1. 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

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

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

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

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

6. Aortic Valve Crossing
Aortic valve crossing
Guidewire positioning

7. Guidewire across the Mitral Valve

8. Balloon Valvuloplasty

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

10. Stent Deployment (Edwards Sapien)
Trans-femoral approach

11. Final Assessment

12. Better Valve Positioning New Imaging Systems

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

14. Detection of Complications
Severe AR
Tamponade …
LV obstruction
Coronary occlusion

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

16. Mild AR

17. Massive AR

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

19. Small Periprosthetic Leak

20. Massive Central AR

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

22. AR along the Guidewire

23. Structural Dysfunction

24. Native Valve Prolapse Impending Prosthesis

25. Prosthesis too Low

26. Underexpansion of the Valve

27. TEE after over expansion of an MCV

28. Could we perform TAVI without TEE/general anesthesia?

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

30. Loco Regional Anesthesia vs General Anesthesia (Bichat)
Dehédin et al J Cardiothorac Vasc Anesth
2011;25:

31. Loco Regional Anesthesia vs General Anesthesia (Bichat)
Dehédin et al J Cardiothorac
Vasc Anesth 2011;25:

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

34. 2011-12 pilot European Sentinel Registry
Di Mario et al Eur Heart J. In press

35. 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

36. STOP

37. Immediate Post-Implantation TEE

38. Position of the Valve
Post Delivery TEE

39. Prosthetic Positioning (CoreValve)
Stepwise Deployment

40. Prosthetic Positioning (CoreValve)
Stepwise Deployment

42. Immediate Result (Edwards Sapien)