Clinical Investigation
Novel Echocardiographic Techniques in Aortic Valve Disease
Orifice Areas of Balloon-Expandable Transcatheter Heart Valves: A Three-Dimensional Transesophageal Echocardiographic Study

https://doi.org/10.1016/j.echo.2021.12.009Get rights and content

Highlights

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    Establishing expected EOAs for THVs is crucial for TAVI planning and follow-up.

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    EOAs by TEE for BE THVs are significantly larger than by TTE.

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    EOAs for BE THVs by TEE agree with GOAs by 3D planimetry.

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    EOAs for BE THVs by TEE correlate better with annular area than EOAs by TTE.

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    Current EOAs for BE THVs may be underestimated, while PPM rates may be overestimated.

Background

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).

Methods

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 30 days were also calculated in a subset of 170 patients.

Results

The average EOA for all BE THV valves (77% SAPIEN 3) was 2.3 ± 0.5 cm2, while the average EOA was 1.6 ± 0.2 cm2 for 20-mm, 2.0 ± 0.2 cm2, for 23-mm, 2.5 ± 0.3 cm2 for 26-mm, and 3.0 ± 0.3 cm2 for 29-mm THV size (P < .001). Bland-Altman analysis demonstrated very good agreement between EOA and GOA3D (bias −0.04 ± 0.15 cm2). 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 ± 0.43 cm2) was not as strong. The overall PPM rate was 2% in the TEE cohort and 12% in the TTE cohort.

Conclusions

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.

Section snippets

Patient Population

We retrospectively reviewed intraprocedural transesophageal echocardiographic examinations performed during TAVI at our institution between December 2013 and February 2020. We excluded cases performed with self-expanding THVs, without TEE, for valve-in-valve procedures, and with absent or suboptimal Doppler interrogation or 3D TEE of the THV. After exclusions, we analyzed transesophageal echocardiographic images from 212 patients who underwent TAVI with the SAPIEN (Edwards Lifesciences, Irvine,

Results

Baseline patient and procedural characteristics are shown in Table 1. The majority of THVs (77%) implanted were SAPIEN 3 devices, with the remaining patients receiving earlier generation BE THVs. Baseline imaging parameters are shown in Table 2. The mean preimplantation aortic valve area was 0.7 cm2, with a peak VEL just under 4 m/sec.

There were significant differences after THV deployment for each iteration of THV size for EOAVTI, EOAVEL, GOA3D, indexed EOAVTI, indexed EOAVEL, and indexed GOA3D

Discussion

This study is the first to exclusively use intraprocedural Doppler and 3D TEE to systematically assess orifice areas for all sizes of BE THVs after TAVI. The main findings of our study are as follows: (1) The calculated orifice areas for BE THVs are significantly larger compared with previously published data using TTE.1, 2, 3 (2) TEE-based EOAs agree very well with Doppler-independent GOA3D. (3) The correlation between annular and orifice areas was stronger for 3D TEE compared with TTE-based

Conclusion

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 function during follow-up of TAVI patients. Further research using TEE-based EOAs for both BE and self-expanding THVs is needed to confirm our findings.

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    • Conflicts of interest: None.

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    2021 by the American Society of Echocardiography.