SHA24/031001

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