 case of intraprocedural TTE failing to recognize moderate PVL, without clinical implication. In 99% of patients, TTE-TAVI adequately assessed PVL compared with 24-h and 1-month follow-up TTE.
With the current generation of TAVI, TTE-TAVI is adequate intraprocedurally when performed by specialized sonographers and dedicated cardiologists in a highly experienced TAVI center.
The role of TTE in assessment of the patient before and following TAVI for AS
John Fryearson, Nicola C Edwards, Sagar N Doshi, and Richard P Steeds
Transcatheter aortic valve implantation is now accepted as a standard mode of treatment for an increasingly large population of patients with severe aortic stenosis. With the availability of this technique, echocardiographers need to be familiar with the imaging characteristics that can help to identify which patients are best suited to conventional surgery or transcatheter aortic valve implantation, and what parameters need to be measured. This review highlights the major features that should be assessed during transthoracic echocardiography before presentation of the patient to the ‘Heart Team’. In addition, this review summarises the aspects to be considered on echocardiography during follow-up assessment after successful implantation of a transcatheter aortic valve.
A retrospective analysis of mitral valve pathology in the setting of bicuspid aortic valves
Annari van Rensburg, Philip Herbst, and Anton Doubell
The therapeutic implications of bicuspid aortic valve associations have come under scrutiny in the transcatheter aortic valve implantation era. We evaluate the spectrum of mitral valve disease in patients with bicuspid aortic valves to determine the need for closer echocardiographic scrutiny/follow-up of the mitral valve. A retrospective analysis of echocardiograms done at a referral hospital over five years was conducted in patients with bicuspid aortic valves with special attention to congenital abnormalities of the mitral valve. One hundred and forty patients with a bicuspid aortic valve were included. A congenital mitral valve abnormality was present in eight (5.7%, P = 0.01) with a parachute mitral valve in four (2.8%), an accessory mitral valve leaflet in one (0.7%), mitral valve prolapse in one, a cleft in one and the novel finding of a trileaflet mitral valve in one. Minor abnormalities included an elongated anterior mitral valve leaflet (P < 0.001), the increased incidence of physiological mitral regurgitation (P < 0.001), abnormal papillary muscles (P = 0.002) and an additional chord or tendon in the left ventricle cavity (P = 0.007). Mitral valve abnormalities occur more commonly in patients with bicuspid aortic valves than matched healthy individuals. The study confirms that abnormalities in these patients extend beyond the aorta. These abnormalities did not have a significant functional effect.
Quadruple valve replacement in a patient with severe rheumatic heart disease
Isaac Adembesa, Adriaan Myburgh, and Justiaan Swanevelder
We present a patient with rheumatic heart disease involving all the heart valves. An intraoperative transoesophageal echocardiography confirmed severe mitral stenosis, severe aortic regurgitation, severe tricuspid regurgitation and stenosis, and severe pulmonary stenosis. The patient underwent successful quadruple valve replacement during a single operation at the Groote Schuur Hospital, Cape Town, South Africa.
Rheumatic heart disease can affect all the heart valves including the pulmonary valve.
Intraoperative transoesophageal echocardiography is key for diagnosis, monitoring and confirmation of successful surgical result during heart valve surgery.
Combined surgical procedure of all four valves is possible though associated with long procedural time.
Indications for echocardiography of replacement heart valves: a joint statement from the British Heart Valve Society and British Society of Echocardiography
John B Chambers, Madalina Garbi, Norman Briffa, Vishal Sharma, and Richard P Steeds
Echocardiography plays a vital role in the follow-up of patients with replacement heart valves. However, there is considerable variation in international guidelines regarding the recommended time points after implantation at which routine echocardiography should be performed. The purpose of routine echocardiography is to detect early structural valve deterioration in biological valves to improve the timing of redo interventions. However, the risk of valve deterioration depends on many valve-related factors (valve design and patient prosthesis mismatch) and patient-related factors (age, diabetes, systemic hypertension, renal dysfunction and smoking). In this statement, the British Heart Valve Society and the British Society of Echocardiography suggest practical guidance. A plan should be made soon after implantation, but this may need to be modified for individual patients and as circumstances change. It is important that patients are managed in a multidisciplinary valve clinic.