Intracardiac echocardiography for guidance of transcatheter aortic valve implantation under monitored sedation: a solution to a dilemma?
Transcatheter aortic valve implantation (TAVI) has been established as a valuable alternative to surgical aortic valve replacement in patients deemed to have high or prohibitive perioperative risk. However, there are several technical constraints and procedural risks inherent to TAVI. These risks include annulus rupture, ventricular perforation, aortic dissection, coronary occlusion, and dislodgement or migration of the valve prosthesis to the aorta or the left ventricle (LV). Other complications may be related to inappropriate valve deployment and subsequent paravalvular leak. Most complications cannot be detected at an early stage without echocardiographic guidance. Although not addressed by current guidelines, some European centres have advocated a 'minimalist' approach with exclusively fluoroscopic and angiographic guidance. Transoesophageal echocardiography (TEE), including real-time three-dimensional (RT-3D) imaging, has been established as a standard approach for peri-interventional guidance of TAVI. However, TEE monitoring almost always necessitates general anaesthesia and endotracheal intubation. A potential alternative to TEE is intracardiac echocardiography (ICE) that may provide a solution to a common dilemma: the most important advantage of ICE being the compatibility with monitored anaesthesia care without endotracheal intubation. Other advantages of ICE include uninterrupted monitoring, no fluoroscopic interference, and precise Doppler-based assessment of pulmonary artery pressures. Limitations of ICE include the need for additional venous access, the learning curve associated with a new device, and potentially increased cost.
Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, PO Box 112412, Abu Dhabi, United Arab Emirates BartelT@ClevelandClinicAbuDhabi.ae.
Thomas
T
Bartel
Department of Cardiology, Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, PO Box 112412, Abu Dhabi, United Arab Emirates.
Ahmad
A
Edris
Department of Anesthesiology, Innsbruck Medical University, Innsbruck, Austria.
Corinna
C
Velik-Salchner
Division of Cardiology, Department of Internal Medicine III, Innsbruck Medical University, Innsbruck, Austria.
Silvana
S
Müller
D018618:Echocardiography, Doppler, Color; D017548:Echocardiography, Transesophageal / Q000379:methods; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D006993:Hypnotics and Sedatives / Q000008:administration & dosage*; D007091:Image Processing, Computer-Assisted; D016343:Monitoring, Intraoperative / Q000379:methods; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional / Q000379:methods
D006993:Hypnotics and Sedatives
intracardiac echocardiography; peri-procedural guidance; three-dimensional imaging; transcatheter aortic valve replacement; transoesophageal echocardiography