Brief Clinical Reports

Feasibility of transapical aortic valv

e implantation guided byintracardiac ultrasound without angiography

Enrico Ferrari, MD,a Carlo Marcucci, MD,b Stefano Di Bernardo, MD,c and Ludwig Karl von

Segesser, MD,a Lausanne, Switzerland

Transcatheter aortic valve implantation (TAVI) is indicated

for high-risk patients requiring aortic valve replacement.

Valve positioning and postoperative control traditionally

are based on intraoperative transesophageal echocardiogram

(TEE) and aortography.1,2 We report, for the first time in

humans, a transapical TAVI performed using an intracardiac

echocardiogram (ICE) without angiography.

CLINICAL SUMMARYA 78-year-old man with symptomatic aortic stenosis was

evaluated for TAVI. Concomitant comorbidities were coro-

nary artery sclerosis, peripheral vascular disease, bilateral

carotid stenosis, and pulmonary hypertension (50 mm Hg).

He also had alcohol-related liver cirrhosis (Child score A)

complicated by grade 2 esophageal varices (treated with

propranolol) and a platelet count chronically less than

80 3 103/dL. The echocardiogram showed severe aortic ste-

nosis (orifice area, 0.55 cm2) with transvalvular peak and

mean gradients of 68 mm Hg and 38 mm Hg, respectively,

moderate left ventricular hypertrophy, and preserved function

(left ventricular ejection fraction, 60%). The logistic Euro-

SCORE was 18%. However, the EuroSCORE does not

take into consideration the liver cirrhosis, which is an impor-

tant risk factor negatively influencing the outcome of high-

risk patients undergoing standard cardiac surgery. Therefore,

we offered the patient a less-invasive procedure, and a transap-

ical TAVI was scheduled. Computed tomography scan mea-

surements showed the following: aortic annulus ¼ 24 mm

diameter; distances between the annulus and the coronary

ostia¼ 10.5 mm (left) and 11 mm (right); and C-arm fluoros-

copy pre-orientation ¼ 18 degrees left (lateral position) and

11 degrees cranial. Before the procedure, a gastroscopy (per-

formed with care under general anesthesia) confirmed the

presence of esophageal varices contraindicating TEE use.

From the Departments of Cardiovascular Surgerya and Cardiac Anaesthesia,b and the

Paediatric Cardiology Unit,c University Hospital of Lausanne (CHUV), Lausanne,

Switzerland.

Disclosures: None.

Received for publication Aug 28, 2009; accepted for publication Jan 1, 2010;

available ahead of print March 18, 2010.

Address for reprints: Enrico Ferrari, MD, Department of Cardiovascular Surgery,

Centre Hopitalier Universitaire Vaudois (CHUV), 46, rue du Bugnon, CH-1011

Lausanne, Switzerland (E-mail: enricoferrari@bluewin.ch).

J Thorac Cardiovasc Surg 2010;140:e32-4

0022-5223/$36.00

Copyright � 2010 by The American Association for Thoracic Surgery

doi:10.1016/j.jtcvs.2010.01.007

e32 The Journal of Thoracic and Cardiovascular Surg

Therefore, we decided to use, for the first time in humans,

an ICE system to guide the procedure.3 The left subclavian

vessels were exposed and equipped as follows: a 14F sheath,

followed by the ICE probe (Acuson AcuNav; Siemens

Medical Solutions, Germany), was introduced into the vein

and advanced into the right atrium (Figure 1, A), and a 6F

pigtail catheter was introduced into the artery and advanced

toward the aortic leaflets. Once the probe connected, ICE

provided optimal long- and short-axis views of the aortic

root with good valve images (comparable to TEE images).

We routinely use echocardiographic guidance and fluoros-

copy without angiography for stent-valve implantation (to

prevent contrast-induced nephrotoxicity). In this particular

case, we used the same technique for the following reasons:

(1) To avoid parallax among the 3 aortic leaflets (all in 1

plane), the C-arm fluoroscopy was preoriented (computed

tomography scan measurements); (2) specific landmarks

for the valve positioning were identified under ICE and fluo-

roscopy: the valve calcifications, hinge point of the aortic

valve cusps (ideal landing zone), hinge point of the anterior

mitral valve leaflet (the ventricular-side limit), coronary

ostia, and pigtail into the aorta; (3) under ICE, the aortic

and ventricular edges of the crimped stent valve (26 mm

Edwards-Sapien; Edwards Lifesciences, Irvine, Calif) were

identified for the fine-tuned positioning (Figure 2, A); and

(4) the crimped device was deployed in the ideal landing

zone (straddle the native valve) under ICE and fluoroscopic

control without contrast (Figure 1, B). Postoperatively, ICE

showed good positioning, patent coronary ostia, a gradient

of 12 mm Hg, and no leaks (Figure 2, B, C). The operative

time was 105 minutes, and the recovery was uneventful with

fast extubation, 1 day of intensive care unit stay, and dis-

charge after 8 days.

DISCUSSIONPatients who are candidates for transapical TAVI carry

several comorbidities. Among them, clinically relevant

esophageal varices contraindicate intraoperative TEE use,

an indispensable tool for stent-valve positioning. Advan-

tages of using TEE during the key phases of the procedure

have been outlined in previous reports,1,2,4 and errors occur-

ring during the valve positioning/implantation can lead to

potential life-threatening complications (embolization,

malpositioning).5 Moreover, although a stent valve can be

oriented and implanted solely under angiography, TEE

ery c August 2010

FIGURE 2. Images taken from the ICE inserted through the left subclavian

vein. A, Edwards-Sapien stent-valve positioning (Edwards Lifesciences,

Irvine, Calif). The ventricular and aortic edges of the crimped stent valve

(thin and thick arrows, respectively) are identified, and the valve is posi-

tioned in the ideal landing zone. B and C, Postoperative control showing

the correct opening and closure of the device during systole and diastole.

FIGURE 1. A, Image taken from the fluoroscopic machine shows the ICE

probe in the superior vena cava (black arrow), a pigtail catheter in the

ascending aorta against the valve leaflets, and a super-stiff guidewire

through the cardiac apex and the aortic valve. B, Image taken from the fluo-

roscopic machine shows the ICE probe (black arrow) placed into the right

atrium during stent-valve deployment.

Brief Clinical Reports

remains crucial for the hemodynamic assessment at the end

of the procedure, especially when repositioning or re-bal-

looning is required. Also, the valve implantation, solely un-

der angiography, may be challenging and the extensive use

of contrast can lead to postoperative renal failure. This report

confirms that ICE can provide good images (comparable to

The Journal of Thoracic and Cardiovascular Surgery c Volume 140, Number 2 e33

Brief Clinical Reports

TEE images, in our limited experience) and seems to be an

adequate guide in positioning the stent valve and performing

postprocedural controls. Nevertheless, echocardiographic

guidance for TAVI can be limited by low-quality images

or shadows (ie, presence of a mechanical prosthesis in the

mitral position) and strongly depends on the operator’s abil-

ity and skills.

CONCLUSIONSWe do not believe that ICE will become a routine tool for

TAVI, but we demonstrated that a TAVI procedure guided

by ICE and fluoroscopy without angiography is feasible

and can be used for select high-risk patients with TEE

e34 The Journal of Thoracic and Cardiovascular Surg

contraindications or TAVI procedures under epidural

anesthesia in conscious patients.

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aortic valve implantation. Eur J Cardiothorac Surg. 2009;36:938-40.

3. Huber CH, Cohn LH, von Segesser LK. Direct-access valve replacement a novel

approach for off-pump valve implantation using valved stents. J Am Coll Cardiol.

2005;46:366-70.

4. Moss RR, Ivens E, Pasupati S, Humphries K, Thompson CR, Munt B, et al. Role of

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Imaging. 2008;1:15-24.

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Unexpected complications of transapical aortic valve implantation. Ann Thorac

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ery c August 2010