ECHO 2013 / Interventional Echocardiography
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TAVR Technologies
Current Generation Devices
Edwards Lifesciences |
Medtronic CoreValve |
>30,000 Patients have been treated worldwide with these 1st Generation Devices
Echocardiographic Assessment of
TAVR
Pre-procedural Imaging
(TTE/TEE)
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Aortic valve morphology |
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Intra-procedural Imaging |
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and hemodynamics |
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(TEE) |
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Aortic root and LVOT |
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Immediately following |
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morphology |
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Confirmation of transcatheter |
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Mitral and tricuspid v lve |
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deployment (TEE) |
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heart valve (THV) choice |
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function |
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Evaluate THV position, |
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Balloon Aortic Valvuloplasty |
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Ventricular function (LV and |
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shape and leaflet motion |
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RV) |
(BAV) assessment |
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Positioning of THV Evaluate for complications Aortic regurgitation
Aortic complications Left main patency
Mitral valve function
JAm Soc Echocardiogr 2013;26:359-69
•THV sizing strategies, based solely on 2D annular dimension, would have changed in
23% of patients, with selection of smaller prostheses in most (19%).
•Threedimensional TEE provided superior spatial visualization and anatomic orientation and optimized procedural performance.
Columbia Data
Table 1: The table shows the mean ± SD for the indicated annular measurements for the group as a whole, as well as by implanted transcatheter heart valve (THV) size.
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Total (114) |
THV size 23 |
THV size 26 |
THV size 29 |
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(44) |
(67) |
(3) |
Sagittal |
22.4±1.9 |
20.6±0.2 |
23.4±0.2 |
26.56±1.7 |
Ave(Perimeter) |
23.2±2.1 |
21.2±0.2 |
24.3±0.2 |
27.9±0.5 |
Mean Diameter |
22.9±2.9 |
20.6±0.5 |
24.1±0.2 |
27.7±0.6 |
Ave (Area) |
22.7±2.8 |
20.5±0.5 |
23.9±0.1 |
27.5±0.6 |
Table 2: AnnSag discordance with respective 3DE measurements for predicting the required THV size using the sizing algorithm
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AnnPerim |
AnnMean |
AnnArea |
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(n,%) |
(n,%) |
(n,%) |
AnnSag Discordant |
37 (32.5) |
29 (25.4) |
23 (20.2) |
Overestimates 3DE |
2 |
2 |
3 |
Underestimates 3DE |
35 |
27 |
20 |
J Am Coll Cardiol Img 2013; 6:249 – 62
The “Turnaround Rule”
1.Transverse and sagittal and coronal planes are oriented
•All planes intersect at the center of the opened valve
•Sagittal and coronal planes aligned parallel to the long axis of the ascending aorta.
2.The orthogonal planes are rotated to identify the most caudal attachments of the aortic valve
leaflets (hinge points)
• Transverse plane is repositioned to the level of the hinge points.
3.The orthogonal planes are repeatedly rotated (the turnaround rule) to ensure that the hinge points of the aortic valve leaflets are transected by the transverse plane.
Minimum 19.6 mm Maximum 24.4 mm Area= 376 mm2
3D Echo Annular Measurements
3DE could allow more accurate measurement of the annulus for more accurate THV sizing and can be performed intraprocedurally.
A new sizing algorithms using both the 3DE maximum dimension and perimeter-derived average annular
diameter should be developed
Area |
4.15 cm2 |
5.31 cm2 |
23 mm |
26 mm |
Perimeter |
72.24 cm |
81.7 cm |
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Area |
3.49 cm2 |
4.46 cm2 |
16% oversize |
Perimeter |
66.5 cm |
75.2 cm |
8% oversize |
Hahn RT et al (presented TCT 2012)
Intra-procedural
Imaging
THV positioning
Use of 3D narrow sector or thin slice imaging may be helpful if the stent cannot be identified on 2D images.
Pacing Check
Echo for Hemodynamic Instability
Differential diagnoses for refractory hypotension during TAVI.
Major bleeding
Look for hypovolemia/underfilled LV
Pericardial effusion
Other: Ventricular Septal Defect
Echo for Hemodynamic Instability 
Hypotension
Severe AR
Aortic trauma
Dissection
Annular rupture