Echocardiography in TAVR  Implantation

Irina Staicu, MD, FACC, RPVI

Director Noninvasive Cardiology

Echo Lab

Good Shepherd Hospital

Objectives

• Understand novel alternatives for treatment of AS

• Identify candidates for TAVR

• Review the pre, intra and post procedure role of Echo

• Role of Echo in intraprocedural evaluation of position, size, complications of TAVR

WHY TAVR AND WHY ECHO IN  TAVR

" Treat 4 to save 1" or 1000 for 250

The strongest treatment effect on mortality trials in Cardiology

Dr Henning Rud Andersen, 1988

"VIP" PIG 

France, Dr Alain Cribier, April 2002

Pre TAVR Planning  Echo check list   

American Society of Echocardiography - 2017

Confirm trileaflet/bileaflet AV morphology

Presence/Degree of AR, MR, TR

Presence of basal septal hypertrophy/LVOT obstruction

Presence of Pericardial effusion

Exclude LA or LV thrombus

TAVR: Echo Measurements Pre, Post And Intra Procedure

2017 ASE Florida, Orlando, FLhttp://asecho.org/wordpress/wp-content/uploads/2017/.../2017_10_10_Saric_TAVR-1.pdf

Intra /post TAVR implantation Echo check list    American Society of Echocardiography - 2017

Ensure proper prosthesis placement

Assess prosthesis position/function after deployment

Assess ventricular function

Identify immediate post deployment complications

TAVR: Echo Measurements Pre, Post And Intra Procedure

2017 ASE Florida, Orlando, FLhttp://asecho.org/wordpress/wp-content/uploads/2017/.../2017_10_10_Saric_TAVR-1.pdf

FDA approved valves for TAVR

Medtronic Melody

Edwards Sapien 3

 Medtronic Corevalve

Echo for TAVR

• Select the device size (Annular size/perimeter)

• Extent and location of calcification

• TAVR function

• Optimal implantation

• Severity of Aortic Regurgitation

• Intraprocedural complications

Select the device size (Annular size/perimeter)

Undersized prosthesis

• Periprosthetic AR

• Device migration

• Prosthesis -patient mismatch

Oversized prosthesis

• Underexpansion with central AR

• Annular rupture

• Coronary ostial obstruction

Select the device size (Annular size/perimeter)

How do we do sizing?

• 2D echo

• 3D TEE

• CT

• 3D TEE and CT

Aortic annulus and LVOT

 Ovoid shape

2D echo underestimates the valve area

CT overestimates the valve area

• Undersizing predicts AR

• CT better than TTE/TEE diameter

• 3D TEE equivalent to CT in sizing and  predicting AR

https://www.ncbi.nlm.nih.gov/pubmed/23998695

http://read:http://www.acc.org/latest-in-cardiology/articles/2015/05/27/11/08/use-of-intraoperative-transesophageal-echocardiography-in-transcatheter-aortic-valve-replacement

• Select the device size (Annular size/perimeter)

• Extent and location of calcification

• TAVR function

• Optimal implantation

• Severity of Aortic Regurgitation

• Intraprocedural complications

TAVR Function : Shape, Gradient, PAR

Valve Shape and location

• short axis: circular rather than ovoid

• long axis: 2-3 mm in the LVOT

TAVR Function

If Suboptimal

• Reposition

• Post dilatation

• Valve in Valve implantation

Valve Regurgitation

• No significant PAR, or Central Regurgitation

Valve Gradient

• < 2.0 m/sec

• Annular size/perimeter

• Extent and location of calcification

• TAVR function

• Optimal implantation

• Severity of Aortic Regurgitation

• Intraprocedural complications

Everything is about landing

Optimal valve position at deployment

• 2-3 mm bellow the annulus

• 2 mm coverage of native cusps.

During deployment there is an upward movement of the valve and shortening

Optimal valve position at deployment

• Superior motion

• Shortening

5-6 mm below annulus during pacing, just before deployment

Malposition : too low in the ventricle

• Uncovered native leaflets

• Entrapment of THV in native leaflets

• Severe central A R

Malposition : too low in the ventricle

Malposition : too high in the aorta

• Aortic regurgitation

• Valve embolization

• Coronary obstruction,

• Aortic dissection

Malposition : too high in the aorta

Malposition : too low in the ventricle

Malposition : too low in the ventricle

Optimal 

Too high

Aorta

Too low

LVOT

• Annular size/perimeter

• Extent and location of calcification

• TAVR function

• Optimal implantation

• Severity of Aortic Regurgitation

• Intraprocedural complications

Paravalvular Aortic Regurgitation  PAR

Grading of PAR by Circumferential Extent

Mild PAR :jet arc lengths are discontinuous, but total <10% of the AV  annulus

Moderate PAR :jet arc lengths are discontinuous, but total 10% to 30% of the AV annulus

Severe PAR :jet arc lengths are discontinuous, but total >30% of the AV annulus

Mild PAR

Moderate PAR

Text

Severe PAR

http://asecho.org/wordpress/wp-content/uploads/2016/02/Mankad-TAVR.pdf

• Annular size/perimeter

• Extent and location of calcification

• TAVR function

• Optimal implantation

• Severity of Aortic Regurgitation

• Intraprocedural complications

Intraprocedural Complications

Stiff wire entanglement in the mitral apparatus.

Stiff wire entanglement 

Ballon aortic valvuloplasty complications

• Coronary occlusion

• Severe aortic regurgitation

• Aortic trauma

LM Coronary Artery Occlusion

with BAV

 With BAV the bulky calcium occludes the ostium of LM .  LM stent performed after TAVR

Aortic Trauma Predicted by BAV

Periaortic hematoma within minutes of transcatheter valve deployment

BAV Complication

Avulsed leaflet , resulting in severe aortic regurgitation

• 1. Exclude acute valvular regurgitation

• 2. Exclude aortic root trauma

• 3. Exclude acute ventricular dysfunction

• 4. Exclude coronary obstruction

• 5. Exclude pericardial effusion/tamponade

Acute Hemodynamic compromise

Secondary to superior motion of balloon during BAV in setting of large sigmoid septum/dynamic LVOT obstruction  

Failure to implant / Malposition

LVH/dynamic LVOT obstruction  

Invaluable, real time for intraprocedural imaging

• TAVR position and function

• PAR

• Complications

Thank you   Irina Staicu

See you in 2019

PARTNER 1 B - Inoperable Cohort

TAVR vs Standard Tx 

TAVR vs SAVR  

Trials

Mortality

NYHA class

Six minutes walking test

• Annular size/perimeter

• Extent and location of calcification

• TAVR function

• Optimal implantation

• Severity of Aortic Regurgitation

• Intraprocedural complications

Malposition : too low in the ventricle

Paravalvular Aortic Regurgitation  PAR

THV malposition and Central Aortic Regurgitation

Salvage

Valve in Valve

Ms Coolkissovsky, 89 YOF , with heavy European accent, presents with Syncope

Admitted with Chest Pain

On the floor, a nursing student  hears a faint, "tiny" murmur

Cardiology eval: loud 4/4 systolic murmur, radiating everywehere

Severe AS

HTN, CKI, on HD, COPD on 2L O2