Role of Echocardiography in TAVI Dr. Saeed AL Ahmari Prince Sultan Cardiac Center Riyadh
Role of Echo in TAVI
Establish AS severity Assessment of TAVI feasibility Intra- procedural guidance and monitoring Post procedural follow up
Echocardiography Assessment
Assessment of AS severity
Assessment of LV/RV function & intracardiac masses
Annulus size, and aortic root measurements
Assessment of other valve dysfunction
Pulmonary pressure assessment
Low Flow Low Gradient AS with normal EF
Low Flow Low Gradient AS with normal EF
Normal LVEF, “paradoxical” LF-LG AS (10% to 25% of AS population) is characterized by – pronounced LV concentric remodeling – small LV cavity size – Restrictive physiology leading to impaired LV filling, altered myocardial function, and reduced LV outflow
Contraindication for TAVI
Bicuspid AV LVOT obstruction Annulus <18 mm, or > 29 mm Severe LVH ( IVS > 17 mm ) Severe MR EF<20 % Intracardiac Thrombus Apical Aneurysm
TTE measurements of aortic annulus
TEE Assessment
Degree of AV calcification, presence of bicuspid AV Annulus size, and aortic root measurements LM height Intra cardiac masses Other valvular lesions Aorta disease
TEE assessment of aortic annulus
Aortic Annulus
3-D Echo Annulus assessment
Annulus assessment by CTA
Edward Sapien Valve
THV SIZING RECOMMENDATIONS – 18-21 mm Annulus: 23mm Valve – 22-25 mm Annulus :26mm Valve – 24-27 mm Annulus : 29 mm Valve
Sizing Considerations: – 1) Patient Size. – 2) Degree of root and aortic calcification
Edward Valve sizing
Core Valve sizing
Aortic Atheroma
Possible bicuspid Aortic Valve
Bicuspid AV by 3-D echo
LM occlusion due to bicuspid AV leaflets post balooning
Rejected TAVI candidate
Rejected TAVI candidate
Rejected TAVI candidate
Improvement of functional MR post TAVI
Improvement in MR severity post TAVI
Coronary ostia height from the aortic annulus
Heavy Aortic Calcification
LM occlusion post TAVI
TEE TAVI Guidance
TEE TAVI Guidance
TEE TAVI Guidance
3-D TEE post TAVI
Valve in Valve
Valve in Valve
Thrombus formation during TAVI
Thrombus formation during TAVI
Thrombus formation during TAVI
Cardiac Tamponade during TAVI
Under deployment of Core valve
Under deployment of Core valve
ICE during TAVI
Dramatic LV improvement post TAVI
Dramatic LV improvement post TAVI
Dramatic LV improvement post TAVI
Post TAVI Gradient Reduction
Mean and Peak Gradients (AT) Peak Gradient - TAVR Mean Gradient - TAVR Peak Gradient - AVR
Gradient (mmHg)
Mean Gradient - AVR
Numbers at Risk TAVR
307
275
233
218
144
AVR
295
228
168
155
112
AVA (AT) TAVR
Valve Area (cm2)
AVR
p = 0.001
p = 0.002
p = 0.003
p = 0.16
Numbers at Risk TAVR
301
269
223
210
139
AVR
290
224
162
151
110
Delayed Increment in AV gradient
Delayed increase in prosthesis gradient
Delayed Increment in AV gradient
PARTNER Grading Criteria for Paravalvular AR
Circumference = 6″ AR = 0.1+0.35 = 0.45″ Ratio = 8% Severity = Mild (< 10%)
Circumference = 6″ AR = 0.5+0.5 = 1.0″ Ratio = 17% Severity = Moderate (10 – 20%) (Trans AR also present) Circumference = 6″ AR = 0.6+1.1 = 1.7″ Ratio = 28% Severity = Severe (> 20%)
Images courtesy of Pamela Douglas, MD, FASE
Paravalvular Aortic Regurgitation (AT) p < 0.0001
N = 277
N = 226
p < 0.0001
N = 230
N = 172
p < 0.0001
N = 216
N = 155
p < 0.0001
N = 145
N = 112
Para-valvular Leak
Paravalvular AR and Mortality TAVR Patients (AT) None - Trace Mild - Moderate - Severe
HR [95% CI] = 2.01 [1.38, 2.92] p (log rank) = 0.0002
Mortality
39.5% 29.5% 24.8% 14.5%
Months Post Procedure Numbers at Risk None-Tr
167
149
140
126
87
41
16
Mild-ModSev
160
134
112
101
64
26
12
Under deployment, under sizing of Core valve
Low implantation of core valve
Delayed apical leak post TAVI
Delayed apical leak post TAVI
Prosthesis Thrombosis
Conclusion
Echocardiography has a pivotal role in TAVI procedures
It is essential to establish the diagnosis of severe AS, & exclude contraindication for the procedure
It has important role in guiding the procedure, and in early detection of complications.
Integrating information from different imaging modalities is essential for TAVI