Usefulness of TEE as the Primary Imaging Technique to Guide Transcatheter Transapical Aortic Valve Implantation

Study Questions:

Is transesophageal echocardiography (TEE) useful as the primary technique to guide transapical (TA) aortic valve implantation (TAVI)? Additionally, how does TEE compare to angiography as the primary imaging modality?

Methods:

One hundred high surgical risk consecutive patients who underwent TA-TAVI were assessed. The 23- or 26-mm Edwards SAPIEN or SAPIEN-XT transcatheter valves (Edwards Lifesciences, Inc., Irvine, CA) were used in all cases, and all procedures were performed in operating rooms without hybrid facilities. Angiography guided the first 25 cases and TEE was the primary modality in the remaining 75 cases.

Results:

The average age of the population was 79 ± 9 years, and 41% were male. When TEE-guided TA-TAVI patients were compared to angiography-guided TA-TAVI, the groups were similar in regard to baseline functional classification, medical comorbidities and pre- and post-procedure hemodynamics. Less intravenous (IV) contrast volume was used in the TEE-TAVI group compared with the angiography-guided group (12 cc [5-20] vs. 40 cc [20-50]). Procedure times were shorter in the TEE group (72 ± 20 vs. 91± 29 minutes, p = 0.005). TEE- and angiography-guided TAVI had similar procedural success of 97.3% (TEE) and 100% (angiography), p = 1.0. There was no difference in procedure-related complications including valve embolization, valve malposition requiring a second valve implantation, or post-procedure aortic insufficiency. More patients had moderate-severe mitral regurgitation diagnosed in the TEE group (34.6% vs. 8%, p = 0.001). Survival was similar, at a mean follow-up period of 6 months (84% in the angiography group vs. 75% in the TEE group, log-rank = 0.49).

Conclusions:

The authors concluded that TEE is a reasonable and safe primary imaging modality in guiding TA-TAVI, and significantly reduces IV contrast exposure.

Perspective:

TAVI is likely to become a standard procedure in high-risk surgical patients with aortic stenosis. These data suggest that TEE can be useful as both a primary and adjunct imaging modality to guide valve placement even in facilities without hybrid operating room suites. Decreasing contrast exposure is important in this high-risk group to avoid acute kidney injury. All of the patients in this study had TA-TAVI, as opposed to a transfemoral approach and, therefore, the results may not be applicable to the transfemoral technique. As these technologies evolve, the optimal methods of periprocedural monitoring will require more study.

Clinical Topics: Noninvasive Imaging, Echocardiography/Ultrasound

Keywords: Follow-Up Studies, Hemodynamics, Echocardiography, Transesophageal


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