Echo for new transcatheter
interventions for valvular heart
disease
1

Echocardiography for transcatheter aortic
valve implantation
• currently being assessed in the treatment of patients with severe
aortic stenosis who are at high risk from conventional open surgery
• Procedural success rates of 75–88% have previously been published,
in association with reduction in aortic valve mean pressure gradients
from 37–46 to 9 mmHg
2

3

CoreValve prosthesis
4

• prosthetic size is determined by the external diameter of the ventricular
end the 26 and 29 mm size prostheses have mid-portion diameters of 22
and 24 mm, aortic end-diameters of 40 and 43 mm, and prosthetic
lengths of 55 and 53 mm, respectively
5

Edwards–Sapien prosthesis
6

• Valve size is determined by the external diameter of the cylinder-the 23
and 26 mm prostheses have relatively short lengths of 14.2 and 16.1
mm, respectively
• ventricular two-thirds of the prosthesis has a skirt to prevent paravalvar
regurgitation-the coronary ostia must therefore be at least 10 or 11 mm,
respectively, above the AVA to avoid obstruction by the skirt
7

• SOURCE registry
• Overall short term procedural success 93.8%
• 30 day mortality was 6.3%(transfemoral) & 10.3%(trans apical)
8

Role of echocardiography in anatomical
case selection
• patients with severe aortic stenosis, defined by an AV effective orifice
area (EOA) of <1 cm2, mean AV gradient of >40 mmHg, or AV peak
systolic velocity of >4 m/s.
• CoreValve-EOA of <1 cm2
• Edwards-EOA of < 0.8 cm2.
unicuspid and bicuspid valves are contraindicated
9

10

11

12

Aortic root geometry
CoreValve
• 26 mm - native AVA 20–23 mm,
SOV of 27 mm,
STJ 40 mm, and
AVA-coronary ostial
distance of 14 mm.
• 29 mm : AVA 24–27 mm,
SOV 28 mm,
STJ or ascending aorta
of 43 mm,
AVA-coronary ostial
distance of 14 mm
Edwards–Sapien
• 23 mm - native AVA 18–21mm ,
and an AVA coronary ostial height
of >10 mm.
• 26 mm -AVA diameter of 22–24.5
mm and an AVA-ostial height of
>11 mm
13

• Undersizing – device migration , PVR, mismatch
• Oversizing – vascular access complications, difficult native valve
crossing, underexpansion (folds)-central AR
14

• Length of the cusps measured in long axis view.
• Rt coronary ostial-annular distance measured by 2d TEE
• Characteristics of asc aorta ,arch & des thoracic aorta
15

• SOV diameter and AVA-ostial height requirements-reflect the clearance
necessary to avoid occlusion of the coronary ostia by TAVI-displaced
native valve material or the prosthetic skirt
• STJ and ascending aorta diameters are specific for ensuring that the
aortic end of the CoreValv has sufficient anchorage to prevent
embolization
16

17

Subaortic geometry
• CoreValve Inc. recommends that the implantation should not be
performed if subaortic disease is sufficient to cause stenosis or if the
septal wall thickness of >17 mm
18

• co-exist with AV stenosis and take the form of protruberant calcification
extending from the AVA into the LVOT or the anterior mitral leaflet, or
moderate–severe hypertrophy of the septal walls - risk of low
deployment and its complications
• HOCM- contraindicated ( prosthesis displacement).
19

• Mitral regurgitation of more than grade 2 severity is a contraindication
for CoreValve- LV component of the prosthesis can potentially interfere
with mitral function by disrupting the secondary chordae or restricting
anterior leaflet mobility
20

• Stress TTE is used to diagnose the flow-limitation in proximal coronary
stenoses of 70% (CoreValve exclusion) or large areas of ischaemic
burden (Edwards exclusion) that will exclude patients
21

• LV ejection fraction of <20% is a TAVI contraindication
• Patients with low ejection fractions but mean AV gradients of >40
mmHg at rest, may still have sufficient contractile reserve to undergo
valve replacement
22

• Those patients with low ejection fractions and mean gradients of
<40 mmHg can be risk stratified by Dobutamine stress
echocardiography the subset with LV contractile reserve during stress
may be suitable for TAVI
23

• detecting the sources of cardiovascular embolism, and the procedure
should not be performed in patients with thrombus in the left heart
chambers
24

Role of echocardiography in procedural
guidance
• Marking the position of lv apex to guide thoracotomy.
• 2 views
• Surgeon & echocardiorapher on the same side
• No movement after marking
25

AV Crossng
AV crossing points can be
imaged in the 30–50o AV
short-axis and 110–
150°long-axis scan planes.
Biplane or X-plane TOE
can be helpful in
identifying the
appropriate approach to
the orifice, particularly
when combined with
fluoroscopic data
26

BAV
• Successful or unsuccessful inflation and de-waisting of the balloon is
documented
• Systolic motion of the balloon caused by LV ejection should not be
seen during balloon inflation and deflation.
• Full deflation should be confirmed prior to retrieval.
• In patients with small roots, native valve material can cause
posterior root tenting
• TEE to know stable position & if cor ostia are near
27

28

Deployment
• CoreValve prosthesis requires precise placement with the ventricular
end 5–10 mm below the native AVA-easily identified on TOE.
• As the delivery catheter is withdrawn, TOE is used to closely observe
the emergence and expansion of the ventricular end of the
prosthesis.
• The device has a high radial force at its LV end and may forcefully
descend into the LVOT as it expands against the rigid AVA.
• The partially deployed prosthesis may therefore adopt a low position
that may affect mitral valve function.
29

Prosthesis too low
• Impinge on MV apparatus
• Native valve cusps fold over the top
Prosthesis too high
• Migrate in aorta
• Obstruct ostia
• Signif pvr
30

31

32

Manual adjustment in
the position is
required so that the LV
rim of the prosthesis
covers ,50% of the
anterior mitral leaflet
and lies above the
attachment of the
secondary chordae to
the leaflet The
aortic end is then
deployed and the pros
33

• Smaller than expected dimensions indicate suboptimal expansion, and
prosthetic balloon valvuloplasty can be performed.
• Valvuloplasty should be avoided if TOE shows the presence of native
valve material adjacent to the coronary ostia.
34

• Edwards–Sapien prosthesis is manipulated across the AV to a position
parallel to the long axis of the root within the AVA.
• The device may migrate towards the aorta for up to 5 mm during
deployment, and the optimal position of the prosthesis requires the
ventricular end to be positioned up to 2 - 4 mm below the native AVA, a
point just ventricular to the anterior mitral leaflet hinge.
• The aortic end should be close to the tips of the native AV leaflets
35

36

COMPLICATIONS:
• Coronary Occlusion, Mitral valve dysfunction, Prosthetic dysfunction,
Loss of blood, Cardio-Aortic Trauma, and Stroke
37

• Perioperative cardiopulmonary resuscitation for loss of cardiac output
may be expected in 11% of patients
• Rapid ventricular pacing may induce ventricular fibrillation in 2.5% of
cases.
• Myocardial infarction or coronary occlusion is seen in 1.5% of CoreValve
and 2% of Edwards TAVIs.
• Aortic dissection and perforation is seen in 1.4to 2% of cases.
• Acute vascular injury may be expected in 1.9 to 6% of procedures.
• Bradyarrhythmias resulting in permanent pacing have not been reported
following the Edwards implant, but this is an outcome in 11% of
CoreValve implants
38

• Early assessment of PVR is crucial ( undersized prosthesis)
• Significant transvalvular aortic regurgitation suggests overexpansion of
the prosthesis, which may require deployment of a second prosthetic
valve within the first.
39

• Following prosthetic valve deployment, TEE can immediately assess
prosthetic valve position in relation to the LV outflow tract and aortic
valve plane , prosthetic valve leaflet mobility, valve area, and
gradients and presence of central and PV regurgitation
40

Paravalvular AR
• occur if the fabric cuff is not approximated to the plane of the
annulus.
• Even with correct device positioning, AR may occur at sites adjacent
to areas of leaflet compression where accumulated nodular calcium
and leaflet tissue mean that a snug seal cannot be obtained.
41

42

• graded higher by TEE than by early postprocedural TTE.
• due to interpretative differences between the 2 imaging techniques,
• restitution of leaflet shape after initial balloon deformation
• thrombosis in the zone between the crushed aortic valve leaflet and
stent
43

• traditional echocardiographic approaches to quantitating paravalvular
AR may be limited
• vena contracta of the paravalvular AR jet is either crescentic in shape or
consists of multiple small jets
• An ideal solution would be to volumetrically determine regurgitant
fraction and regurgitant volume
• Pressure half-time determination of AR severity is limited in that it
reflects aortic and ventricular compliance as well as orifice area, and like
the other techniques, is unvalidated in this setting
44

• most common site of regurgitation is in relation to the posterior aspect
of the stent -may occur in any part of the circumference of the annulus
45

46

EVALUATION OF HYPOTENSION
• TEE provides a rapid early assessment of changes in global left
ventricular systolic function, mitral regurgitation, and the presence or
absence of regional wall motion abnormalities
47

48

FOLLOW UP
• Calculation of EOA or other indices of valve opening (ratio of pre to
post valvular velocities)
• Flow acceleration in stent prox to valves ( overestimation of valve
areas)
• Accurate quantification of AR ( central & PVR)
• Central (<25% , 26 – 64% ,>65%)
• PVR (<10%, 10- 20%, >20%)
• Excessive rocking of the prosthesis (>40% dehiscence)
49

PERCUTANEOUS TRANSCATHETER REPAIR OF
PVR
CAUSES
Dehiscence of sutures
Infection
Annular calcification
Friable tissue at site of suturing
• common in mitral
• Rashkind umbrella, cardioseal device, amplatzer septal occluder, duct
occluder
• Defects are irregular & multiple ( so 3DTEE )
• Significant hemolysis
50

Echocardiography in paravalvular leak
repair
• seen with mechanical and bioprosthetic valves
• Interrogation in multiple angles including off-axis views is required to
determine the location and severity of the regurgitation
• Doppler flow outside the sewing ring of the valve, often in an
eccentric direction
51

• Because of artifacts and reverberations, prosthetic MV PV regurgitation,
however, may be missed on TTE, and TEE is required for diagnosis,
location, and assessment of severity
• TEE helps evaluate contraindications to percutaneous closure of PV
leaks, such as
mechanical instability of the prosthetic valve
intracardiac thrombus
endocarditis
52

• Actual area of dehisence as echo dropout outside the sewing ring.
53

• Location of dehiscence is best described in relation to internal
landmarks like LAA, AV & crux of heart.
54

• Jet area & jet width are the commonly used parameters
• Flow convergence area in aortic root is carefully sought.
• PW of pulm veins pattern is useful (systolic retrograde flow)
• Transgastric view , valve ring in short axis , provides enface view of
entire circumference
• 3D TEE
55

56

57

• Aortic prosthetic PVR
• 2D TEE less successful.
• Anterior aspect of the valve ring is frequently obscured
• Location of the coronary ostia are routinely assessed
58

59

60

61

62

63

64

• If the dehiscence is large ( >25% of circumference) single device is
insufficient & high risk of device embolisation , rocking
65

66

67

MANAGEMENT OF MS-Mitral Balloon
Valvuloplasty
• May delay or avoid surgery
• 80% patients have long term relief of symptoms
• 7% restenosis rate at 7 years
• ECHO to determine ‘pliability’,MR
• Wilkins score, cormier’s method

Guiding the Procedure and Detecting Acute
Complication
• During the percutaneous valvotomy procedure,
echo-Doppler studies can be
 Valuable in helping guide the transeptal
puncture.
 Assessing acute complications such as
 Atrial or ventricular perforation with
tamponade
 Acute mitral regurgitation
 Valvular disruption.

Evaluating the short- and long-term results of the intervention.
 Immediate Complications
 Mitral regurgitation
1. In 50% doesn’t change , by 1 grade in another 33% , by 2
grades in remainder
2. No preprocedure clinical. hemodynamic. or morphologic
characteristic is useful in predicting patients in whom
regurgitation is likely to appear or increase
3. Large balloon diameters did increase regurgitation
 ASD
1. 15-89%(ECHO> hemodynamic series)

Evaluating the short- and long-term results of the intervention.
 Assessment of valve area
• Planimetry ideal , half time shoudnt be used
 Long term results
• Assessment can be done by all methods with predictors
of restenosis being echo score and valve area following
procedure

ECHOCARDIOGRAPHY IN MV REPAIR
• provides accurate quantification of MR severity and is able to
determine etiology of MR as degenerative, ischemic, or functional
• Quantitative assessment of MR by vena contracta and measurement
of effective regurgitant orifice area and regurgitant volume is now
the gold standard for MR quantitation
72

73

74

• PERCUTANEOUS ANNULOPLASTY TECHNIQUES
• To revert mitral leaflet coaptation abnormalities & asso MR
• Functional or ischemic MR
• Annular dilation or deformation is predominant
• Symmet leaflet tethering due to LV remodelling or leaflet coaptation
loss due to annular dilation
75

NOT SUITABLE
• Extreme asymmetrical tethering
• Struc MV abnorm
• Prolapse , flail, rupture chordae, fibrotic &calcific restriction, annular
calcification
76

• CS annuloplasty – reshapes the AP annular dimension to correct
leaflet apposition –coaptation abnormality
• Anat relation between CS & post annulus
• Placing device in CS to attempt sept- lat diameter red & annulus
clinching
• TTE and TEE - determine acute or chronic mitral annular diameter
reduction with coronary sinus stent placement and its effect on MR
severity.
• assessment of coronary sinus length and its relation to the mitral
annulus and to the circumflex coronary artery remains difficult by
TEE (CT scan)
77

MITRAL LEAFLET REPAIR
78

• MITRACLIP system is a polyester fabric-covered cobalt chromium
implant with 2 arms.
• Functional MR ( flail or prlapsed leaflets) & degenerative MR (tethered
leaflets)
• Tissue bridge bet leaflets , limits annular dilat
• Restrains LV wall by restricting LV dilat
Clinical indications
• High risk for surgery
• Previous cardiac surgery
• Who decline surgery
79

• TTE often provides limited information on valve reparability.
• Three dimensional TTE may improve MV assessment although
resolution of 3D TTE remains an important limitation
• MR jet origin in the short-axis-evaluate location and severity of
pathology and complements information obtained by long-axis views
• screening by echocardiography involves measurement of coaptation
depth and coaptation length in ischemic MR and of flail gap and flail
width in degenerative MR
80

81

82

83

• Percutaneous MV repair technique by the edge-to-edge technique aims
to repair MR originating from the A2 and P2 scallops of MV rather than
commissures or posteriorly or anteriorly located MV scallops.
• TEE evaluates location of diseased mitral scallop/s by using 2D and color
Doppler in multiple imaging planes by location of flow convergence and
by assessment of site of origin of MR jet.
84

85

86

87

88

• Puncture site should sit 3.5 – 4.0 cm above the leaflets
89

90

91

92

93

94

• percutaneous MV repair is the edge-to-edge technique, which creates a
double MV orifice replicating the surgical intervention
• success rate of the technique is high (80% to 90%), and the degree of
MR can be reduced to mild in two-thirds of cases
95

96

TEE -confirms the final MR grade and size of residual atrial septal defect
detection of procedural complications –
• Leaflet tear
• Partial dehiscence of clip
• development of thrombus on catheters
• pericardial effusion (atrial wall perforation)
• tangling of device with chordae.
• Mirtal stenosis
• Residual MR severity during follow-up, device stability and effect on LV
size and function, and pulmonary artery pressure
97

98

• MR severity during follow-up, device stability and effect on LV size
and function, and pulmonary artery pressure
• Colour doppler using semiquantitative tech based on regurg jet
dimen & use of 3D TEE to planimeter regurg orifices are best suited
for long term followup
99

THANK U
100