Is Transoesophageal Echocardiography during TAVR Essential?

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Presentation transcript:

Is Transoesophageal Echocardiography during TAVR Essential? CHU Bichat - Claude Bernard Is Transoesophageal Echocardiography during TAVR Essential? Alec Vahanian, MD Cardiology Department Hospital Bichat University Paris VII Paris

Alec Vahanian, MD Consulting: Edwards Lifesciences, LLC Honoraria: Abbott Vascular Medtronic, Inc. Valtech

Multimodality Imaging Fluoro / Angiography Echocardiography TEE under general anesthesia TTE under local anesthesia ICE under local anesthesia

Goals of Imaging during TAVI During the procedure procedure guidance detection of complications After the procedure Result assessment

Guidance of the Procedure Aortic valve crossing Guide positioning Balloon valvuloplasty Prosthetic positioning and deployment Immediate result assessment

Aortic Valve Crossing Aortic valve crossing Guidewire positioning

Guidewire across the Mitral Valve

Balloon Valvuloplasty

Stent Positioning (Edwards Sapien) Moss R et al JACC Imag. 2008;1: 15-24

Stent Deployment (Edwards Sapien) Trans-femoral approach

Final Assessment

Better Valve Positioning New Imaging Systems

Goals of Imaging during TAVI During the procedure procedure guidance detection of complications After the procedure Result assessment

Detection of Complications Severe AR Tamponade … LV obstruction Coronary occlusion

TAVI and AR Confirm the severity Locate the AR: central or paravalvular Check the function and deployment of the prosthesis

Mild AR

Massive AR

TAVI and AR Confirm the severity Locate the AR: central or paravalvular Check the function and deployment of the prosthesis

Small Periprosthetic Leak

Massive Central AR

TAVI and AR Confirm the severity Locate the AR: central or paravalvular Check the function and deployment of the prosthesis

AR along the Guidewire

Structural Dysfunction

Native Valve Prolapse Impending Prosthesis

Prosthesis too Low

Underexpansion of the Valve

TEE after over expansion of an MCV

Could we perform TAVI without TEE/general anesthesia?

Loco Regional Anesthesia without TEE for All The Rouen Experience Durand et al JACC Cardiovasc Interv 2012;5:461-7

Loco Regional Anesthesia vs General Anesthesia (Bichat) Dehédin et al J Cardiothorac Vasc Anesth 2011;25:1036-43

Loco Regional Anesthesia vs General Anesthesia (Bichat) Dehédin et al J Cardiothorac Vasc Anesth 2011;25:1036-43

FRANCE 2 Procedural characteristics 69.0 % General anesthesia, % Per-procedure TEE, % 61.3 %

2011-12 pilot European Sentinel Registry Di Mario et al Eur Heart J. In press

Conclusions In the early experience general anesthesia and TEE guidance are recommended Then the Heart Team could move towards simplification of the procedure: loco regional anesthesia, abandoning of radial artery /urinary catheters in « simple cases » then as a default approach Loco regional anesthesia does not mean absence of an anesthetist TEE should be available in both transapical and transaortic approach and in cases of complication especially severe AR

STOP

Immediate Post-Implantation TEE

Position of the Valve Post Delivery TEE

Prosthetic Positioning (CoreValve) Stepwise Deployment

Prosthetic Positioning (CoreValve) Stepwise Deployment

Immediate Result (Edwards Sapien)