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Intraprocedural monitoring protocol using routine transthoracic echocardiography with backup transesophageal probe in transcatheter aortic valve replacement: a single center experience

Session Poster session 4

Speaker Stefano Stella

Congress : EuroEcho-Imaging 2016

  • Topic : valvular, myocardial, pericardial, pulmonary, congenital heart disease
  • Sub-topic : Aortic Valve Stenosis
  • Session type : Poster Session
  • FP Number : P980

Authors : S Stella (Milan,IT), I Rosa (Milan,IT), C Marini (Milan,IT), F Ancona (Milan,IT), A Latib (Milan,IT), M Monitorano (Milan,IT), A Colombo (Milan,IT), A Margonato (Milan,IT), E Agricola (Milan,IT)

S Stella1 , I Rosa1 , C Marini1 , F Ancona1 , A Latib2 , M Monitorano2 , A Colombo2 , A Margonato1 , E Agricola1 , 1San Raffaele Hospital of Milan (IRCCS), Division of Noninvasive Cardiology - Milan - Italy , 2San Raffaele Hospital of Milan (IRCCS), Interventional Cardiology Unit - Milan - Italy ,

European Heart Journal Supplements ( 2016 ) 17 ( Supplement 2 ), ii193

Background: Intraprocedural imaging in transcatheter aortic valve replacement (TAVR) relies on fluoroscopic guidance, with echocardiography used as a supportive imaging modality. Intraprocedural transthoracic (TTE) and transesophageal echocardiography (TEE) offer real-time imaging throughout the procedure and may contribute to improve procedural results by ensuring guidance, prompt complications detection and leak evaluation. However there are no evidences if a routine use of systematic intraprocedural TEE protocol vs. an on-demand TEE approach provides advantages in terms of cost/effectiveness in TAVR monitoring.

Aim:  To describe our 8-year experience in TAVR imaging monitoring using TTE as a routine intraprocedural imaging modality, with TEE as a backup.

Methods and Results: From 2008 to May 2016, 1042 patients underwent TAVR in our Institution. Almost all the procedures have been performed under conscious sedation. With the exception of the first 20 cases in whom TEE was routinely used, TAVR intraprocedural imaging monitoring relied on fluoroscopic guidance using TTE as a routine supportive imaging modality. Once the TTE evaluation resulted suboptimal for final result assessment or once a complication was either suspected or identified on TTE because of hemodynamic instability, presence of pericardial effusion without hemodynamic instability, cardiac arrest, or myocardial ischemia, TEE evaluation was promptly started under general anesthesia.

Only 22 (2.1%) cases required a switch to TEE. In more details the switch was due to suboptimal TTE leak quantification (6 pts, 27.2%); hemodynamic instability (9 pts, 41%: 2 cardiac tamponade due to aortic annular rupture, 1 peri-aortic hematoma, 1 severe acute mitral regurgitation due to papillary muscle rupture, 1 ventricular septal perforation, 2 ascending aorta dissections, 1 vagal response to pain, 1 severe acute paravalvular regurgitation); pericardial effusion without hemodynamic instability (2 pts, 9%: right ventricle perforation due to temporary pace-maker lead); prosthesis sizing in an emergent TAVR without previous CT scan (3 pts = 13.6%);  myocardial ischemia with hemodynamic instability (1 pt = 4.5%). In 2 cases of myocardial ischemia without hemodynamic instability, in 1 case of left ventricle outflow tract dynamic obstruction and in 4 cases of cardiac arrest with rapid return of spontaneous circulation and no evidence of pericardial effusion or coronary artery occlusion TTE evaluation was sufficient.

Conclusions: Our experience highlights that routine use of systematic TEE protocol may be considered not an essential part of TAVR procedure. TTE monitoring, not requiring general anesthesia, seems to provide a thorough imaging tool for intraprocedural monitoring for final results evaluation, not delaying the diagnosis of possible reversible complications. However, TEE is undoubtedly essential in identifying the exact mechanism in most of the complications.

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