2/18/2018

1

Rebecca T. Hahn, MD, FACC, FASE

Director of Interventional Echo

Professor of Medicine

Columbia University

Company Nature of AffiliationUnlabeled Product

Usage

• Abbott Vascular

• Gore&Assoc

• NaviGATE

• Medtronic

• Consultant/Advisory

Board• None

• Boston Scientific

• GE Medical

• Philips Healthcare

• Speaker • None

*Core lab for numerous trials, for which I receive no direct compensation from sponsors.

2/18/2018

2

Parameter TTE TEE

Sedation during

TAVR

• None required (sedation for procedure only)

• General anesthesia, monitored anesthetic care or conscious sedation

Imaging Advantages • Standard windows for assessing ventricular and valvular structure & function

• Higher resolution with high frame rates for 2D and 3D imaging

• Pre-procedural imaging may avoid complications (i.e. paravalvular regurgitation, annular/aortic rupture, coronary occlusion)

• Immediate, accurate intra-procedural diagnosis of complications

Imaging

Disadvantages

• Image quality dependent on patient factors (i.e. chest morphology, lung hyperinflation, suboptimal patient positioning)

• Procedural delay during image acquisition (to minimize radiation exposure to imager)

• Non-continuous imaging during procedure• Low resolution with low frame rates for 2D

and 3D imaging• Limited imaging windows for non-

transfemoral access routes•

• Special windows required for assessing ventricular and valvular structure & function

• Image quality dependent on patient factors (i.e. calcific acoustic shadowing, cardiac position relative to esophagus and stomach)

• Probe interference with fluoroscopic imaging (minimized by articulation of probe)

Other Advantages • Early recovery and discharge • Continuous imaging throughout procedure, irrespective of access route

Other Disadvantages • Possible higher radiation exposure to imager

• Interference with sterile field

• Need for post-procedure monitoring (Note: may not be different than for TTE)

• Trauma to oropharynx, esophagus or stomach

Retroflexion Anteflexion

Right Flexion Left Flexion

Left+Ante Right+Ante

Continuous Imaging is KEY to early detection of complications

2/18/2018

3

DOI: 10.1016/j.echo.2017.10.022

Figure 4

Journal of the American Society of Echocardiography DOI: (10.1016/j.echo.2017.10.022)

Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 5

Pre-procedural Imaging

2/18/2018

4

DOI: 10.1016/j.echo.2017.10.022

Journal of the American Society of Echocardiography DOI: (10.1016/j.echo.2017.10.022)

Copyright © 2017 American Society of Echocardiography Terms and Conditions

Figure 8

Post-procedural Imaging

Figure 12

2/18/2018

5

DOI: 10.1016/j.echo.2017.10.022

An 80-year-old female with a past medical history of

Severe mitral stenosis status-post valvuloplasty in Moscow in 1963

Atrial fibrillation on Coumadin

Hypertension

Chronic kidney disease

Complained of increased dyspnea on exertion and fatigue that started six months prior and had progressively worsened.

2/18/2018

6

Pre-procedural transthoracic echocardiogram showed:

Rheumatic mitral valve with stenosis and a mitral valvuloplasty score of 9 (Mobility = 2, Leaflet thickness = 2, Subvalvular thickening = 4 and Calcification = 2) Mean gradient 5 mmHg

Heavily calcified aortic valve. Severe aortic stenosis Peak/mean gradients of 96.4/43.8mmHg

Ejection fraction 65-70%

Given the findings on transthoracic echocardiogram the plan was to perform a transcatheter aortic valve implantation (TAVI).

Mitral valve area of 1.2 cm2

by continuity equation

Mitral valve area of 1.35 cm2 by 3D

planimetry

Dense “smoke” in markedly dilated LAA

(no MR)

Intra-procedural TEE showed:• Severe mitral stenosis by multiple methods• Dense “smoke” in the LAA consistent with

very slow flow but no thrombus• No mitral regurgitation

In light of TEE findings, an intra-procedural decision was made to perform a percutaneous

balloon mitral valvuloplasty (PBMV) prior to TAVR

2/18/2018

7

Valvuloplasty Valvuloplasty

Percutaneous balloon mitral valvuloplasty was performed using a 23mm Inoue balloon. Two inflations were performed resulting in lateral

commissural fracture and improved valve opening

Pre-PBMV

Post-PBMV

Planimetered MVOA= 1.7 cm2

• Single jet of mild mitral regurgitation was seen (EROA by 3D = 13mm2)

• Smoke resolved

2/18/2018

8

Pre-PBMV Post-PBMV

MG 9.1 mmHg MG 4.9 mmHg

Annular perimeter = 67 mm

Annulus-to-left main distance of 10.7mm and a left coronary cusp (LCC) length of 14.5 mm with a sinus of Valsalva (SOV) diameter of 2.85 cm.

A 26mm Evolut-R selected Significant discordance L Main and LCC, small SOV

2/18/2018

9

20mm Z-Med IIballoon

During BAV the left main coronary ostium was covered by the left coronary cusp (yellow arrow) on TEE with slow/faint filling was seen

on contrast injection (red arrow).

• 6F JL 3.5

• 6F Guideliner

• 3.5 x 15mm DES placed in mLAD

2/18/2018

10

ST elevations noted on monitor

Evolut-R 26mm

Marked reduced flow in LM ostiumEvolut-R 26mm

2/18/2018

11

Deployed at 12 atm

Urgent stent deployment in LM

ST segments rapidly resolved and no wall motion abnormalities were detected

2/18/2018

12

Final AR Assessment

2+ ARNo Post-dilatation was

performed

83 year-old man

Class III heart failure

Known Severe AS for 2 years with preserved EF

PV 4.5 m/s

MG 43 mmHg

AVA 0.7cm2

EF 55%, Moderate MR. Mild pHTN.

Type II DM, CKD on HD, Morbid obesity, OSA on BiPAP

TAVR/SAVR were deferred in the past since he had Stevens-Johnson syndrome when exposed to contrast dye, twice.

In the past 5 months experienced increased fatigue after HD and was requiered to start on Midodrine.

STS 13%

2/18/2018

13

26 mm vs 29 mm valve

2/18/2018

14

Trivial agitated bubbles in the LV during BAVGood Annular Sealing – Aorta stretching

2/18/2018

15

2/18/2018

16

Trivial PVL

No central Ao Regurgitation

AVA 2.33 cm2

PV 1.6 m/s P/MG: 11/5 mmHg DI 0.44

Mild MR (No change during procedure)

HPI: 84 y/o F with Diastolic HF (NYHAIV,EF 50%), Aortic insufficiency, ESRD(on HD MWF, LUE AV fistula;still makes some urine),COPD(no intubations), HTN, hyperlipidemia, anemia, h/o GIB 2/2 to high consumption of NSAIDS(pt now reports allergy to ASA/NSAIDS

Experiencing increasing episodes of SOB, resulting in increased hospitalizations, on 2/5/18 pt presented to Outside Hospital ED c/o SOB was admitted

Echo showed worsening aortic regurgitation

2/18/2018

17

2/18/2018

18

3D EROA = 50 mm2

PISA EROA = 40 mm2Quantitative Doppler EROA = 51 mm2

2/18/2018

19

Repositioning required: Pacing used

2/18/2018

20

Complete Heart Block with lower position

Original Pacemaker Dislodged Removal of first Pacer

2/18/2018

21

2/18/2018

22