(A) Accurate transthoracic echocardiography (TTE) measurement of the aortic annulus is essential to determine a patient's suitability for percutaneous heart valve (PHV) placement. Patients are deemed unsuitable if the aortic annulus is either too large (>26 mm) or (rarely) too small. The TTE image shows a zoomed-in parasternal long-axis view of the aortic annulus. The aortic annulus measures 24 mm. (B) Before PHV deployment, transesophageal echocardiography (TEE) is used to check the aortic annulus measurement obtained by TTE. A difference of up to 4 mm between the TTE and the TEE annulus measurements can occur and may lead to a change in device size. Transesophageal echocardiography long-axis image of the patient as shown in panel A shows the aortic annulus measured at 28 mm.

Important differences may exist between aortic annulus size as determined by either TTE or TEE. The red circles indicate larger dimensions by TTE; the black circles indicate agreement; the green circles indicate larger dimensions by TEE. Annular dimension was determined by TTE before PHV implantation and TEE dimension at time of implantation. Abbreviations as in Figures 1 and 4.

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Good awareness of the echocardiographic appearance of the undeployed PHV (stent) and its relation to the deployment catheter and balloon is critical to correct device positioning. (A) Transesophageal echocardiography long-axis view showing satisfactory stent position before deployment. The undeployed PHV is identified as an echogenic rectangular structure, which is seen in contrast to the larger and less echodense balloon. The ventricular (red arrow) and aortic (yellow arrow) ends of the stent are indicated in relation to the native aortic valve (blue arrow). Online Video 1 shows the ideal position for the stented PHV prior to deployment. (B) Long-axis view at the moment of balloon deployment of the PHV. The blue arrowheads indicate the balloon and yellow arrows the prosthesis. Online Video 2 shows deployment of the PHV by rapid balloon inflation. The final appearance of the deployed PHV is seen in panel C. The yellow arrows indicate the stent and the white arrow the prosthetic valve leaflet. The fully deployed PHV is shown in the short-axis view in Online Video 3. Online Video 4 shows imaging of the deployed prosthesis in the long-axis view. The prosthesis is in good position and no aortic regurgitation is seen. Abbreviations as in Figure 1.

Early assessment of paravalvular AR is an indicator of procedural success but may also help to determine the need for subsequent balloon dilatation of the PHV. (A) Transesophageal echocardiography showing mild paravalvular regurgitation (red arrow) in the long-axis view. (B) TEE showing mild paravalvular regurgitation (red arrow) in the short-axis view. It is the short-axis view that most reliably distinguishes paravalvular AR from transvalvular AR, especially if the vena contracta of the paravalvular jet is out of plane in the long-axis view. Online Video 5 shows a short-axis view of AR following PHV deployment. Paravalvular AR is seen at the 3 o'clock position along with a smaller jet of transvalvular AR. AR = aortic regurgitation; other abbreviations as in Figure 1.

Immediately after PHV deployment, paravalvular AR must be distinguished from transvalvular AR. The short-axis views may be especially useful in this instance. Transesophageal echocardiography showing mild valvular regurgitation (red arrow) in the long-axis (A) and short-axis (B) views. Abbreviations as in Figures 1 and 4.

Periaortic hematoma as a result of rupture of the lower descending thoracic aorta is an unusual complication of PHV deployment. In this instance the patient became hypotensive as the PHV assembly was being advanced through the abdominal and lower thoracic aorta. Contrast injection showed extravasation of dye, after which TEE was used to identify peri-aortic hematoma. Abbreviations as in Figure 1.

A PHV implantation has the potential to give excellent early morphologic and hemodynamic results. Transesophageal echocardiography long-axis views are shown before (A) and after (B) implantation of a PHV. Successful PHV implantation also leads to a marked early reduction in transaortic pressure gradient. Transaortic Doppler gradients in the same patient are shown before (C) and after (D) PHV implantation. Abbreviations as in Figure 1.

The grade of paravalvular and valvular AR tended to be higher in the early TEE assessment, although this was only significant for valvular AR (p = 0.02). (A) A comparison of paravalvular AR assessed by early TEE and TTE. (B) A comparison of valvular AR assessed by TEE and TTE. Less valvular AR was observed at post-implantation TTE assessment. Transesophageal echocardiography AR grade is the final grade at the end of the procedure. Transthoracic echocardiography refers to the grade of AR on the pre-discharge TTE. Abbreviations as in Figures 1 and 4.