Intraprocedural Transesophageal Echocardiography Research Articles

The effect of a smaller spacer in the PASCAL Ace on residual mitral valve orifice area.

Mitral transcatheter edge-to-edge repair (M-TEER) is an established treatment for functional mitral regurgitation (FMR) associated with a risk of creating iatrogenic stenosis. To investigate the impact of the P10 and its larger spacer compared to the narrower Ace and its smaller spacer on reduction of mitral valve orifice area (MVOA) during M-TEER. Consecutive patients undergoing M-TEER for treatment of severe FMR were screened retrospectively. Patients with a single PASCAL device implantation within the central segments of the MV leaflets, non-complex anatomy, and baseline MVOA ≥ 3.5cm2 were selected. Intraprocedural transesophageal echocardiography was used to compare MVOA reduction with 3D multiplanar reconstruction and direct planimetry. Device selection did not follow a prespecified MVOA threshold. Seventy-two patients (81.0 years, IQR {74.3-85.0}) were included. In 32 patients, the P10 was implanted (44.4%). MR severity (p = 0.66), MR reduction (p = 0.73), and body surface area (p = 0.56) were comparable. Baseline MVOA tended to be smaller in P10 patients with the larger spacer (5.0 ± 1.1 vs. 5.4 ± 1.3cm2, p = 0.18), however, residual MVOA was larger in these patients (2.7 ± 0.7 vs. 2.3 ± 0.6cm2, p = 0.03). Accordingly, relative MVOA reduction was significantly less in P10 patients (- 45.9 ± 7.6 vs. - 56.3 ± 7.0%, p < 0.01). Indirect annuloplasty was more pronounced in Ace patients whereas mean transmitral gradients were similar. In FMR patients with non-complex anatomy, the larger spacer of the P10 maintains greater MVOA with similar MR reduction. Hence, the use of the PASCAL Ace device in patients with small MVOAs might correlate with a risk of both clinically relevant orifice reduction and even iatrogenic stenosis.

Deep learning for transesophageal echocardiography view classification

Transesophageal echocardiography (TEE) imaging is a vital tool used in the evaluation of complex cardiac pathology and the management of cardiac surgery patients. A key limitation to the application of deep learning strategies to intraoperative and intraprocedural TEE data is the complexity and unstructured nature of these images. In the present study, we developed a deep learning-based, multi-category TEE view classification model that can be used to add structure to intraoperative and intraprocedural TEE imaging data. More specifically, we trained a convolutional neural network (CNN) to predict standardized TEE views using labeled intraoperative and intraprocedural TEE videos from Cedars-Sinai Medical Center (CSMC). We externally validated our model on intraoperative TEE videos from Stanford University Medical Center (SUMC). Accuracy of our model was high across all labeled views. The highest performance was achieved for the Trans-Gastric Left Ventricular Short Axis View (area under the receiver operating curve [AUC] = 0.971 at CSMC, 0.957 at SUMC), the Mid-Esophageal Long Axis View (AUC = 0.954 at CSMC, 0.905 at SUMC), the Mid-Esophageal Aortic Valve Short Axis View (AUC = 0.946 at CSMC, 0.898 at SUMC), and the Mid-Esophageal 4-Chamber View (AUC = 0.939 at CSMC, 0.902 at SUMC). Ultimately, we demonstrate that our deep learning model can accurately classify standardized TEE views, which will facilitate further downstream deep learning analyses for intraoperative and intraprocedural TEE imaging.

The predictive value of compression rate on residual leak after left atrial appendage occlusion with watchman FLX

Abstract Background Incomplete left atrial appendage (LAA) occlusion due to residual leaks may occur after percutaneous closure procedure with Watchman FLX. Before release of device PASS (position, anchor, size and seal) criteria must be verified. Optimal compression rate for watchman FLX device is between 10-30% according to company recommendations. Purpose The aim of this study is to evaluate the correlation between compression rate and leak presence after left atrial appendage closure. Methods This is an observational retrospective study including patients that underwent LAA closure under transesophageal echocardiography (TEE) with at least one follow-up where complete LAA closure was assessed by TEE in our center between January 2021 and August 2022. TEE images were reviewed by the first author. Compression rate was calculated based on intraprocedural TEE images using the following formula: (original device size—size after deployment)/original device size*100. Patients were divided into 2 groups based on the compression rate: group 1: 10-30%; group 2: &amp;gt;30%. The rate of leak between groups was compared using the Chi-square test. Results 203 patients (mean age 79± 8 years) were included in the study. The implanted device size was 20 mm in 7 (3.4%), 24 mm in 30 (14.8%), 27 mm in 49 (24.1%), 31 mm in 75 (36.9%) and 35 mm in 42 (20.7%) patients. Based on the compression rate, patients were classified into group 1: &amp;gt;30% [n=37 (18.2%)] and group 2: ≤30% [n=166 (81.8%)]. Mean compression rate was 38.5% and 21.3% in group 1 and 2 respectively. At follow-up TEE, 1 (2.7%) patient in group 1 and 32 (19.3%) patients in group 2 were found to have a residual leak of &amp;gt;1 mm. When comparing leaks between the two groups, there was 1 leak in group 1 whereas in group 2 there were 32 leaks (1/37 vs 32/166, p value 0.01, RR 0.14, 95% CI, 0.02-0.74). Conclusion Devices with compression rate ≤30% were associated with significantly higher risk of residual leak.

Impact of intracardiac echocardiography usage on the safety of cryoballoon atrial fibrillation ablation: Subanalysis of the prospective FREEZE cluster cohort study.

Cryoballoon ablation (CBA) aiming at pulmonary vein isolation (PVI) became a standardized atrial fibrillation (AF) ablation procedure. Life-threatening complications like cardiac tamponade exist. Intracardiac echocardiography (ICE) usage is associated with superior safety in radiofrequency ablation. It is unclear if ICE has an impact on safety of CBA. The FREEZE Cohort (NCT01360008) subanalysis included patients undergoing "PVI only" CBA. Patients with intraprocedural transesophageal echocardiography were excluded. Group A comprises conventional, group B ICE-guided CBA. Periprocedural results were compared. From 2011 to 2016, a total of 4189 patients were enrolled, and 1906 (45.5%) were included in this subanalysis, split up in two groups (A: 1066 [55.9%], B: 840 [44.1%]). Group A was younger (60.6 ± 10.8 vs. 62.4 ± 10.5 years, p < .001), with smaller left atria (41 vs. 43 mm, p < .001), and less persistent AF (23.1 vs. 38.1%, p < .001). Procedure, left atrial, and fluoroscopy times were shorter in group A as compared to group B. Dose area product was significantly higher in group A (2911 vs. 2072 cGyxcm2 , p < .001). In-hospital major adverse cerebrovascular and cardiac event rates including two deaths in group A were not different between groups (0.5% vs. 0.1%, p = .18). The rate of total procedural (10.4% vs. 5.1%, p < .001) and major complications (3.2% vs. 1.3%, p < .001) was significantly higher in group A. Cardiac tamponade occurred significantly more frequently in group A (8 [0.8%] vs. 1 [0.1%], p = .046). Independent predictors for major complications were female sex (odds ratio [OR] 2.03, p = .03) and non-ICE usage (OR 2.38, p = .02). No differences were observed for persistent phrenic nerve palsy, nor for groin complications. CBA was significantly safer and required less radiation if ICE was used, although the procedures were more complex. The risk of groin complications was not increased with ICE usage. Non-ICE usage was the only modifiable independent predictor of major complications.

Transcatheter edge-to-edge-repair of functional mitral regurgitation induces significant remodeling of mitral annular geometry.

Mitral annular alterations in the context of heart failure often lead to severe functional mitral regurgitation (FMR), which should be treated with transcatheter edge-to-edge repair (M-TEER) according to current guidelines. M-TEER's effects on mitral valve (MV) annular remodeling have not been well elucidated. 141 consecutive patients undergoing M-TEER for treatment of FMR were included in this investigation. Comprehensive intraprocedural transesophageal echocardiography was used to assess the acute effects of M-TEER on annular geometry. Average patient age was 76.2 ± 9.6 years and 46.1% were female patients. LV ejection fraction was reduced (37.0% ± 13.7%) and all patients had mitral regurgitation (MR) grade ≥III. M-TEER achieved optimal MR reduction (MR ≤ I) in 78.6% of patients. Mitral annular anterior-posterior diameters (A-Pd) were reduced by -6.2% ± 9.5% on average, whereas anterolateral-posteromedial diameters increased (3.7% ± 8.9%). Overall, a reduction in MV annular areas was observed (2D: -1.8% ± 13.1%; 3D: -2.7% ± 13.7%), which strongly correlated with A-Pd reduction (2D: r = 0.6, p < 0.01; 3D: r = 0.65, p < 0.01). Patients that achieved A-Pd reduction above the median (≥6.3%) showed significantly lower rates of the composite endpoint rehospitalization for heart failure or all-cause mortality than those with less A-Pd reduction (9.9% vs. 28.6%, p = 0.037, log-rank p = 0.039). Furthermore, patients reaching the composite endpoint had an increase in annular area (2D: 3.0% ± 15.4%; 3D: 1.9% ± 15.3%), whereas those not reaching the endpoint showed a decrease (2D: -2.7% ± 12.4%; 3D: -3.6% ± 13.3%), although residual MR after M-TEER was similar between these groups (p = 0.57). In multivariate Cox regression adjusted for baseline MR, A-Pd reduction ≥6.3% remained a significant predictor of the combined endpoint (OR: 0.35, 95% CI: 0.14-0.85, p = 0.02). Our findings indicate that effects of M-TEER in FMR are not limited to MR reduction, but also have significant impact on annular geometry. Moreover, A-Pd reduction, which mediates annular remodeling, has a significant impact on clinical outcome independent of residual MR.

Volumetric Intracardiac Echocardiogram-Guided MitraClip in Patients Intolerant to Transesophageal Echocardiogram: Results From a Multicenter Registry

The success of mitral transcatheter edge-to-edge repair (mTEER) requires high fidelity intraprocedural transesophageal echocardiography (TEE) for optimal transeptal puncture guidance, device steering, and clip implantation. Patients with absolute or relative contraindications to TEE (eg, esophageal/gastric disease, cervical/thoracic spinal disease, and coagulopathies) have limited options. Previous case reports or single-center series have demonstrated the feasibility of volumetric intracardiac echocardiogram (vICE) to provide adjunctive imaging or as a means to guide the entire procedure.

PO-03-168 IMPORTANCE OF COMPRESSION RATE DURING LEFT ATRIAL APPENDAGE CLOSURE WITH WATCHMAN FLX

Left atrial appendage (LAA) closure is an option for patient with atrial fibrillation that cannot take oral anticoagulant due to high bleeding risk. Before release of device PASS (position, anchor, size and seal) criteria must be verified. Optimal compression rate for watchman FLX device is between 10-30% according to company recommendations. The study evaluates the correlation between compression rate and leak presence after left atrial appendage closure. This is a study including patients that underwent LAA closure under transesophageal echocardiography (TEE) with at least one follow-up where complete LAA closure was assessed by TEE in our center. All TEE images were reviewed by the first author. Compression rate was calculated based on intraprocedural TEE images using the following formula: (original device size—size after deployment)/original device size*100. Patients were divided into 2 groups based on the compression rate: group 1: 10-30%; group 2: >30%. The rate of leak between groups was compared using the Chi-square test. 83 patients (mean age 77± 7 years) were included in the study. The implanted device size was 20 mm in 2 (2.4%), 24 mm in 11 (13.2%), 27 mm in 21 (25.3%), 31 mm in 32 (38.5%) and 35 mm in 17 (20.4%) patients. Based on the compression rate, patients were classified into group 1: >30% [n=11 (13.2%)] and group 2: ≤30% [n=72 (86.7%)]. Mean compression rate was 37.1% and 20.78% in group 1 and 2 respectively. At follow-up TEE, 20 (24%) patients were found to have a residual leak of <5 mm. When comparing leaks between the two groups, there was no leak in patients with > 30% compression rate whereas in the group with ≤30% there were 20 leaks (0/11 vs 20/72, p value 0.04, RR 0, 95% CI, 0-1). Devices with compression rate ≤30% were associated with significantly higher risk of residual leak.

Exploratory use of intraprocedural transesophageal echocardiography to guide implantation of the leadless pacemaker.

Fluoroscopy is the standard tool for transvenous implantation of traditional and leadless pacemakers (LPs). LPs are used to avoid complications of conventional pacemakers, but there still is a 6.5% risk of major complications. Mid-right ventricular (RV) septal device implantation is suggested to decrease the risk, but helpful cardiac landmarks cannot be visualized under fluoroscopy. Transesophageal echocardiography (TEE) is an alternative intraprocedural imaging method. The purpose of this study was to explore the spatial relationship of the LP to cardiac landmarks via TEE and their correlations with electrocardiographic (ECG) parameters, and to outline an intraprocedural method to confirm mid-RV nonapical lead positioning. Fifty-six patients undergoing implantation of LP with TEE guidance were enrolled in the study. Device position was evaluated by fluoroscopy, ECG, and TEE. Distances between the device and cardiac landmarks were measured by TEE and analyzed with ECG parameters with and without RV pacing. Mid-RV septal positioning was achieved in all patients. TEE transgastric view (0°-40°/90°-130°) was the optimal view for visualizing device position. Mean tricuspid valve-LP distance was 4.9 ± 0.9 cm, mean pulmonary valve-LP distance was 4.2 ± 1 cm, and calculated RV apex-LP distance was 2.9 ± 1 cm. Mean LP paced QRS width was 160.8 ± 28 ms and increased from 117.2 ± 34 ms at baseline. LP RV pacing resulted in left bundle branch block pattern on ECG and 37.8% QRS widening by 43.5 ± 29 ms. TEE may guide LP implantation in the nonapical mid-RV position. Further studies are required to establish whether this technique reduces implant complications compared with conventional fluoroscopy.

Only transesophageal echocardiography guided patentforamen ovale closure: Asingle-center experience.

BackgroundAn increasing number of studies have proved that patent foramen ovale (PFO) occlusion could reduce the incidence of recurrent stroke more than drug therapy alone under certain conditions. Which is the “best” guidance technique still remains to be discussed.MethodsA single center retrospective study enrolled 120 patients (mean age 52.51 ± 14.29 years) who underwent PFO closure between April 2019 and March 2021. 87 patients (72.5%) had suffered cryptogenic stroke (CS) at least one time, and 24 patients (20%) had repetitive episodes of hemicrania unsourced. 65 patients were in the transesophageal echocardiography (TEE) guidance group (T-group), and the other 55 patients were in the angiographic guidance group (A-group).ResultsThere were no significant differences in crucial clinical characteristics between the two groups. In T-group, the procedural success rate was higher (100% vs. 92.7%, P = 0.028), and the procedural time was shorter (23.15 ± 13.87 vs. 25.75 ± 7.19, P = 0.001). No difference was detected in the procedural complication rate. Follow-up were performed at least 12 months. At 12 months, new atrial fibrillation occurred in 1 patient (1.5%) in the T-group and in 1 patient (1.8%) in the A-group (P = 0.905). Residual shunt occurred in 1 patient (1.5%) in the T-group and in 3 patients (5.5%) in the A-group (P = 0.236). Recurrent cerebral ischemia occurred in 2 patient (3.1%) in the T-group and in 2 patients (3.6%) in the A-group (P = 0.865).ConclusionThe use of only intra-procedural TEE guidance for PFO closure is safe and effective. The whole procedure can be performed without fluoroscopy and contrast medium. The short and medium follow-up results are satisfactory, especially in the residual shunt.

Detection of left coronary ostial obstruction during transcatheter aortic valve replacement by coronary flow velocity measurement in the left main trunk by intraoperative transesophageal echocardiography

BackgroundCoronary obstruction is a rare but catastrophic complication of transcatheter aortic valve replacement (TAVR) and occurs mostly at the left coronary artery (LCA) ostium. However, some patients do not show any clinical findings, and thus, its detection is sometimes difficult. The peak diastolic flow velocity in left main coronary artery (LM) was reportedly increased in significant stenosis lesions. We evaluated the effectiveness of measuring blood flow velocities in LM by transesophageal echocardiography (TEE) for the detection of LCA ostial obstruction during a TAVR procedure. MethodsA total of 1105 consecutive patients who underwent TAVR in Sendai Kousei Hospital between September 2014 and December 2020 were enrolled. The LM blood flow velocity was measured at pre- and post-valve implantation. ResultsAmong the 1105 patients, 9 had LCA ostial obstruction. The peak LM blood flow velocity at post-TAVR [0.90 (0.39–1.15) vs. 0.37 (0.28–0.50) m/s; p = 0.0046) was significantly higher in 9 patients who had LCA ostial obstruction, compared with the remaining 1096 patients who had not (controls), although no significant difference was observed before the TAVR procedures between the two groups. The post- to pre-TAVR LM flow velocity ratio [2.26 (1.31–3.42) vs. 1.06 (0.82–1.36); p = 0.0030] was also significantly higher in patients with LCA obstruction, compared to the controls. Furthermore, the post- to pre-TAVR LM blood flow velocity ratio was >2.0 in all six hemodynamically stable patients with LCA obstruction, whereas <2.0 in all three patients with LCA obstruction who showed hemodynamic collapse at post-TAVR procedure. ConclusionCoronary blood flow velocity in LM significantly increased in hemodynamically stable LCA obstruction patients. The intraprocedural TEE measurement of the LM flow velocities would be potentially useful to detect asymptomatic and hemodynamically stable LCA ostial obstruction.

Design and Evaluation of Novel Bite Block for Invasive Imaging Procedures.

Commercially available bite blocks used for invasive imaging procedures have design limitations, including bulky profile, being made of hard plastic that may damage surrounding tissue, and tendency to dislodge. We designed a novel bite block to address these limitations and evaluated this bite block in 50 patients undergoing diagnostic or intraprocedural transesophageal echocardiography examinations. Nine of 11 (82%) imagers who used the redesigned bite block preferred it over the standard bite block used at our institution. The novel bite block is an alternative device to standard bite blocks that was redesigned to protect both the patient and probe.

Curriculum for Subspecialty Anesthesia Training in Adult Structural Heart Disease Imaging: A Single-Center Experience

Intraprocedural transesophageal echocardiography imaging is an integral part of percutaneous structural heart disease (SHD) interventions. The rapid growth in the number, scope, and complexity of SHD interventions has outpaced the efforts to develop training and proficiency standards in periprocedural imaging. At the Beth Israel Deaconess Medical Center in Boston, Massachusetts, the authors have developed a 6-month duration fellowship in interventional echocardiography for SHD to address this issue. The purpose of this fellowship is to train cardiac anesthesiologists to address the unique challenges of interventional echocardiography. In this paper, the authors describe the rationale for and specific features of this training program. Their fellowship curriculum follows a multimodal integrative approach to training in SHD imaging, which includes simulation sessions, online modules, deliberate practice in the clinical setting, and interdisciplinary team-based training. In the next several years, there will be an increased need for echocardiographers who are proficient in intraprocedural SHD imaging. In this article, the authors describe their experience with a competency-based curriculum for subspecialty anesthesia training in SHD imaging.

PO-638-07 GUIDING CATHETER ABLATION COMBINED WITH LEFT ATRIAL APPENDAGE OCCLUSION PROCEDURE BY FLUOROSCOPY WITH OR WITHOUT TRANSESOPHAGEAL ECHOCARDIOGRAPHY ACHIEVED COMPARABLE OUTCOMES

Several studies published the safety and efficacy of performing catheter ablation (CA) combined with left atrial appendage occlusion (LAAC) guided by transesophageal echocardiography (TEE). However, intra-procedural TEE monitoring could be difficult as some patients are intolerant. To compare safety and efficacy of guiding CA combined with LAAO by digital subtraction angiography (DSA) with or without TEE. From February 2019 to December 2020, 138 patients with non-valvular atrial fibrillation (AF) underwent CA combined with LAAO procedure were consecutively included, and two cohorts were built according to intra-procedural guidance (DSA or DSA with TEE). Periprocedural and follow-up outcomes were compared to investigate the feasibility and safety between the two cohorts. 71 patients and 67 patients were included in DSA cohort and TEE cohort respectively. Age and gender were comparable, despite TEE cohort has a higher proportion of persistent AF [37 (55.2%) VS 26 (36.6%)] and hemorrhage history [9 (13.4%) VS 0]. The procedure time of the DSA cohort was significantly reduced (95.7±27.6 min VS 108.9±30.3 min, P=0.018), with a non-significant longer fluoroscopic time (15.2±5.4 min vs 14.4±7.1 min, P=0.074) All combined procedure was performed successfully in both cohorts. And the overall incidence of peri-procedural complications were similar between cohorts. After an average of 24 months of clinical follow-up, only three patients in the TEE cohort had ≤ 3mm residual flow (P=0.232). Kaplan-Meier estimates showed non-significant differences between the cohorts for freedom from atrial arrhythmia (log-rank P value=0.964), major adverse cardiovascular events (log-rank P value=0.502) and other events. Compared with DSA and TEE guidance, DSA-guided combined procedure could shorten procedural time, while achieve similar periprocedural and long-term feasibility and safety.

Delivery balloon volume positively correlates with the diameter and effective orifice area of implanted SAPIEN 3

BackgroundIn transcatheter aortic valve replacement (TAVR) using SAPIEN 3 (S3) (Edwards Lifesciences, Irvine, CA, USA), some clinicians decrease or increase the delivery balloon volume (VOL) when deploying S3 or conducting post-dilatation. However, the effects of controlling VOL on transcatheter heart valve diameter (THVD) and valve function remain unclear. We assessed associations among VOL, THVD, and effective orifice area (EOA) of S3. MethodsWe enrolled patients undergoing TAVR using 23- and 26-mm S3 in Sendai Kousei Hospital between 2017 and 2019. VOL was controlled based on preprocedural computed tomography and intraprocedural transesophageal echocardiography (TEE). THVD were defined as the diameters of transcatheter heart valve at mid-level measured by TEE. ResultsIn enrolled 332 patients (23-mm, n = 188; 26-mm, n = 144), one (0.3%) and two (0.6%) developed annulus rupture and moderate/severe paravalvular leak, respectively. VOL at deployment was positively correlated with THVD on deployment (23-mm, r = 0.44, p < 0.001; 26-mm, r = 0.57, p < 0.001) and EOA (23-mm, r = 0.23, p = 0.0019; 26-mm, r = 0.22, p = 0.0094). In multiple regression analyses, VOL and post-dilatation were significant determinants of THVD, although aortic annulus area, calcium volume, and pre-dilatation were not. The areas under the receiver operating characteristic curve that were used to evaluate the accuracy of the index obtained by dividing THVD by body surface area (indexed THVD) to predict patient–prosthesis mismatch (PPM) were 0.744 and 0.811 in the 23- and 26-mm cohorts, respectively. A cut-off indexed THVD of ≤11.5 and 12.1 mm/m2 well predicted PPM (23-mm, odds ratio, 5.20; 95% confidence interval, 1.33–20.3; 26-mm, odds ratio 14.1, 95% confidence interval 2.40–81.0). ConclusionVOL was positively correlated with THVD and EOA. Smaller indexed THVD was associated with a higher incidence of PPM. Controlling VOL under on-site THVD evaluation may be useful in reducing the PPM incidence.

Wyniki przezskórnego zamknięcia ubytku typu Gerbode z zastosowaniem Nit-Occlud Le VSD (PFM) coil.

Introduction: Left ventricle-to-right atrial (LV-RA) communications termed Gerbode defects are a special and very rare type of ventricular septal defects. Transcatheter closure using Nit-Occlud Le VSD-coils is a new and not well-known alternative to cardiac surgery in selected cases. The aim of our study was to describe results and our experience with interventional closure of Gerbode defects using Nit-Occlud Le VSD-Coil. Material and Methods: The procedures were performed between October 2014 and October 2018. Patients were selected based on detailed transthoracic echocardiography (TTE). The diameter of the defects based on the TTE study was verified and comparable to values found in the angiocardiography. Despite of the fluoroscopy guidance the intraprocedural transesophageal echocardiography was carried out in every case. Finally, the effectiveness of the procedure and the occurrence of complications during the observation were assessed in each case. Results: The study involved eight children, including an infant with native Gerbode defect and seven older children with acquired post-operative LV-RA shunts. Age ranged from 8 months to 17.8 years, body weight from 7.4 kg to 56 kg, body weight from 7.4 kg to 56 kg, 5/8 females. The diameter mean of the defects in the angiocardiography was 3.86±0.82 mm and it was comparable to values from TTE. All procedures were successful. The coils ranged from 8x6 mm to 12x6 mm. Early complications after procedure: one case of a transient haemolysis which required blood transfusion and steroids, one case of temporary arrhythmia. The follow-up period ranged 2-36 months, with only one case of a permanent small residual shunt was observed. Conclusions: The interventional treatment of very rare Gerbode defect seems to be a safe alternative to surgery in selected cases. This study is one of the largest suchlike published.

Orifice Areas of Balloon-Expandable Transcatheter Heart Valves: A Three-Dimensional Transesophageal Echocardiographic Study

Accurate expected effective orifice area (EOA) values for balloon-expandable (BE) transcatheter heart valves (THV) are crucial for preventing patient-prosthesis mismatch (PPM) and assessment of THV function. Currently published reference EOAs, however, are based on transthoracic echocardiography (TTE), which may be subject to left ventricular outflow tract diameter underestimation and/or suboptimal THV Doppler interrogation. The objective of this study was to establish reference EOA values for BE THVs on the basis of Doppler and three-dimensional (3D) transesophageal echocardiography (TEE). Two hundred twelve intraprocedural transesophageal echocardiographic examinations performed during BE THV implantation with optimal postimplantation Doppler and 3D imaging were retrospectively reviewed. Continuity equation-derived EOAs were compared with geometric orifice areas by 3D planimetry (GOA3D). Performance indices (i.e., EOA normalized to valve size) and PPM rates were determined. TTE-based EOAs obtained within 30days were also calculated in a subset of 170 patients. The average EOA for all BE THV valves (77% SAPIEN 3) was 2.3±0.5cm2, while the average EOA was 1.6±0.2cm2 for 20-mm, 2.0±0.2cm2, for 23-mm, 2.5±0.3cm2 for 26-mm, and 3.0±0.3cm2 for 29-mm THV size (P<.001). Bland-Altman analysis demonstrated very good agreement between EOA and GOA3D (bias -0.04±0.15cm2). There were strong correlations between annular area and TEE-based EOA (R=0.84) and GOA3D (R=0.87). The mean performance index was 47±5% and was similar for all THV sizes (P=.21). EOAs based on TTE were smaller compared with those based on TEE, while the correlation with annular area (R=0.67) and agreement with GOA3D (bias -0.26±0.43cm2) was not as strong. The overall PPM rate was 2% in the TEE cohort and 12% in the TTE cohort. EOAs for BE THVs based on intraprocedural Doppler and 3D TEE suggest that previously published TTE-based reference values for EOA are underestimated, while PPM rates may be overestimated. Our findings have important clinical implications for preimplantation decision-making and for the evaluation of THV hemodynamics and function during follow-up.

Abstract 11056: Thoracoscopic Left Atrial Appendage Occlusion with Atriclip TM : An Initial Experience

Introduction: Left atrial appendage (LAA) closure is an important tool in stroke prevention. Totally thoracoscopic LAA closure using the AtriClip™ device avoids intracardiac components, although early outcomes have not been systematically documented. Methods and Results: 105 consecutive fully thoracoscopic AtriClip TM procedures were examined, involving 84(80%) males, 21(20%) females and mean (+/- SD) age 70.1+/-9.2 years. The most common indication was as part of an AF ablation procedure (n=38, 36.2%), or anticoagulation-related hemorrhage (n=27, 25.7%). Median (interquartile range, IQR) CHADS 2 VaSc = 3 (2-4) and HAS-BLED = 3 (1-3). Half the patients (n=51, 48.6%) underwent isolated AtriClip insertion, 90% had a size 40 or 45mm AtriClip device, and none experienced circumflex coronary artery or phrenic nerve compromise. Intraprocedural transesophageal echocardiography demonstrated complete occlusion in all patients. Follow-up at 6 weeks with CT or transesophageal echocardiography confirmed occlusion in all patients (79% follow-up). The length of stay for isolated thoracoscopic AtriClip TM was 3 days (IQR 2-4) with longer admissions due to unrelated conditions (e.g. heart failure, AF or chest infection). No cases of LAA perforation were recorded and no patients with isolated AtriClip required transfusion. Transient pericarditis occurred in 10 patients (9.5%, 5 requiring readmission within 30 days) with a pericardial effusion in 3 patients (2.9%, requiring pericardiocentesis in one patient). No strokes occurred and 93% of isolated Atriclip patients had ceased anticoagulation at 30 days. Conclusions: Total thoracoscopic LAA closure using the AtriClip device is safe and effective. The most common complication is transient pericarditis (9.5%) and major complications were not seen.

Transgastric imaging-The key to successful periprocedural TEE guiding for edge-to-edge repair of the tricuspid valve.

Intraprocedural transesophageal echocardiography (TEE) guidance plays an essential role in transcatheter repair therapy of the tricuspid valve (TV). So far, several different imaging concepts are in use. We propose an imaging protocol that fully addresses the morphological complexity of the TV and further offers efficacious workarounds for the frequently occurring restrictions of TV imaging in edge-to-edge repair of the TV. As a tertiary referral center with a large experience of more than 250 cases of transcatheter edge-to-edge repair (TEER) of the TV performed at the Heart Valve Center in Mainz/Germany, we have constantly adapted our peri-interventional echocardiographic approach to accomplish both. As a key measure for success, we intensely rely on the transgastric acoustic windows that not only deliver high-resolution information on the morphology of the TV and all relevant procedural steps but also help to avoid the frequent shadowing artifacts experienced in transesophageal imaging.

General Anesthesia Leads to Underestimation of Regurgitation Severity in Patients With Secondary Mitral Regurgitation Undergoing Transcatheter Mitral Valve Repair

To evaluate the effect of general anesthesia (GA) on severity of mitral regurgitation (MR) in patients undergoing transcatheter mitral valve repair (TMVR). Retrospective cohort study. Tertiary care university hospital. Fifty consecutive patients with symptomatic severe MR and extremely high surgical risk. TMVR under GA. Transesophageal echocardiography was performed during the preprocedural workup under conscious sedation and during TMVR under GA. After the parameters of MR were assessed, color-flow jet area (CJA), vena contracta (VC), effective regurgitant orifice area (EROA), regurgitant volume (RVOL), three-dimensional (3D) vena contracta area (VCA), and severity of MR were compared between the two examinations. In patients with primary MR (n=11), there were no significant differences in CJA, VC, EROA, RVOL, or 3D-VCA between pre- and intraprocedural transesophageal echocardiography. In patients with secondary MR (n=39), GA led to significant decreases of CJA (10 ± 7 v 7 ± 3 cm², p < 0.001), VC (5.5 ± 1.6 v 4.7 ± 1.5 mm, p=0.002), EROA (30 ± 11 v 24 ± 10 mm², p < 0.001), and RVOL (47 ± 17 v 34 ± 13 mL/beat, p < 0.001). Consequently, GA led to a downgrade of regurgitation severity classification in 44% of patients when assessed by two-dimensional analysis. When evaluated by 3D analysis, GA also led to a significant but less extensive decrease of MR (3D-VCA: 66 ± 27 v 60 ± 29 mm², p=0.002), and subsequent downgrade of MR classification in 20% of patients. GA underestimates regurgitation severity in patients with secondary, but not primary MR, undergoing TMVR. This effect must be considered when evaluating the immediate result of the procedure.

Outcomes after transcatheter valve-in-valve implantation using a balloon-expandable Edwards Sapien valve in patients with degenerated Freestyle aortic bioprosthesis.

Transcatheter aortic valve-in-valve implantation (ViV TAVI) in degenerated Medtronic Freestyle aortic bioprosthesis (FSB) has been reported as being technically challenging. This study sought to evaluate procedural data and outcomes after ViV TAVI using a balloon-expandable Edwards valve in patients with failed FSB. Between August 2014 and December 2020, twenty-seven consecutive patients underwent ViV TAVI for symptomatic FSB failure at our institution using a Sapien XT (n=1) and Sapien 3 (n=26) valve, respectively. Endpoints were defined according to the Valve Academic Research Consortium-2 (VARC-2) criteria and were retrospectively analyzed. Mean patient age was 75.7±8.2 years (female n=5, male n=22); Society of Thoracic Surgeons Predicted Risk of Mortality score was 7.3%±6.2%. ViV implantation with correct positioning of the Edwards Sapien valve within the FSB was successful in all cases. Intraprocedural transesophageal echocardiography revealed none/trace paravalvular regurgitation in twenty-five patients (92.6%), mild paravalvular regurgitation was present in two patients (7.4%). Neither of the patients had a mean gradient ≥20.0 mmHg excluding significant patient-prosthesis mismatch. Three early deaths (≤thirty days) occurred resulting in a device success rate of 88.8%. One-year and three-year survival rates for patients alive beyond day thirty after ViV TAVI were 95.8% and 70.0%, respectively. ViV TAVI with Edwards Sapien valves lead to acceptable functional results in high-risk patients with degenerated FSB but early complications must be considered particularly during hospital stay.