Is real time 3D transesophageal echocardiography a feasible approach to detect coronary ostium during transapical aortic valve implantation?

Delayed right coronary ostial obstruction after J-valve deployment in transcatheter aortic valve implantation: A case report

BACKGROUND

Aortic stenosis is the most common valve disease in adults. Transcatheter aortic valve implantation (TAVI) is being increasingly applied for intermediate- to low-risk patients. Here, we describe an uncommon complication of delayed right coronary obstruction in a transapical TAVI case.

CASE SUMMARY

A 73-year-old woman with a EuroSCORE II of 1.21% underwent transapical TAVI because of severe aortic stenosis. The surgical procedure was uneventful. However, during routine monitoring after valve placement, the patient had a sudden onset of slow heart rate, the systolic blood pressure dropped sharply from 115 to 60 mmHg, and the central venous pressure abruptly increased from 10 to 33 cmH₂O. The patient had a poor response to vasoactive agents. Transesophageal echocardiography revealed poor myocardial contractility, and electrocardiography showed a significant depression of ST-segment. Another angiography was performed immediately, which suggested complete obstruction of the right coronary artery. An emergency protocol was initiated. Cardiopulmonary bypass was established immediately. An aortic biological valve replacement under cardiopulmonary bypass was performed.

CONCLUSION

Perioperative monitoring, early recognition, and diagnosis of obstruction of coronary arteries in TAVI are important. Transesophageal echocardiography is a useful diagnostic and monitoring tool in this situation. Emergency protocols should be established during TAVI.

The functional aortic annulus in the 3D era: focus on transcatheter aortic valve replacement for the perioperative echocardiographer

The functional aortic annulus represents a sound clinical framework for understanding the components of the aortic root complex. Recent three-dimensional imaging analysis has demonstrated that the aortic annulus frequently is elliptical rather than circular. Comprehensive three-dimensional quantification of this aortic annular geometry by transesophageal echocardiography and/or multidetector computed tomography is essential to guide precise prosthesis sizing in transcatheter aortic valve replacement to minimize paravalvular leak for optimal clinical outcome. Furthermore, three-dimensional transesophageal echocardiography accurately can quantify additional parameters of the functional aortic annulus such as coronary height for complete sizing profiles for all valve types in transcatheter aortic valve replacement. Although it is maturing rapidly as a clinical imaging modality, its role in transcatheter aortic valve replacement is seen best as complementary to multidetector computed tomography in a multidisciplinary heart team model.

Quantitative Analysis of Aortic Valve Stenosis and Aortic Root Dimensions by Three-Dimensional Echocardiography in Patients Scheduled for Transcutaneous Aortic Valve Implantation

Accurate assessment of the aortic valve area (AVA) and evaluation of the aortic root are important for clinical decision-making in patients being considered for transcatheter aortic valve implantation (TAVI). Real-time three-dimensional transesophageal echocardiography (RT3D-TEE) provides accurate and reliable quantitative assessment of aortic valve stenosis and the aortic root. We performed two-dimensional transthoracic echocardiography (2D-TTE), real-time 2D transesophageal echocardiography (RT2D-TEE) and RT3D-TEE in 71 consecutive patients referred for TAVI. RT3D-TEE multiplanar reconstruction was used to measure aortic root parameters, including left ventricular outflow tract (LVOT) diameter and area, aortic annulus diameter, aortic annulus area, and AVA. RT3D-TEE methods for planimetry and the LVOT-derived continuity equation for the estimation of AVA showed a good correlation. As iatrogenic coronary ostium occlusion is a potentially life-threatening complication, we evaluated the distances from the aortic annulus to the coronary ostia using RT3D-TEE. Based on our findings, we conclude that the geometry of the aortic root and aortic valve can be reliably and feasibly evaluated using RT3D-TEE, which is important for protecting against potential complications of TAVI, such as underestimation of the size of the aortic annulus that can result in aortic regurgitation and dislocation of the valve, or overestimation can lead to annulus rupture.