Optimal prosthesis sizing in transcatheter aortic valve implantation by exclusive use of three-dimensional transoesophageal echocardiography

Transcatheter aortic valve replacement: Past, present, and future

Transcatheter aortic valve replacement (TAVR) has emerged as a ground-breaking, minimally invasive alternative to traditional open-heart surgery, primarily designed for elderly patients initially considered unsuitable for surgical intervention due to severe aortic stenosis. As a result of successful large-scale trials, TAVR is now being routinely applied to a broader spectrum of patients. In deciding between TAVR and surgical aortic valve replacement, clinicians evaluate various factors, including patient suitability and anatomy through preprocedural imaging, which guides prosthetic valve sizing and access site selection. Patient surgical risk is a pivotal consideration, with a multidisciplinary team making the ultimate decision in the patient's best interest. Periprocedural imaging aids real-time visualization but is influenced by anaesthesia choices. A comprehensive postprocedural assessment is critical due to potential TAVR-related complications. Numerous trials have demonstrated that TAVR matches or surpasses surgery for patients with diverse surgical risk profiles, ranging from extreme to low risk. However, long-term follow-up data, particularly in low-risk cases, remains limited, and the applicability of published results to younger patients is uncertain. This review delves into key TAVR studies, pinpointing areas for potential improvement while delving into the future of this innovative procedure. Furthermore, it explores the expanding role of TAVR technology in addressing other heart valve replacement procedures.

Comparison of postoperative outcomes following multidetector computed tomography based vs transesophageal echocardiography based annulus sizing for transcatheter aortic valve replacement: A systematic review and meta-analysis

BACKGROUND

The purpose of this paper was to evaluate the difference in postoperative outcomes following multidetector computed tomography (MDCT) and transesophageal echocardiography (TEE)-based annulus sizing for transcatheter aortic valve replacement (TAVR).

METHODS

Electronic search of PubMed, Biomed Central, Scopus, and Google Scholar databases was conducted until August 15, 2019. We included all types of studies comparing MDCT-based annulus sizing with TEE-based annulus sizing and assessing paravalvular regurgitation (PVR). Data were summarized using the Mantel-Haenszel odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

A total of six studies were included. Pooled analysis of 431 participants in the MDCT group and 509 participants in the TEE group demonstrated that MDCT-based annulus sizing is associated with a significantly lower incidence of more than moderate PVR as compared to 2DTEE-based sizing (OR: 0.31, 95% CI: 0.18-0.54, P < .0001; I2  = 0%). There was no statistical difference in annulus rupture (OR: 0.57, 95% CI: 0.12-2.66, P = .91; I2  = 0%), procedural mortality (OR: 0.97, 95% CI: 0.19-4.86, P = .97; I2  = 0%), and 30-day mortality (OR: 0.63, 95% CI: 0.26-1.50, P = .29; I2  = 0%) with MDCT or 2DTEE-based annulus sizing. Compared with 3DTEE, the incidence of PVR in the MDCT group was lower, but there was no statistical difference in 30-day mortality.

CONCLUSION

Use of MDCT in comparison with 2DTEE is associated with significantly lower incidence of more than moderate PVR after TAVR. There seems to be no difference in annulus rupture and 30-day mortality with either imaging modality.

Left atrial appendage morphology, echocardiographic characterization, procedural data and in-hospital outcome of patients receiving left atrial appendage occlusion device implantation: a prospective observational study

Background

Implantation of left atrial appendage (LAA) occlusion devices was shown to be a feasible and effective alternative to oral anticoagulation in patients with non-valvular atrial fibrillation. However, only few data about in-hospital and peri-procedural data are currently available. This study aims to report about echocardiographic, procedural and in-hospital data of patients receiving LAA occlusion devices.

Methods

This single-center, prospective and observational study includes consecutively patients being eligible for percutaneous implantation of LAA occlusion devices (either Watchman™ or Amplatzer™ Cardiac Plug 2). Data on pre- and peri-procedural transesophageal echocardiography (TEE), implantation and procedure related in-hospital complications were collected. The primary efficacy outcome measure was a successful device implantation without relevant peri-device leaks (i.e., < 5 mm).

Results

In total, 37 patients were included, 22 receiving the Watchman™ and 15 ACP 2 device. Baseline characteristics did not differ significantly in both patient groups. The primary efficacy outcome measure was reached in 91.9 % of patients (90.9 % for the Watchman™, 93.3 % for the ACP 2 group). One device embolization (Watchman™ group) with successful retrieval occurred (2.7 % of patients). No thromboembolism or device thrombosis were present. The majority of bleedings was caused by access site bleedings (88.3 % of all bleedings), consisting mostly of mild hematomas corresponding to a BARC type 1 bleeding (80.0 % of all access-site complications). One patient died due to septic shock (non-procedure related).

Conclusions

In daily real-life practice, percutaneous treatment with LAA occlusion devices appears to be an effective and safe.

Accuracy and reproducibility of novel echocardiographic three-dimensional automated software for the assessment of the aortic root in candidates for thanscatheter aortic valve replacement

AIMS

A specialized three-dimensional transoesophageal echocardiography (3D-TOE) reconstruction tool has recently been introduced; the system automatically configures a geometric model of the aortic root from the images obtained by 3D-TOE and performs quantitative analysis of these structures. The aim of this study was to compare the measurements of the aortic annulus (AA) obtained by the new model to that obtained by 3D-TOE and multidetector computed tomography (MDCT) in candidates to transcatheter aortic valve implantation (TAVI) and to assess the reproducibility of this new method.

METHODS AND RESULTS

We included 31 patients who underwent TAVI. The AA diameters and area were evaluated by the manual 3D-TOE method and by the automatic software. We showed an excellent correlation between the measurements obtained by both methods: intra-class correlation coefficient (ICC): 0.731 (0.508-0.862), r: 0.742 for AA diameter and ICC: 0.723 (0.662-0.923), r: 0.723 for the AA area, with no significant differences regardless of the method used. The interobserver variability was superior for the automatic measurements than for the manual ones. In a subgroup of 10 patients, we also found an excellent correlation between the automatic measurements and those obtained by MDCT, ICC: 0.941 (0.761-0.985), r: 0.901 for AA diameter and ICC: 0.853 (0.409-0.964), r: 0.744 for the AA area.

CONCLUSION

The new automatic 3D-TOE software allows modelling and quantifying the aortic root from 3D-TOE data with high reproducibility. There is good correlation between the automated measurements and other 3D validated techniques. Our results support its use in clinical practice as an alternative to MDCT previous to TAVI.