Catheterization and Cardiovascular Interventions 00:00–00 (2014)
Case Report Intracardiac Echocardiography-Guided Transcatheter Aortic Valve Replacement Mitul B. Kadakia, MD, Frank E. Silvestry, MD, and Howard C. Herrmann,* MD, FSCAI Echocardiographic imaging is an essential component of successful transcatheter aortic valve replacement (TAVR). Currently, transesophageal echocardiography (TEE) is the imaging modality of choice for TAVR. However, a limitation of TEE is the need for general anesthesia and endotracheal intubation in most centers. Additionally, the TEE probe can obscure fluoroscopic views during valve positioning and deployment. Intracardiac echocardiography (ICE) has been used for imaging guidance for structural and valvular intervention, though its use has rarely been reported for primary imaging guidance during TAVR. Recently, a new volumetric three-dimensional intracardiac ultrasound (volume ICE) system has become available with the potential for improved visualization of intracardiac structures. We describe a recent TAVR case that was successfully performed with the use of volume ICE exclusively for imaging guidance. We found that assessment of valve positioning and aortic insufficiency were comparable to that provided by conventional TEE imaging, though there were several important limitations. ICE-guided TAVR may represent an important alternative to TEE for TAVR imaging guidance and possibly allow for less-intensive sedation or anesthesia. VC 2014 Wiley Periodicals, Inc.
Key words: intracardiac echo; valvular heart disease; aorta
INTRODUCTION
Echocardiographic imaging is an essential component of successful transcatheter aortic valve replacement (TAVR). It is used to determine the appropriate prosthetic valve sizing, positioning of the prosthesis, assessing valvular and paravalvular aortic insufficiency (AI) postimplantation, and for identifying possible procedural complications. Initially, transesophageal echocardiography (TEE) was the imaging modality of choice for TAVR as it provides excellent image quality for precise real-time procedural guidance. Recently, real-time threedimensional (3D) TEE has also been used for guidance of TAVR [1–3]. A limitation of TEE is the need for general anesthesia and endotracheal intubation in most centers, although successful TEE-guided TAVR performed under conscious sedation has been reported [4]. In addition, during prosthetic valve positioning and deployment, the TEE probe may need to be repositioned in the esophagus so as not to obscure the fluoroscopic image. As a result, simultaneous fluoroscopic and echocardiographic guidance can be difficult to achieve in all patients. C 2014 Wiley Periodicals, Inc. V
Additional Supporting Information may be found in the online version of this article. Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Conflict of interest: Dr. Herrmann receives research funding to the institution from Edwards Lifesciences, Inc., Siemens Medical Inc., and from an anonymous foundation supporting research in valvular heart disease. He is also a consultant to Siemens Medical, Inc. and Edwards Lifesciences, Inc. Dr. Kadakia and Dr. Silvestry have no relevant disclosures. *Correspondence to: Howard C. Herrmann, MD, FSCAI, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104. E-mail: [email protected] Received 9 February 2013; Revision accepted 20 January 2014 DOI: 10.1002/ccd.25409 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com)
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Kadakia et al.
Intracardiac echocardiography (ICE) is an alternative modality for imaging guidance for a variety of structural and valvular interventions [5–8]. ICE can be performed under conscious sedation without the need for endotracheal intubation and may decrease procedure and fluoroscopy time in addition to improving patient comfort. As it does not obscure fluoroscopic views, it can be used simultaneously with fluoroscopy during positioning and deployment of the transcatheter valve. Recently, a new volumetric 3D intracardiac ultrasound (volume ICE) system has become available with the potential for improved visualization of intracardiac structures (AcuNav V, Siemens Acuson, Mountain View, CA) that allows for 2D color Doppler and 3D volumetric imaging in real time. In this report, we describe a TAVR procedure guided exclusively by volume ICE imaging.
obtained by bringing the probe to the level of the tricuspid valve annulus. Preprocedure AI, valve calcification, leaflet motion, and aortic annulus size were assessed. (Fig. 1a–d). Volume ICE was then used to guide balloon valvuloplasty prior to valve placement (Fig. 2). Once the valve was positioned, ICE was used to qualitatively confirm adequate clearance from the coronary ostia on the aortic side and clearance from the mitral valve leaflets on the ventricular side. Threedimensional images were also obtained. Following implantation, we were able to visualize proper positioning of the new valve within the aortic annulus (Fig. 3a and b). The presence of central and paravalvular AI was assessed, and a mild paravalvular leak was observed posteriorly (Fig. 4a and b). Finally, the ICE probe was advanced into the right ventricle to evaluate LV function postprocedure.
CASE REPORT
DISCUSSION
The patient is an 82-year-old male with a history of coronary artery disease treated with prior percutaneous coronary intervention to a diagonal coronary artery, hypertension, hyperlipidemia, chronic kidney disease (baseline creatinine 2.1 mg/dL), atrial fibrillation treated with warfarin, pyoderma gangrenosum on chronic immunosuppression, obstructive sleep apnea, and moderate chronic obstructive pulmonary disease, who had been experiencing increasing fatigue and dyspnea on exertion. His STS score was 14.996%. Preprocedure echocardiography revealed a left ventricular (LV) ejection fraction of 45–50%, an aortic valve mean gradient of 36 mm Hg, and an aortic valve area of 0.77 cm2. Preoperative evaluation revealed that he had an aortic annulus of 25–26 mm necessitating a 29 mm valve. He was enrolled in the PARTNER 2A trial nested registry for a transapical Edwards Sapien XTTM 29 mm valve (Edwards Lifesciences, Irvine, CA). He also consented to participate in an IRB-approved single-center registry for ICE imaging during TAVR procedures (ClinicalTrials.gov, NCT01669551). In the hybrid operating room, the patient underwent general anesthesia and endotracheal intubation. A TEE probe could not be successfully advanced into the esophagus. A decision was made to proceed utilizing ICE alone for imaging and guidance during the procedure with transthoracic echocardiography backup if needed. A 10F AcuNav V catheter with imaging on an SC2000 platform was advanced from the right femoral vein to the right atrium (RA). With counterclockwise rotation and anterior flexion of the catheter, a longitudinal view of the left ventricular outflow tract (LVOT), aortic valve, aortic root, and sinotubular junction was obtained. Short-axis views of the aortic valve were
We were able to successfully complete the procedure solely with ICE guidance demonstrating the feasibility of performing TAVR safely and effectively without the need for TEE. Imaging guidance with the use of ICE is an important step in moving toward performing TAVR under conscious sedation without endotracheal intubation. This has the added potential to decrease length of hospital stay and improve patient comfort. ICE has successfully been used for imaging guidance in numerous structural and electrophysiology procedures, including atrial septal defect closures, transseptal puncture, balloon valvuloplasty, and complex ablations. The use of ICE during TAVR has been reported in a European study which found that ICE provided comparable procedural imaging guidance to TEE [9]. However, this has not yet been reported in the United States, and there have been no reports of the use of volume ICE for TAVR with the potential for improved imaging and image manipulation. By the use of orthogonal views, volume ICE offers the potential for improved accuracy in sizing the LVOT and aortic annulus as compared to 2D ICE. However, true long-axis views of the aortic valve, annulus, and outflow tract are difficult to obtain, and, thus, annular and coronary height measurements are not as accurate as those obtained by preprocedure multislice computed tomography (MSCT) [10]. This technology also affords 3D localization of paravalvular AI. We found that the assessment of valve positioning and paravalvular and transvalvular AI was comparable to that provided by conventional 2D and 3D TEE imaging. However, complete assessment of paravalvular AI may be limited by shadowing in the LVOT that can affect visualization of the substent
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
ICE-Guided TAVR
Fig. 1. (a–d) The aortic valve viewed in long axis with the volume ICE probe in the RA. Significant calcification and restricted motion of the aortic valve (*) is observed both on 2D (Fig. 1a) and 3D (Fig. 1b) images. Color Doppler demonstrates turbulent, high-velocity flow across the stenotic valve (Fig. 1c). Measurement of the aortic annulus in long axis (Fig. 1d, left panel) demonstrates an annular diameter of 2.65 cm. Mea-
3
surement of the annulus in short axis demonstrates a major axis diameter of 2.67 cm and minor axis diameter of 2.61 cm (Fig. 1d, right panel). (RA 5 right atrium, LVOT 5 left ventricular outflow tract, LV 5 left ventricle). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary. com.]
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
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Kadakia et al.
Fig. 2. 3D long-axis view of the aortic valve demonstrating the balloon valvuloplasty wire(*) across the aortic valve prior to valvuloplasty. (RA 5 right atrium, LVOT 5 left ventricular outflow tract, LV 5 left ventricle, RV 5 right ventricle). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 4. (a and b) 2D long-axis (Fig. 4a) and short-axis (Fig. 4b) views of the newly deployed Edwards Sapien aortic valve with color Doppler demonstrating mild, posteriorly directed paravalvular aortic regurgitation postimplantation. A vena contracta width of 0.29 cm is consistent with mild aortic regurgitation. (RA 5 right atrium, LVOT 5 left ventricular outflow tract, LV 5 left ventricle). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 3. (a and b) 3D long-axis (Fig. 3a) and short-axis (Fig. 3b) views following deployment of the Edwards Sapien aortic valve. The accurate position of the valve and stent struts (*) can be assessed within the aortic annulus. (RA 5 right atrium, LV 5 left ventricle). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
region. This may be addressed by advancing the ICE catheter into the right ventricle and imaging the LVOT through the interventricular septum. We did not routinely enter the right ventricle to assess the LVOT with the ICE catheter and thus this was not evaluated in our study. Limitations of the volume ICE catheter include the lack of continuous wave Doppler and, consequently, the inability to accurately obtain aortic valve gradients. The 3D color mapping capabilities are not as robust as those of 3D TEE. Precise annular and coronary height measurements are more limited than those obtained with TEE. Orthogonal long-axis views can be difficult to obtain, also affecting the ability to make accurate measurements. As the ICE catheter is imaging from the right side of the heart visualization of far field structures can be suboptimal. ICE does require additional venous vascular access and one must use caution in the setting of pacemaker/defibrillator leads.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
ICE-Guided TAVR
Additionally, it may require the interventionalist to focus on an additional task during the procedure.
4.
CONCLUSIONS
Future improvements in the volume ICE imaging catheter to provide a wider field of view will likely further enhance the capability of this imaging modality. In combination with preprocedure MSCT, we believe that ICE-guided TAVR has the potential to be a viable alternative to TEE guidance and could allow for lessintensive sedation or anesthesia.
5.
REFERENCES
8.
1. Janosi RA, Kahlert P, Plicht B, et al. Guidance of percutaneous transcatheter aortic valve implantation by real-time three-dimensional transesophageal echocardiography–A single-center experience. Minim Invasive Therapy Allied Technol 2009;18:142– 148. 2. Siegel RJ, Luo H, Biner S. Transcatheter valve repair/implantation. Int J Cardiovasc Imaging 2011;27:1165–1177. 3. Smith LA, Dworakowski R, Bhan A, et al. Real-time threedimensional transesophageal echocardiography adds value to
6. 7.
9.
10.
5
transcatheter aortic valve implantation. J Am Soc Echocardiogr 2013;26:359–369. Ben-Dor I, Looser PM, Maluenda G, et al. Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation. Cardiovasc Revasc Med 2012; 13:207–210. Bortnick A, Silvestry F, Herrmann H. Intracardiac echocardiography. In: Eeckhout E, Serruys PW, Wijns W, Vahanian A, van Sambeek M, Palma R, editors. Percutaneous Interventional Cardiovascular Medicine: The PCR-EAPCI Textbook. Paris: Europa Edition; 2012. pp 815–834. Silvestry F, Wiegers S. Intracardiac Echocardiography. 1st ed. Boca Raton: Taylor Francis, 2006. Hijazi ZM, Shivkumar K, Sahn DJ. Intracardiac echocardiography during interventional and electrophysiological cardiac catheterization. Circulation 2009;119:587–596. Mullen MJ, Dias BF, Walker F, Siu SC, Benson LN, McLaughlin PR. Intracardiac echocardiography guided device closure of atrial septal defects. J Am Coll Cardiol 2003;41:285– 292. Bartel T, Bonaros N, Muller L, et al. Intracardiac echocardiography: A new guiding tool for transcatheter aortic valve replacement. J Am Soc Echocardiogr 2011;24:966–975. Ussia GP, Barbanti M, Sarkar, K et al. Accuracy of intracardiac echocardiography for aortic root assessment in patients undergoing transcatheter aortic valve implantation. Am Heart J 2012; 163:684–689.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Case Report Intracardiac Echocardiography-Guided Transcatheter Aortic Valve Replacement Mitul B. Kadakia, MD, Frank E. Silvestry, MD, and Howard C. Herrmann,* MD, FSCAI Echocardiographic imaging is an essential component of successful transcatheter aortic valve replacement (TAVR). Currently, transesophageal echocardiography (TEE) is the imaging modality of choice for TAVR. However, a limitation of TEE is the need for general anesthesia and endotracheal intubation in most centers. Additionally, the TEE probe can obscure fluoroscopic views during valve positioning and deployment. Intracardiac echocardiography (ICE) has been used for imaging guidance for structural and valvular intervention, though its use has rarely been reported for primary imaging guidance during TAVR. Recently, a new volumetric three-dimensional intracardiac ultrasound (volume ICE) system has become available with the potential for improved visualization of intracardiac structures. We describe a recent TAVR case that was successfully performed with the use of volume ICE exclusively for imaging guidance. We found that assessment of valve positioning and aortic insufficiency were comparable to that provided by conventional TEE imaging, though there were several important limitations. ICE-guided TAVR may represent an important alternative to TEE for TAVR imaging guidance and possibly allow for less-intensive sedation or anesthesia. VC 2014 Wiley Periodicals, Inc.
Key words: intracardiac echo; valvular heart disease; aorta
INTRODUCTION
Echocardiographic imaging is an essential component of successful transcatheter aortic valve replacement (TAVR). It is used to determine the appropriate prosthetic valve sizing, positioning of the prosthesis, assessing valvular and paravalvular aortic insufficiency (AI) postimplantation, and for identifying possible procedural complications. Initially, transesophageal echocardiography (TEE) was the imaging modality of choice for TAVR as it provides excellent image quality for precise real-time procedural guidance. Recently, real-time threedimensional (3D) TEE has also been used for guidance of TAVR [1–3]. A limitation of TEE is the need for general anesthesia and endotracheal intubation in most centers, although successful TEE-guided TAVR performed under conscious sedation has been reported [4]. In addition, during prosthetic valve positioning and deployment, the TEE probe may need to be repositioned in the esophagus so as not to obscure the fluoroscopic image. As a result, simultaneous fluoroscopic and echocardiographic guidance can be difficult to achieve in all patients. C 2014 Wiley Periodicals, Inc. V
Additional Supporting Information may be found in the online version of this article. Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania Conflict of interest: Dr. Herrmann receives research funding to the institution from Edwards Lifesciences, Inc., Siemens Medical Inc., and from an anonymous foundation supporting research in valvular heart disease. He is also a consultant to Siemens Medical, Inc. and Edwards Lifesciences, Inc. Dr. Kadakia and Dr. Silvestry have no relevant disclosures. *Correspondence to: Howard C. Herrmann, MD, FSCAI, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104. E-mail: [email protected] Received 9 February 2013; Revision accepted 20 January 2014 DOI: 10.1002/ccd.25409 Published online 00 Month 2014 in Wiley Online Library (wileyonlinelibrary.com)
2
Kadakia et al.
Intracardiac echocardiography (ICE) is an alternative modality for imaging guidance for a variety of structural and valvular interventions [5–8]. ICE can be performed under conscious sedation without the need for endotracheal intubation and may decrease procedure and fluoroscopy time in addition to improving patient comfort. As it does not obscure fluoroscopic views, it can be used simultaneously with fluoroscopy during positioning and deployment of the transcatheter valve. Recently, a new volumetric 3D intracardiac ultrasound (volume ICE) system has become available with the potential for improved visualization of intracardiac structures (AcuNav V, Siemens Acuson, Mountain View, CA) that allows for 2D color Doppler and 3D volumetric imaging in real time. In this report, we describe a TAVR procedure guided exclusively by volume ICE imaging.
obtained by bringing the probe to the level of the tricuspid valve annulus. Preprocedure AI, valve calcification, leaflet motion, and aortic annulus size were assessed. (Fig. 1a–d). Volume ICE was then used to guide balloon valvuloplasty prior to valve placement (Fig. 2). Once the valve was positioned, ICE was used to qualitatively confirm adequate clearance from the coronary ostia on the aortic side and clearance from the mitral valve leaflets on the ventricular side. Threedimensional images were also obtained. Following implantation, we were able to visualize proper positioning of the new valve within the aortic annulus (Fig. 3a and b). The presence of central and paravalvular AI was assessed, and a mild paravalvular leak was observed posteriorly (Fig. 4a and b). Finally, the ICE probe was advanced into the right ventricle to evaluate LV function postprocedure.
CASE REPORT
DISCUSSION
The patient is an 82-year-old male with a history of coronary artery disease treated with prior percutaneous coronary intervention to a diagonal coronary artery, hypertension, hyperlipidemia, chronic kidney disease (baseline creatinine 2.1 mg/dL), atrial fibrillation treated with warfarin, pyoderma gangrenosum on chronic immunosuppression, obstructive sleep apnea, and moderate chronic obstructive pulmonary disease, who had been experiencing increasing fatigue and dyspnea on exertion. His STS score was 14.996%. Preprocedure echocardiography revealed a left ventricular (LV) ejection fraction of 45–50%, an aortic valve mean gradient of 36 mm Hg, and an aortic valve area of 0.77 cm2. Preoperative evaluation revealed that he had an aortic annulus of 25–26 mm necessitating a 29 mm valve. He was enrolled in the PARTNER 2A trial nested registry for a transapical Edwards Sapien XTTM 29 mm valve (Edwards Lifesciences, Irvine, CA). He also consented to participate in an IRB-approved single-center registry for ICE imaging during TAVR procedures (ClinicalTrials.gov, NCT01669551). In the hybrid operating room, the patient underwent general anesthesia and endotracheal intubation. A TEE probe could not be successfully advanced into the esophagus. A decision was made to proceed utilizing ICE alone for imaging and guidance during the procedure with transthoracic echocardiography backup if needed. A 10F AcuNav V catheter with imaging on an SC2000 platform was advanced from the right femoral vein to the right atrium (RA). With counterclockwise rotation and anterior flexion of the catheter, a longitudinal view of the left ventricular outflow tract (LVOT), aortic valve, aortic root, and sinotubular junction was obtained. Short-axis views of the aortic valve were
We were able to successfully complete the procedure solely with ICE guidance demonstrating the feasibility of performing TAVR safely and effectively without the need for TEE. Imaging guidance with the use of ICE is an important step in moving toward performing TAVR under conscious sedation without endotracheal intubation. This has the added potential to decrease length of hospital stay and improve patient comfort. ICE has successfully been used for imaging guidance in numerous structural and electrophysiology procedures, including atrial septal defect closures, transseptal puncture, balloon valvuloplasty, and complex ablations. The use of ICE during TAVR has been reported in a European study which found that ICE provided comparable procedural imaging guidance to TEE [9]. However, this has not yet been reported in the United States, and there have been no reports of the use of volume ICE for TAVR with the potential for improved imaging and image manipulation. By the use of orthogonal views, volume ICE offers the potential for improved accuracy in sizing the LVOT and aortic annulus as compared to 2D ICE. However, true long-axis views of the aortic valve, annulus, and outflow tract are difficult to obtain, and, thus, annular and coronary height measurements are not as accurate as those obtained by preprocedure multislice computed tomography (MSCT) [10]. This technology also affords 3D localization of paravalvular AI. We found that the assessment of valve positioning and paravalvular and transvalvular AI was comparable to that provided by conventional 2D and 3D TEE imaging. However, complete assessment of paravalvular AI may be limited by shadowing in the LVOT that can affect visualization of the substent
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
ICE-Guided TAVR
Fig. 1. (a–d) The aortic valve viewed in long axis with the volume ICE probe in the RA. Significant calcification and restricted motion of the aortic valve (*) is observed both on 2D (Fig. 1a) and 3D (Fig. 1b) images. Color Doppler demonstrates turbulent, high-velocity flow across the stenotic valve (Fig. 1c). Measurement of the aortic annulus in long axis (Fig. 1d, left panel) demonstrates an annular diameter of 2.65 cm. Mea-
3
surement of the annulus in short axis demonstrates a major axis diameter of 2.67 cm and minor axis diameter of 2.61 cm (Fig. 1d, right panel). (RA 5 right atrium, LVOT 5 left ventricular outflow tract, LV 5 left ventricle). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary. com.]
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
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Kadakia et al.
Fig. 2. 3D long-axis view of the aortic valve demonstrating the balloon valvuloplasty wire(*) across the aortic valve prior to valvuloplasty. (RA 5 right atrium, LVOT 5 left ventricular outflow tract, LV 5 left ventricle, RV 5 right ventricle). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 4. (a and b) 2D long-axis (Fig. 4a) and short-axis (Fig. 4b) views of the newly deployed Edwards Sapien aortic valve with color Doppler demonstrating mild, posteriorly directed paravalvular aortic regurgitation postimplantation. A vena contracta width of 0.29 cm is consistent with mild aortic regurgitation. (RA 5 right atrium, LVOT 5 left ventricular outflow tract, LV 5 left ventricle). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
Fig. 3. (a and b) 3D long-axis (Fig. 3a) and short-axis (Fig. 3b) views following deployment of the Edwards Sapien aortic valve. The accurate position of the valve and stent struts (*) can be assessed within the aortic annulus. (RA 5 right atrium, LV 5 left ventricle). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
region. This may be addressed by advancing the ICE catheter into the right ventricle and imaging the LVOT through the interventricular septum. We did not routinely enter the right ventricle to assess the LVOT with the ICE catheter and thus this was not evaluated in our study. Limitations of the volume ICE catheter include the lack of continuous wave Doppler and, consequently, the inability to accurately obtain aortic valve gradients. The 3D color mapping capabilities are not as robust as those of 3D TEE. Precise annular and coronary height measurements are more limited than those obtained with TEE. Orthogonal long-axis views can be difficult to obtain, also affecting the ability to make accurate measurements. As the ICE catheter is imaging from the right side of the heart visualization of far field structures can be suboptimal. ICE does require additional venous vascular access and one must use caution in the setting of pacemaker/defibrillator leads.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
ICE-Guided TAVR
Additionally, it may require the interventionalist to focus on an additional task during the procedure.
4.
CONCLUSIONS
Future improvements in the volume ICE imaging catheter to provide a wider field of view will likely further enhance the capability of this imaging modality. In combination with preprocedure MSCT, we believe that ICE-guided TAVR has the potential to be a viable alternative to TEE guidance and could allow for lessintensive sedation or anesthesia.
5.
REFERENCES
8.
1. Janosi RA, Kahlert P, Plicht B, et al. Guidance of percutaneous transcatheter aortic valve implantation by real-time three-dimensional transesophageal echocardiography–A single-center experience. Minim Invasive Therapy Allied Technol 2009;18:142– 148. 2. Siegel RJ, Luo H, Biner S. Transcatheter valve repair/implantation. Int J Cardiovasc Imaging 2011;27:1165–1177. 3. Smith LA, Dworakowski R, Bhan A, et al. Real-time threedimensional transesophageal echocardiography adds value to
6. 7.
9.
10.
5
transcatheter aortic valve implantation. J Am Soc Echocardiogr 2013;26:359–369. Ben-Dor I, Looser PM, Maluenda G, et al. Transcatheter aortic valve replacement under monitored anesthesia care versus general anesthesia with intubation. Cardiovasc Revasc Med 2012; 13:207–210. Bortnick A, Silvestry F, Herrmann H. Intracardiac echocardiography. In: Eeckhout E, Serruys PW, Wijns W, Vahanian A, van Sambeek M, Palma R, editors. Percutaneous Interventional Cardiovascular Medicine: The PCR-EAPCI Textbook. Paris: Europa Edition; 2012. pp 815–834. Silvestry F, Wiegers S. Intracardiac Echocardiography. 1st ed. Boca Raton: Taylor Francis, 2006. Hijazi ZM, Shivkumar K, Sahn DJ. Intracardiac echocardiography during interventional and electrophysiological cardiac catheterization. Circulation 2009;119:587–596. Mullen MJ, Dias BF, Walker F, Siu SC, Benson LN, McLaughlin PR. Intracardiac echocardiography guided device closure of atrial septal defects. J Am Coll Cardiol 2003;41:285– 292. Bartel T, Bonaros N, Muller L, et al. Intracardiac echocardiography: A new guiding tool for transcatheter aortic valve replacement. J Am Soc Echocardiogr 2011;24:966–975. Ussia GP, Barbanti M, Sarkar, K et al. Accuracy of intracardiac echocardiography for aortic root assessment in patients undergoing transcatheter aortic valve implantation. Am Heart J 2012; 163:684–689.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
