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Role of Echocardiography in Percutaneous Aortic Valve Implantation

Robert R. Moss, MB, BS^_*,,_*,_*, Emma Ivens, MB, BS^_*,, Sanjeevan Pasupati, MB, ChB^_*,, Karin Humphries, PhD^_*,,, Christopher R. Thompson, MD, CM^_*,, Brad Munt, MD^_*,, Ajay Sinhal, MD^_*,, John G. Webb, MD^_*,

^_* Division of Cardiology
Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital
University of British Columbia, Vancouver, British Columbia, Canada

^_* Reprint requests and correspondence: Dr. Robert R. Moss, St. Paul's Hospital, Room 474 Burrard Building, 1081 Burrard Street, Vancouver V6Z1Y6 BC Canada (Email: rmoss{at}providencehealth.bc.ca).

Objectives: This study was designed to investigate the usefulness and limitations of echocardiography in optimizing the outcome of percutaneous aortic valve implantation.

Background: Percutaneous aortic valve implantation is an emerging technique that has the potential to revolutionize the treatment of aortic valve disease. To date, however, the technique has been limited by technical constraints. Precise positioning of the valve is essential to minimize the potential for paravalvular regurgitation or device migration. Initial experience with device placement utilized fluoroscopic guidance only.

Methods: Candidates for percutaneous aortic valve implantation were evaluated with transthoracic echocardiography (TTE) to assess aortic annular dimension and aortic valve hemodynamics. Fifty consecutive patients were deemed suitable for percutaneous aortic valve implantation. Seventy-four percent (37 of 50) of patients underwent transesophageal echocardiography (TEE) during the procedure.

Results: Eighty-six percent (43 of 50) of patients had successful implantation, of which 77% (33 of 43) had TEE. Transthoracic echocardiography was used to determine annular dimension and was useful in guiding correct device sizing. Transesophageal echocardiography was able to successfully guide device implantation in 97% (33 of 34) of patients in whom the native valve was crossed with the percutaneous heart valve. Transesophageal echocardiography was used for the early detection of paravalvular aortic regurgitation (AR) and complemented fluoroscopy in the detection of complications. Additional balloon dilatation of the percutaneous heart valve was performed in 12 patients because of significant paravalvular AR, with 7 showing improvement in AR grade. After the procedure, early outcomes were evaluated using TTE. All patients in whom the device was successfully placed (43 of 50) had improvement in their aortic stenosis. Paravalvular AR, although present in many patients, is usually mild and has not emerged as a significant problem.

Conclusions: Echocardiography has an important role in case selection, in guiding device placement, and in detecting complications of percutaneous aortic valve implantation.

Abbreviations and Acronyms   AR = aortic regurgitation   PHV = percutaneous heart valve   TEE = transesophageal echocardiogram/echocardiography   TTE = transthoracic echocardiogram/echocardiography

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