Article

Multimodal Assessment of the Aortic Annulus Diameter Implications for Transcatheter Aortic Valve Implantation

INSERM, U698, University Paris 7, Paris, France.
Journal of the American College of Cardiology (Impact Factor: 15.34). 01/2010; 55(3):186-94. DOI: 10.1016/j.jacc.2009.06.063
Source: PubMed

ABSTRACT We sought to compare 3 methods of measurements of the aortic annulus, transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and multislice computed tomography (MSCT), and to evaluate their potential clinical impact on transcatheter aortic valve implantation (TAVI) strategy.
Exact measurement of the aortic annulus is critical for a patient's selection and successful implantation.
Annulus diameter was measured using TTE, TEE, and MSCT in 45 consecutive patients with severe aortic stenosis referred for TAVI. The TAVI strategy (decision to implant and choice of the prosthesis' size) was based on manufacturer's recommendations (Edwards-Sapien prosthesis, Edwards Lifesciences, Inc., Irvine, California).
Correlations between methods were good but the difference between MSCT and TTE (1.22 +/- 1.3 mm) or TEE (1.52 +/- 1.1 mm) was larger than the difference between TTE and TEE (0.6 +/- 0.8 mm; p = 0.03 and p < 0.0001, respectively). Regarding TAVI strategy, agreement between TTE and TEE overall was good (kappa = 0.68), but TAVI strategy would have been different in 8 patients (17%). Agreement between MSCT and TTE or TEE was only modest (kappa = 0.28 and 0.27), and a decision based on MSCT measurements would have modified the TAVI strategy in a large number of patients (40% to 42%). Implantation, performed in 34 patients (76%) based on TEE measurements, was successful in all but 1 patient with grade 3/4 regurgitation.
In patients referred for TAVI, measurements of the aortic annulus using TTE, TEE, and MSCT were close but not identical, and the method used has important potential clinical implications on TAVI strategy. In the absence of a gold standard, a strategy based on TEE measurements provided good clinical results.

Download full-text

Full-text

Available from: Fabien Hyafil, Dec 15, 2014
0 Followers
 · 
221 Views
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Although CT-studies as well as intraoperative analyses have described broad anatomic variations of the aortic annulus, which is predominantly found non-circular, commercially available transcatheter aortic heart valve prostheses are circular. In this study, we hypothesize that the in vitro hydrodynamic function of a self-expanding transcatheter heart valve (Medtronic CoreValve®) assessed in an oval compartment representing the aortic annulus will differ from the conventionally used circular compartment. Methods Medtronic CoreValve® prostheses were tested in specifically designed and fabricated silicone compartments with three degrees of defined ovalities. The measurements were performed in a left heart simulator at three different flow rates. In this setting, regurgitation flow, effective orifice area, and systolic pressure gradient across the valve were determined. In addition, high speed video recordings were taken to investigate leaflet kinematics. Results The pressure difference across the prosthesis increased with rising ovality. The effective orifice areas were only slightly impacted. The analyses of the regurgitation showed minor changes and partially lower regurgitation when switching from round to slightly oval settings, followed by strong increases for further ovalization. The high speed videos show minor central leakage and impaired leaflet apposition for strong ovalities, but no leaflet/stentframe contact in any setting. Conclusion This study quantifies the influence of oval expansion of transcatheter heart valve prostheses on their hydrodynamic performance. While slight ovalities were well tolerated by a self-expanding prosthesis, more significant ovality led to worsening of prosthesis function and regurgitation.
    Journal of Biomechanics 03/2014; DOI:10.1016/j.jbiomech.2014.01.024 · 2.50 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Transcatheter aortic valve implantation (TAVI), introduced 10 years ago by Alain Cribier, has now been performed in more than 50,000 patients worldwide. Our vision of the main directions for the future are fourfold. Firstly, the 'Heart Team' is and will remain, essential for patient selection and the performance of the procedure. Careful training and controlled diffusion of the technique to medico-surgical centres are also keys to success. Secondly, patient selection must be refined, in order to predict the risk of surgery and that of TAVI. The technique is currently limited to very high-risk patients or those with contraindications to surgery. It will be extended to include lower risk patients once there are adequate trial data, the safety of the procedure has been improved and better knowledge of long-term outcomes from the procedure has been obtained. Thirdly, the procedure will be simplified, and should also be safer with an expected decrease in the occurrence of strokes, vascular complications and perivalvular regurgitation. Fourthly, the devices will also improve, with the addition of the potential for repositioning and improvement in durability. The role of imaging with the use of multimodality techniques will no doubt increase and ease the efficacy and safety of the procedure. Overall, the use of TAVI will undoubtedly increase over time, enabling a larger number of patients with severe aortic stenosis to be treated in an effective and safe way, in complement to surgical aortic valve replacement.
    Archives of cardiovascular diseases 03/2012; 105(3):181-6. DOI:10.1016/j.acvd.2012.01.004 · 1.66 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: La sélection des patients est une étape essentielle avant une implantation valvulaire aortique percutanée afin de poser les bonnes indications et choisir la voie d’abord. La technique s’adresse aux patients ayant un rétrécissement aortique serré symptomatique et ayant soit une contre-indication à la chirurgie, soit un haut risque chirurgical. L’indication de l’implantation doit être évaluée au cours d’une réunion multidisciplinaire. L’échographie et/ou la tomodensitométrie sont indispensables pour évaluer la taille de l’anneau aortique et choisir la bonne taille de prothèse. La possibilité d’une implantation trans-fémorale est évaluée par l’angiographie et par la tomodensitométrie en se basant sur les diamètres artériels mais également sur l’existence de tortuosités et de calcifications artérielles.
    La Presse Médicale 06/2012; 41(6):628–633. DOI:10.1016/j.lpm.2012.03.009 · 1.17 Impact Factor