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Echocardiographic Imaging of ProceduralComplications During Balloon-ExpandableTranscatheter Aortic Valve Replacement
Rebecca T. Hahn, MD,* Susheel Kodali, MD,* E. Murat Tuzcu, MD,y Martin B. Leon, MD,* Samir Kapadia, MD,yDeepika Gopal, MD,z Stamatios Lerakis, MD,x Brian R. Lindman, MD,k Zuyue Wang, MD,{ John Webb, MD,#Vinod H. Thourani, MD,x Pamela S. Douglas, MD**
ABSTRACT

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Transcatheter aortic valve replacement (TAVR) using a balloon-expandable valve is an accepted alternative to surgical

replacement for severe, symptomatic aortic stenosis in high risk or inoperable patients. Intraprocedural transesophageal

echocardiography (TEE) offers real-time imaging guidance throughout the procedure and allows for rapid and accurate

assessment of complications and procedural results. The value of intraprocedural TEE for TAVR will likely increase in the

future as this procedure is performed in lower surgical risk patients, who also have lower risk for general anesthesia, but a

greater expectation of optimal results with lower morbidity and mortality. This imaging compendium from the PARTNER

(Placement of Aortic Transcatheter Valves) trials is intended to be a comprehensive compilation of intraprocedural

complications imaged by intraprocedural TEE and diagnostic tools to anticipate and/or prevent their occurrence.

(J Am Coll Cardiol Img 2015;8:288–318) © 2015 by the American College of Cardiology Foundation.

T ranscatheter aortic valve replacement(TAVR) using a balloon-expandable valve isan accepted alternative to surgical replace-

ment for severe, symptomatic aortic stenosis inhigh-risk or inoperable patients (1,2). Although echo-cardiography is important in the pre-procedural eval-uation of patients undergoing TAVR (particularly tocharacterize and quantitate the severity of aortic ste-nosis [3,4] and assist in valve sizing [5,6]), other im-aging modalities (e.g., computed tomography) arealso useful for assessing the aortic valvular complexbefore transcatheter heart valve (THV) implantation(7–18). However, intraprocedural transesophagealechocardiography (TEE) offers the significant advan-tage of accurate real-time imaging and is incompa-rable in its ability to anticipate proceduralcomplications and verify procedural results (19–21).

m the *Columbia University Medical Center/New York-Presbyterian

undation, Cleveland, Ohio; zBaylor Scott & White Health, Plano, Texa

orgia; kWashington University School of Medicine, St. Louis, Missouri; {Mniversity of British Columbia and St. Paul’s Hospital, Vancouver, Onta

dicine, Duke University Medical Center, and Duke Clinical Research Ins

b contracts with Edwards Lifesciences for which she receives no d

althcare, St. Jude Medical, and Boston Scientific. Dr. Kodali has receiv

bb has served as a consultant to Edwards Lifesciences. Dr. Thoura

esciences. Dr. Douglas has received research grants to her institution.

ationships relevant to the contents of this paper to disclose.

nuscript received December 5, 2014; revised manuscript received Decem

Moreover, intraoperative TEE provides rapid and ac-curate information for detection of potentially lethalcomplications. Prompt diagnosis and subsequenttreatment improve outcomes (21). Although somecenters choose not to use this imaging tool duringTAVR (22), other sites have advocated using TEE asthe primary imaging tool (23), reporting a significantreduction in contrast media use with no reductionin safety.

The value of intraprocedural TEE is unlikely todiminish in the future. Current guidelines continue toadvocate the use of TEE as a critically importantcomponent of the intraprocedural and immediatepost-procedural success of TAVR (19,24,25). Recentstudies suggesting that intraprocedural TEE may notbe necessary for TAVR (22,26–29) fail to appreciatethat the safety bar will be even higher in moderate

Hospital, New York, New York; yCleveland Clinic

s; xEmory University School of Medicine, Atlanta,

edstar Health Research Institute, Washington, DC;

rio, Canada; and the **Division of Cardiovascular

titute, Durham, North Carolina. Dr. Hahn has Core

irect compensation; and is a speaker for Philips

ed consulting fees from Edwards Lifesciences. Dr.

ni has received research support from Edwards

All other authors have reported that they have no

ber 19, 2014, accepted December 22, 2014.

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http://dx.doi.org/10.1016/j.jcmg.2014.12.013

AB BR EV I A T I O N S

AND ACRONYM S

AV = aortic valve

CMR = cardiac magnetic

resonance

LCA = left coronary artery

LV = left ventricular

PAR = paravalvular aortic

regurgitation

TAVR = transcatheter aortic

J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 8 , N O . 3 , 2 0 1 5 Hahn et al.M A R C H 2 0 1 5 : 2 8 8 – 3 1 8 Complications of TAVR

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risk patients who are subjected to TAVR. Sites usingthe “minimalist approach” are highly experienced,and recommending this approach to implant opera-tors with lower procedural volumes may be illadvised. In fact, in a study of an intermediate riskpopulation using the minimalist approach (26) the30 day mortality rate is in fact higher than that re-ported in a higher risk patient population of thePARTNER (Placement of Aortic Transcatheter Valves)trial (30).

SEE PAGE 337valve replacement

TEE = transesophageal

echocardiography

THV = transcatheter heart
Because TAVR is a relatively new procedure, it isimportant for both experienced and novice operatorsto be aware of the echocardiographic appearance ofmajor complications and for the interventionaliststo react to those findings. There have been multi-ple reports of complications of the procedure,including access issues (31–33), aortic root trauma(34–36), malpositioning of the THV (37–39), coronaryobstruction (40,41), paravalvular regurgitation (PAR)(42–49), ventricular septal or mitral leaflet perfora-tion (35), and cardiogenic shock (50,51). This imagingcompendium from the PARTNER trials is intended tobe a comprehensive compilation of intraproceduralcomplications imaged by using intraprocedural TEEand diagnostic tools to anticipate and/or preventtheir occurrence. The compendium uses both stan-dard and structure-specific imaging planes outlinedin the recent American Society of Echocardiography(ASE) guidelines (25) as well as the guidelinesfor 3-dimensional (3D) echocardiographic imagingacquisition and display (52). Imaging planes andtransducer angles are well described in the guidelinesand will not be included in this paper.
The intended audience for this report includesexperienced and beginning “procedural” echocardi-ographers, as well as interventionalists and surgeonsperforming TAVR. It is intended to serve both asa teaching guide providing “tips and tricks” to assistin daily practice and as a reference work con-taining unusual or exceptional findings. Because thePARTNER trials represent the initial experience withTAVR in the United States, many of the findingsindicate steps on the learning curve for the field aswell as for each of the participating research sites,almost none of whom had experience with this pro-cedure. Documenting these early missteps is highlyinformative even though some of these findings mayrarely occur for current, more experienced teams.

A total of 527 patients in the PARTNER 1trial underwent TAVR with the first generationballoon-expandable THV (Edwards SAPIEN, Edwards

Lifesciences, Irvine, California). The list ofcomplications in Table 1 was compiled byreviewing the adverse event log from thePARTNER I trial and the core laboratory re-cords for complications noted on transthoracicechocardiographic follow-up. Complicationsthat could be imaged by intraproceduralechocardiography were determined and sitespolled for the availability of the original TEEimages. Images were collected and reviewed.Of note, all the complications on the list hadassociated images, which are presented here.Important imaging considerations are sum-marized in Table 2.

COMPLICATIONS

STIFF WIRE LOCATION. Complications can occurduring extra-stiff wire positioning. The most commoncomplication is entanglement in the mitral apparatus.This is frequently recognized by paying strict atten-tion to any change in mitral valve morphology orseverity of regurgitation (Figure 1A, Online Video 1).3D imaging may help confirm the site of entangle-ment (Figure 1B). When recognized, repositioning thewire may avoid other complications, such as ruptureof mitral chordal attachments with subsequent flailleaflet (Figures 1C and 1D). The wire may also perforatethe septum during transapical procedures, causing aventricular septal defect.Balloon aortic valvuloplasty complications. For theballoon-expandable valve, most operators use aballoon aortic valvuloplasty (BAV) to increase valveopening and improve precise positioning of the THV.Some investigators use the stability of the ballooncatheter during BAV as a possible predictor ofoperator-independent motion of the THV and sub-sequent malpositioning. BAV is also used asadjunctive imaging for THV sizing (53–55) and topredict the final position of the native cusps afterTAVR. Although complications with BAV are rare,they vary in appearance and many can be imagedduring the procedure (e.g., severe aortic regurgita-tion, pericardial effusion) by using intraproceduralTEE (56).

Immediately after BAV, it is important to assurethe interventionalists that the valve remains intactand that the aortic regurgitation is not significantlyincreased. In the first case (Figures 2A and 2B, OnlineVideo 2), the etiology of the regurgitation is anavulsed aortic valve (AV). In the second case(Figures 2C and 2D, Online Video 3), the etiology is adisplaced and fixed left coronary cusp. The lattercomplication may resolve spontaneously if the cusps

valve

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TABLE 1 Intraprocedural Complications Reported in the PARTNER Database (N ¼ 527)

Failure to implant:a. Secondary to superior motion of balloon during

BAV in setting of large sigmoid septum

1 (0.2%)

Balloon aortic valvuloplasty complicationsa. Severe aortic regurgitation: stuck or avulsed valveb. Aortic trauma

3 (0.6%)

Acute hemodynamic compromisea. LV collapse (expired)b. RV standstill (expired)

Left ventricle ¼ 5 (1%)Right ventricle ¼ 1 (0.2%)

Malpositiona. Requiring surgical bailout (too low) or

valve-in-valve procedureb. Embolization:

i. Into aorta: due to loss of pacing capture (n ¼ 1)ii. Into left ventricle (n ¼ 1)

Surgical bail-out ¼ 2 (0.4%)Valve-in-valve ¼ 2 (0.4%)

Aortic complicationsa. Aortic dissection (proximal) caused by

embolization of first valveb. Aortic annular rupturec. Descending aortic ruptured. Periaortic hematoma

i. With RCA compressionii. With no hemodynamic consequence

Dissection ¼ 2 (0.4%)Annular rupture ¼ 3 (0.6%)Periaortic hematoma ¼ 3 (0.6%)Descending aorta rupture ¼ 1 (0.2%)

Significant aortic regurgitationa. Severe central AR

i. Post-BAVii. Post-THV (malposition, stuck cusp)

b. Severe paravalvular ARi. Treated with post-dilationii. Treated with valve-in-valve procedure (n ¼ 5)

Severe central AR in THV ¼ 2 (0.4%)BAV complication ¼ 3 (0.6%)Valve-in-valve procedure ¼ 5 (1%)

Bleeding/pericardial effusiona. Post transapical TAVR

i. At cannulation siteii. Adjacent to cannulation siteiii. Hemorrhagic pleural effusion

(requiring pleurodesis)b. Pacemaker perforationc. LV or RV teard. Post-BAV after chest compressions

Apical bleeding ¼ 2 (0.4%)RV cannulated ¼ 1 (0.2%)Pacemaker ¼ 2 (0.4%)LV perforation ¼ 3 (0.6%)BAV CPR ¼ 1 (0.2%)

Fistulasa. Aorta-to-right atrium fistulab. Membranous VSD

3 (0.6%)

Coronary occlusiona. RCA (due to periaortic hematoma)b. Left main occlusionc. Post-transapical cannulation (distal LAD)

3 (0.6%)

Mitral valve regurgitation (acute)a. Mitral valve cusp perforationb. Wire entanglement

1 (0.2%)

Total 49 (9.3%)

Values are n (%).

AR¼ aortic regurgitation; BAV¼ balloon aortic valvuloplasty; CPR¼ cardiopulmonary resuscitation; LAD ¼ leftanterior descending coronary artery; LV ¼ left ventricular; PARTNER ¼ Placement of Aortic Transcatheter Valves;RCA ¼ right coronary artery; RV ¼ right ventricular; TAVR ¼ transcatheter aortic valve replacement; THV ¼transcatheter heart valve; VSD ¼ ventricular septal defect.

Hahn et al. J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 8 , N O . 3 , 2 0 1 5

Complications of TAVR M A R C H 2 0 1 5 : 2 8 8 – 3 1 8

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quickly resume their “closed” position; however,because of the acute hemodynamic compromise thatfrequently occurs with torrential acute aortic regur-gitation, immediate deployment of the THV is usuallyindicated.

BAV can also be used as a diagnostic test to antic-ipate possible complications. Rupture of the balloonduring BAV is typically caused by spicules of calcium.If rupture of the balloon occurs during deploy-ment of the THV, the valve may be significantly

underdeployed, which increases the risk of acute THVembolization. Continuous imaging during BAV mayalso predict the final location of the bulky calcifiedcusps in relation to the aortic root wall as well as theleft main coronary artery. In the setting of small si-nuses of Valsalva, bulky calcified cusps may threatenthe integrity of the aortic root, and deformation of theroot can be imaged during BAV (Figure 3A, OnlineVideo 4) and help predict subsequent trauma to theaorta with TAVR, such as a periaortic hematoma(Figure 3B, Online Video 5). Coronary occlusion hasbeen associated with female sex, small aortic root(sinus diameter 27.8 � 2.0 mm), and height of the leftmain coronary above the annulus. Because no ob-structions appear to be related to THV strut obstruc-tion, the likely mechanism is direct obstruction by thecalcified left coronary cusp (41). Intraproceduralmeasurement of the left main coronary height (abovethe annulus) and length of the left coronary cuspusing 3D echocardiography (Figures 4A and 4B) alertsthe interventionalists to the possibility of left maincoronary artery occlusion by a bulky, calcified leftcoronary cusp. Once a discordance between coronaryheight and cusp length is detected (with cusp lengthtypically >2 mm longer than the coronary height), thediameter of the relevant sinus of Valsalva is thenmeasured. If this diameter is #30 mm, the risk forocclusion is significant, and intraprocedural imagingduring BAV can then be used as a diagnostic testallowing direct visualization of the orifice of the leftmain coronary artery with maximum balloon inflation(Figure 5, Online Video 6). In the example shown,bulky calcium filled the left main ostium, and acrimped coronary stent was adjunctively positionedin the left main coronary artery before TAVR. Aftervalve deployment, there was nearly complete occlu-sion of the left main, and the coronary stent wasquickly deployed.Acute hemodynamic compromise. In the setting ofhemodynamic collapse, the prompt and accuratediagnosis of the underlying problem has paramountimportance. While the anesthesiologist is managingthe hemodynamics and the ventilator, the etiologyof the acute hypotension must be rapidly diagnosedby using intraprocedural TEE (25). Rapid assess-ment of valvular (mitral, THV, tricuspid, and pul-monic) morphology/function, aortic pathology,coronary patency, biventricular function, rootrupture, and pericardial effusion can be performedwithin minutes. Hypovolemia and bleeding canbe suggested by comparing ventricular sizewith baseline imaging. Ruling out such causes isinvaluable for the treatment of these potentiallylethal complications.





TABLE 2 Summary of Echocardiographic Imaging Recommendations

Complication Imaging Recommendations

Wire position Entanglement in mitral apparatusor ventricular perforation

1. 2DE and particularly 3DE imaging of wire position2. Imaging of mitral valve: change in severity of mitral regurgitation or chordal

disruption3. Exclude new pericardial effusion or shunt

BAV Coronary occlusionSevere aortic regurgitationAortic trauma

1. Image during and immediately after BAV for aortic leaflet motion and aorticregurgitation

2. Image the coronary arteries (particularly the left main) for obstruction by the calci-fied leaflets

3. Image the location of the displaced calcified leaflets for possible deformation of theaortic wall or annulus

Pacing or at any timeduring procedure

Acute hemodynamic collapse 1. Exclude acute valvular regurgitation2. Exclude aortic root trauma3. Exclude acute ventricular dysfunction4. Exclude coronary obstruction5. Exclude pericardial effusion/tamponade

Positioning of transcatheter valve Malpositioning 1. Three different positions should be imaged typically from the mid-esophageal longaxis view: during native beats, during pacing, and after final deployment

2. During nonpaced beats, the diastolic valve position is w50% above and below theannulus. In the setting of normal ventricular function, the valve is typically higher insystole and should approximate the paced beat position

3. During paced beats the valve should be 30% to 40% (w5 to 6 mm) below theannulus

4. Optimal final position is 10% to 20% (or 2 to 3 mm) below the annulus5. Superior or aortic edge of the stented valve should be imaged; the native calcified

cusps must be covered by 1 to 2 mm while remaining inferior to the sinotubularjunction

Transapical cannulation Cannulation site misplacement 1. Confirm location of the transapical puncture site by imaging the apex (either frommid-esophageal views or transgastric views)

2. The site should avoid the right ventricle and be angulated away from the interven-tricular septum

3. Assess post-TAVR apical wall motion and exclude persistent transapical flow

Deployment Aortic dissection or periaortichematoma

1. Estimate risk of aortic trauma with evaluation of calcium within the left ventricularoutflow tract, sinuses, and sinotubular junction

2. Watch location of displaced calcium during BAV and during valve deployment

Paravalvular aortic regurgitation 1. Appropriately size the THV with 3DE measurement of the annulus2. Estimate risk of paravalvular regurgitation with evaluation of calcium within the

LVOT and annulus3. Assess likelihood for effective post-dilation (less effective with severe LVOT calcium)4. Assess risk of post-dilation (i.e., left main occlusion or annular/aortic rupture)

Coronary occlusion 1. Estimate risk of coronary occlusion with 3DE measurement of left coronary arteryheight and left coronary cusp length

2. Estimate risk of coronary occlusion by observing the left main orifice and displace-ment of calcium during BAV

Acute LVOT obstruction 1. Assess risk (i.e., small, hypertrophied LV, narrow LVOT, septal hypertrophy)

2DE ¼ 2-dimensional echocardiography; 3DE ¼ 3-dimensional echocardiography; LVOT ¼ left ventricular outflow tract; other abbreviations as in Table 1.


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Rapid pacing is used to reduce forward flow duringboth BAV and TAVR. In those patients (typically withsignificantly reduced baseline left or right ventricularfunction), the 5 to 10 s of low forward flow may causesignificant global or regional ischemia, resulting insevere persistent hypotension or even cardiac arrest/pulseless electrical activity (Figure 6). Allowing thesepatients to recover their blood pressure and ventric-ular function between BAV and TAVR may avoidsignificant hemodynamic compromise.Malposition and failure to implant. Marked and typi-cally focal hypertrophy of the basal septum is not un-common in elderly subjectswith severe aortic stenosis.In the setting of marked hypertrophy as well as dy-namic narrowing of the left ventricular outflow tract(LVOT), there are a number of risks, primarily related

to accurate placement of the balloon-expandablevalve. This dynamic narrowing can be best appreci-ated by using 3D TEE (Figure 7, Online Video 7).Operator-independent motion of the valve prosthesis(either ventricular or aortic) due to marked dynamicnarrowing of the LVOT can result in significantmalposition of the valve (Figure 8, Online Video 8).There are no strict criteria for septal thickness or de-gree of LVOT narrowing that would warrant abortingthe procedure; however, the BAVmay again be helpfulin the decision-making process. One patient in thecurrent study had severe septal hypertrophy thatpushed the BAV balloon into the ascending aorta onrepeated valvuloplasties; this increased the concern ofmalpositioning, which prompted the interventionalistto abort the procedure.



FIGURE 1 Acute Severe Mitral Regurgitation

During stiff wire positioning, malcoaptation of the mitral valve leaflet (A, red arrow) (Online Video 1), resulting in severe mitral regurgitation,

may be the first clue to entanglement of the wire in the mitral apparatus (B, dashed red arrow). With repositioning of the wire, coaptation

of the mitral valve is now normal (C, blue arrow) with mild mitral regurgitation. The correct position of the wire is confirmed by using

3-dimensional imaging (D, dashed yellow arrow).



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A large meta-analysis of 9,251 patients from46 studies reported a low rate of bailout surgery(1.1 � 1.1%); the most frequently reported reason foremergent surgery was embolization/dislocation ofthe AV prosthesis (41%) (57). Malpositioning of thevalve is also recognized as an important factorcontributing to the presence of paravalvular aorticregurgitation (PAR) as well as poor THV hemody-namics, mitral valve compromise, and conductiondefects (35,58–66).

Accurate positioning of the balloon-expandablevalve requires an understanding of the motion andshortening of the THV during deployment. Fluoros-copy has shown that the device-center upper move-ment during final deployment was (on average) 2.0 �1.43 mm (range –1.3 to 4.6 mm), with shortening ofthe device due to asymmetrical upward movement ofthe ventricular edge of THV by 3.2 � 1.4 mm and theupper (aortic) edge by only 0.75 � 1.50 mm (67). Theoptimal final THV deployment position resulted in17% of the THV below the base of the aortic sinuses(determined by pigtail catheter position or aorto-graphy); this translated to 33% of the valve below thesinuses during the final pacing run. Multivariate

analysis revealed that greater upward movementwas seen with moderate and severe (vs. mild)AV calcification and smaller aortic sinus volume.Valve design iteration (first generation balloon-expandable or second generation balloon-expandablevalve), procedural access (transfemoral vs. trans-apical), and interventricular septum width did notaffect THV movement. Similar motion and shorteningcan be seen with echocardiography; however, thevalve is positioned not by the lowest border ofthe sinus of Valsalva but rather by the hinge-point ofthe aortic cusps (i.e., the virtual annulus), which maybe slightly “aortic” to the fluoroscopic landmark(Figure 9A). Because the valve typically moves up(aortic) during the pacing run, mimicking the “sys-tolic” position during nonpaced beats, this nonpaced,diastolic valve position should be w50% below thehinge-point of the aortic cusps (Figure 9B). Becausethe ideal position of the valve is 2 to 3 mm below theannulus and the shortening of the second generationballoon-expandable valve is 3 mm primarily fromthe ventricular side, the valve should be typically30% to 40% (w5 to 6 mm) below the echocar-diographic annulus during the final pacing run


FIGURE 3 Aortic Trauma Predicted by BAV

Bulky calcified cusps cause deformation of the root during BAV (A, yellow arrow) (Online Video 4). This patient suffered a periaortic hematoma

within minutes of transcatheter valve deployment (B, red arrow) (Online Video 5). Abbreviation as in Figure 2.

FIGURE 2 Complications of BAV

Long axis views immediately after balloon aortic valvuloplasty (BAV) show an avulsed leaflet seen in systole (A, blue arrow) (Online Video 2),

resulting in severe aortic regurgitation in diastole (B, yellow arrow). Short axis views immediately after BAV show immobile aortic cusps in an

“open” position (C, red arrows) (Online Video 3), resulting in severe aortic regurgitation in diastole (D, yellow arrow).


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FIGURE 4 Intraprocedural Measurement of the LM Coronary Height (Above the Annulus) and Length of the LCC by

Using 3D Echocardiography

(A) Shows multiplanar reconstruction of the 3-dimensional (3D) volume into the transverse, sagittal, and coronal planes. Typically, the coronal

plane must be used to simultaneously image the annulus-to-left main (LM) height (B). LCC ¼ left coronary cusp.



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(Figure 9C, Online Video 9). The final position of theoptimally deployed valve is w10% to 20% (w2 to 3mm) below the hinge-points of the aortic cusps(Figure 9D). In addition to positioning according tothe ventricular edge of the crimped THV, assessingthe superior or aortic edge of the stented valve shouldbe performed; the native calcified cusps must becovered by 1 to 2 mm (given the w1 mm shortening ofthe valve from this end and despite the minimal su-perior [aortic] motion of the THV), while remaininginferior to the sinotubular junction.

With transapical or transaortic deployment, theoperator can reposition the valve during this finalcritical stage in a controlled, predictable way (Figure10A). However, for transfemoral deployment, precisecontrolled movements remain more difficult, whichcan risk malpositioning. Loss of pacing capture dur-ing final deployment may also result in significantsuperior motion of the valve into the aorta in thesetting of active ventricular contraction (Figure 10B).Positioning too low in the ventricle (Figure 10C) risksleaving leaflets uncovered or creating leaflet over-hang, leading to significant central aortic regurgita-tion. Although a small amount of native leafletoverhang is not uncommon (particularly near thecommissures where the leaflet attaches to the sino-tubular junction), leaving a significant amount ofcalcified, rigid leaflet above the THV (Figure 11A,Online Video 10) may lead to complications. Because

the calcified leaflets are the primary means ofanchoring the THV, if the THV has been implantedtoo low with significant leaflet overhang, there can beacute (68,69) or delayed (70–72) migration of thevalve into the ventricle. In theory, the calcifiedoverhanging leaflets may exert continued downwardforce on the THV, thus contributing to the proximalmigration. Leaflet overhang can also contribute tovalve dysfunction or early valve degeneration. Theuse of the intraprocedural TEE is instrumental in thediagnosis of native aortic overhang. The exampleshown (Figure 11B, Online Video 11) reflects acute THVleaflet entrapment, resulting in significant aorticregurgitation.Aortic complications. A number of aortic complicationscan occur as a result of the TAVR procedure,including aortic dissections, thoracic aorta perfora-tion with resulting hemorrhage, and aortic annularrupture.Aortic Dissection. Proximal aortic dissection may occurimmediately (intraprocedural) or become evidentlater. The postulated etiology is trauma from theprocedure itself (i.e., balloon dilation, the intro-ducing catheter, deployment of the THV) or fromdisplacement of sharp, bulky calcium during theprocedure. Some dissections may be treated conser-vatively; however, if an acute dissection extendsproximal into the sinuses of Valsalva, surgical inter-vention may then be necessary (particularly if the




FIGURE 5 LM Coronary Artery Occlusion Predicted by BAV

Simultaneous multiplane imaging shows the patent LM coronary artery (A, yellow arrow) (Online Video 6). With balloon inflation during BAV

(B) the bulky calcium of the LCC occludes the ostium (red arrow). This patient required a LM stent immediately after transcatheter aortic valve

replacement (TAVR). Abbreviations as in Figures 2 and 4.


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coronary arteries are threatened). An acute, intra-procedural proximal dissection is shown in Figure 12(Online Video 12). This complication can lead to acutetamponade necessitating open repair but often with apoor outcome. Some dissections may be undiagnosedat the time of implantation, suggesting a more benigncomplication. Figure 13 (Online Video 13) is anexample of a proximal aortic dissection diagnosedlate (>6 months) after TAVR. The dissection flapextended to the sinotubular junction but not into thesinuses, and the patient was treated conservatively.Aortic Annular Rupture. A recent multicenter retro-spective study (73) studied 31 patients with aorticroot rupture (20 with annular rupture and 11 withperiaortic hematoma) and compared them with31 matched control subjects. Patients with aortic root

rupture had a higher degree of subannular/LVOTcalcification quantified by an Agatston score of181.2 � 211.0 versus 22.5 � 37.6 (p < 0.001), a higherfrequency of $20% annular area oversizing (79.4% vs.29.0%; p < 0.001), and an increased need for balloonpost-dilation (22.6% vs. 0.0%; p ¼ 0.005). In condi-tional logistic regression analysis for the matcheddata, moderate/severe LVOT/subannular calcifi-cations (odds ratio: 10.92 [95% confidence inter-val: 3.23 to 36.91]; p < 0.001) and prosthesisoversizing $20% (odds ratio: 8.38 [95% confidenceinterval: 2.67 to 26.33]; p < 0.001) were associatedwith aortic root contained/noncontained rupture.

TEE imaging can be a valuable tool for evaluatingthe extent and location of LVOT calcium. This in-formation is important in estimating the risk for




FIGURE 6 Acute Hemodynamic Collapse

Baseline ventricular function was normal in simultaneous multiplane imaging (A); however, after a prolonged pacing run during valve deployment,

there was severe significant ventricular dysfunction (B) with resulting dense spontaneous contrast (slow flow) secondary to low cardiac output.

FIGURE 7 Septal Hypertrophy and Dynamic Narrowing of the LVOT

In this dual-plane 3-dimensional image of the aortic valve, dynamic narrowing of the left ventricular outflow tract (LVOT) can be seen

(yellow arrows) (Online Video 7).



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FIGURE 8 Operator-Independent Motion of the THV Due to Dynamic Narrowing of the LVOT

In (A), the position of the transcatheter heart valve (THV) can be seen (red insert and cartoon). With balloon inflation during deployment (B),

there is prominent superior motion of the THV (green insert and cartoon), which results in positioning of the THV above the annulus (yellow

arrow) (Online Video 8). Abbreviation as in Figure 7.

FIGURE 9 Positioning of the THV

(A) (modified from Dvir et al. [67]) shows the desired fluoroscopic position of the valve just before balloon inflation (during rapid pacing).

(B) shows the transesophageal echocardiographic position during native rhythm and in diastole, which results in a superior positioning

during pacing (C). Shortening of the valve results in positioning of the proximal edge of the THV 1 to 2 mm below the native annulus (D)

(Online Video 9). Abbreviation as in Figure 8.


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FIGURE 10 Malpositioning of the Valve

(A) shows a well-positioning valve with typically 20% of the valve below the native annulus. (B) shows a valve position into the aorta (see also

Figure 20). (C) shows a valve positioned within the LVOT. Abbreviation as in Figure 7.

FIGURE 11 Malpositioning of the THV

Positioning of the THV too ventricular (low), with failure to cover the native cusps, risks native leaflet overhang. In this simultaneous multiplane

image, the THV leaflet has become entrapped by the bulky calcium of the overhanging native cusp (A, yellow arrow) (Online Video 10), resulting in

significant aortic regurgitaton (B, yellow arrow) (Online Video 11). Abbreviation as in Figure 8.



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FIGURE 12 Acute Proximal Aortic Dissection

The transcatheter valve (A and C, blue arrows) is well positioned; however, a dissection flap is seen (red arrows) from long axis (A) and short

axis (B) views. The complex nature of the dissection is only appreciated by 3-dimensional imaging (C, multiple red arrows) (Online Video 12).

This complication led to acute tamponade requiring open heart surgery.


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annular rupture, as well as residual PAR (Figure 14,Online Videos 14 and 15). Simultaneous multiplaneimaging allows an accurate assessment of the loca-tion of the calcium, which has been shown to be apredictor of PAR secondary to malapposition of theTHV skirt. A risk/benefit analysis should be per-formed when assessing the possible effectiveness ofre-ballooning to treat PAR because a small leakadjacent to a rigid calcium nodule may not resolveby using this intraprocedural therapy. Severedystrophic calcification extending typically from theleft coronary cusp into the LVOT will be forced

FIGURE 13 Delayed Proximal Aortic Dissection

A proximal aortic dissection was diagnosed late (>6months) after TAVR by

imaging. The dissection flap (red arrows) extends to the sinotubular juncti

Abbreviation as in Figure 5.

through the annulus/adjacent myocardium duringballoon inflation (Figure 15A). The resultant periaortichematoma (Figure 15B, Online Video 16) and rapidlyaccumulating pericardial effusion (Figure 15C), as wellas the atypical flow originating from the annulus(Figure 15D, Online Video 17), should immediatelyindicate the diagnosis of annular rupture. In additionto treatment of tamponade with pericardial drainage,rapid initiation of cardiopulmonary bypass shouldbe considered.Periaortic and Intramural Hematoma. Microrupture ofthe aorta resulting in periaortic hematoma deserves

using 2-dimensional (A and B) and 3-dimensional (C) (Online Video 13)

on but not into the sinuses, and the patient was treated conservatively.







FIGURE 14 LVOT Calcium and Risk of PAR

Using simultaneous multiplane imaging from the long-axis view (A) (Online Video 14), the level of orthogonal imaging plane (indicated by the

dotted white line) is in the LVOT. LVOT calcium is seen in the short-axis view (yellow arrow) with a wire also across the valve (red arrow). After

TAVR (B) (Online Video 15), a small jet of PAR (yellow arrow) was noted adjacent to the LVOT calcium. The mild central regurgitation (green

arrow) resolved once the wire was removed. PAR ¼ paravalvular aortic regurgitation; other abbreviations as in Figures 5 and 7.



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special mention. This complication with a reportedsingle-site incidence of 1.6% can be managed medi-cally if recognized early (34). In contradistinction tointramural hematoma (which is bleeding into the wallof the aorta), periaortic hematoma arises from amicroperforation of all 3 layers of the aorta, and thehematoma that forms appears as a tissue-densitymass around the outside of the aortic root(Figures 16A and 16B). The perforation likely occursafter stretching of the aortic wall from displacedbulky calcium during balloon inflation/deployment ofthe THV. This process appears to be self-limiting,with the microperforation sealing quickly oncethe balloon is deflated or the aorta is no longerstretched. Conservative management of the periaortichematoma (including administration of protamine,

continued intubation with restricted activity, andmeticulous blood pressure control) result in excellentoutcomes. Failure to recognize this complication,however, may result in uncontrolled hypertension,leading to continued bleeding within the wall of theaorta and resulting in an intramural hematoma(Figure 17). Although the outcomes in patients withTAVR are unknown, intramural hematomas in theascending aorta have been associated with mortalityrates as high as 40% when treated medically (74).Aortic Regurgitation. It is important to distinguish be-tween post-TAVR PAR and central aortic regurgita-tion since the approach to treatment of these 2entities are different.Paravalvular Aortic Regurgitation. Numerous studieshave shown an association between post-procedural



FIGURE 15 LVOT Calcium and Risk of Annular Rupture

Immediately after TAVR, the severe dystrophic calcification extending from the left coronary cusp into the LVOT caused annular disruption,

which is easily imaged on 3-dimensional (3D) reconstruction (A, red arrow). Immediately after deployment, a periaortic hematoma (B, yellow

arrows) (Online Video 16) and rapidly accumulating pericardial effusion (C, green asterisk) are seen. Color Doppler showed abnormal flow

originating from the annulus but directed into the center of the LVOT (D, red arrow) (Online Video 17). Abbreviations as in Figures 5 and 7.


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PAR and increased late mortality (30,47,49,75–80),generating intense interest in determining thefactors that predict the occurrence of PAR. A recentmeta-analysis confirms the importance of 3 factors:undersizing of the annulus, severity of aorticcalcification, and implantation depth (49).

Determining the severity and etiology of PAR is aprimary focus of post-TAVR imaging. The extent ofcalcification and asymmetric distribution, as well asthe location of calcium on the aortic wall, valvecommissure, or THV landing zone, have all beenimplicated as etiologies of PAR (44,47,81–86). Thelocation and severity of calcification within the LVOTshould be ascertained before TAVR; if the severity isless than mild, PAR is usually localized to regions inwhich calcium may prevent stent frame apposition(Figure 14). If there is a significant risk of rupture orthe risk of central regurgitation from overexpansionis high, then no further intervention may be war-ranted. If the severity of PAR is greater than mild in

the setting of a low-risk “landing zone” (i.e., no bulkycalcium in the LVOT or annulus), intervention witheither a post-dilation or a valve-in-valve proceduremay then be warranted.

Determining the severity of PAR and thus theappropriate intraprocedural treatment remains chal-lenging for numerous reasons. First, the ASEhas suggested numerous qualitative and semi-quantitative parameters for assessing surgical pros-thetic PAR (87). However, the irregular shape,atypical direction, and number of paravalvular jetsseen after TAVR makes assessment using thesetraditional methods questionable. In addition, 1 ofthe semiquantitative parameters mentioned in theASE guidelines (i.e., circumferential extent of thejet) had little validation. Subsequent to this guide-line, the updated VARC-2 (Valve Academic Re-search Consortium) consensus document (88), aswell as methods used for the PARTNER trial (89),used different cutoffs for this parameter: no PAR



FIGURE 17 Intramural Hematoma

Bleeding into the wall of the aorta is seen as thickening of the wall between the adventitia (yellow arrows) and endothelium (green arrows).

In the long axis view (A), this may be associated with periaortic hematoma (red arrows). (B) shows extension into the descending aorta with

a circumferential thickening of the wall.

FIGURE 16 Periaortic Hematoma

A self-limited microperforation of all 3 layers of the aorta may result in a hematoma forming around the outside of the aortic root. (A) shows a

simultaneous multiplane image of the native aortic root, and B (red arrows) shows the self-contained periaortic hematoma which formed after

transcatheter aortic valve replacement, contained by the aortic adventitia. Failure to recognize and appropriately respond to this complication

may result in continued bleeding into the adventitial space and aortic rupture.



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FIGURE 18 Grading of PAR by Circumferential Extent of the Jet From Short Axis Views

Assessment of the circumferential extent of PAR should be performed just below the THV

stent (within the LVOT). No PAR (no regurgitant color flow) is defined as a trace (pinpoint

jet in aortic valve short axis view). (A) (Online Video 18) shows mild PAR (jet arc lengths are

discontinuous, but total <10% of the aortic valve [AV] annulus short axis view circum-

ference). (B) (Online Video 19) shows moderate PAR (jet arc lengths are discontinuous, but

total 10% to 30% of the AV annulus short axis view circumference). (C) (Online Video 20)

shows severe PAR (jet arc lengths are discontinuous, but total >30% of the AV annulus

short axis view circumference). Abbreviations as in Figures 7, 8, and 14.


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(no regurgitant color flow), a trace (pinpoint jet inAV short axis view), mild (jet arc length is <10% ofthe AV annulus short axis view circumference),moderate (jet arc length is 10% to 30% of the AVannulus short axis view circumference), and severe(jet arc length is >30% of the AV annulus shortaxis view circumference) (Figure 18, Online Videos 18,19 and 20). It is important to note that frequently thejets are multiple and discontinuous. The circumfer-ential extent should be measured as the sum of theseparate jets, not the paravalvular arc which includesthe nonregurgitant space between jets.

Recent studies using cardiac magnetic resonance(CMR) confirm the limitations of echocardiographicmethods. Cawley et al. (90) reported higher interob-server variability of aortic regurgitation quantifica-tion by TTE (r ¼ 0.89) compared with CMR (r ¼ 0.99).Abdel-Wahab et al. (91) also compared echocardio-graphic assessment of PAR with CMR in a subset ofpatients randomized to receive balloon-expandableand self-expanding valves in the CHOICE (Trans-catheter Heart Valves in High Risk Patients WithSevere Aortic Stenosis: Medtronic CoreValve vsEdwards SAPIEN XT) trial. The study found thatechocardiography underestimated PAR severity afterTAVR only for the CoreValve device. Most recently,Ribeiro et al. (92) systematically looked at the semi-quantitative, multiparametric approach advocated bythe ASE as well as the VARC-2 suggestion of circum-ferential extent of the PAR jets. The authors foundthat the multiparametric approach underestimatedaortic regurgitation severity using CMR by 1 grade in59.5% and by 2 grades in 2.4%. Circumferential extentof prosthetic PAR overestimated severity in 38%,exhibiting a poor correlation with CMR regurgitantvolume and fraction (r2 ¼ 0.32, p ¼ 0.084; r2 ¼ 0.36,p ¼ 0.054, respectively).

Although quantitation of PAR by using echocardi-ography is advocated by all guidelines, the currentmethod is limited by the number of technically diffi-cult measurements, which restricts the applicabilityof these techniques for intraprocedural use. Quanti-tation of prosthetic regurgitant volume, effectiveregurgitant orifice area, and regurgitant fractionshould be performed by using ASE methods (87,93).The regurgitant volume should be calculated as thedifference between the stroke volume across anynonregurgitant orifice (right ventricular outflow tractor mitral valve) and the stroke volume across theLVOT. Interobserver variability of this calculation isreasonable, although higher than for CMR (90).

3D echocardiography may overcome the limita-tions of current 2-dimensional (2D) techniques.A recent study compared the 5 VARC-2 2D TTE







FIGURE 19 3D Color Doppler Quantitation of PAR

(A) Simultaneous multiplane 2-dimensional imaging of PAR (yellow arrows), which by circumferential extent suggests moderate to severe

PAR (Online Video 21). (B) Multiplanar reconstruction of the 3-dimensional (3D) color Doppler jet. (C) The 3D planimetry of the narrow,

irregularly shaped jet, which measures 6 mm2 at the vena contracta consistent with mild PAR. Abbreviation as in Figure 14.



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parameters for assessing TAVR PAR versus 3DTTE-quantified regurgitant volume and fraction, aswell as CMR TAVR (94). The narrowest confidenceintervals for regurgitant volume and regurgitantfraction were between CMR and 3D TEE; there was nosignificant difference between these 2 modalities inthe moderate and severe grades. Figure 19 (OnlineVideo 21) presents an example of intraproceduralquantification of PAR by using 3D color Doppler.Central Aortic Regurgitation. Significant central aorticregurgitation following TAVR may require place-ment of a second THV or valve-in-valve procedure(Figure 20). In a recent study of acute valve-in-valveplacement (38), severe central THV regurgitationwas due to leaflet malfunction in 54% of cases, mal-positioning in 41% of cases, and unknown causes in5% of cases. Transcatheter leaflet malfunction mayoccur in a number of situations. Calcium may pro-trude through the stented valve, impinging leafletmotion. A low-lying THV may leave native leafletoverhanging the THV stent, which can entrap theTHV leaflets (Figure 11). Post-dilation may cause

eversion of the THV leaflet (although this does notoccur with newer iterations of the balloon-expand-able valve). Finally, a tilted/canted valve may distortthe THV frame and result in severe central aorticregurgitation (Figures 20A and 20B). This complica-tion can be treated successfully with a valve-in-valveprocedure (Figure 20C). Transcatheter leaflets maybecome pinned open by the stiff wire (Figure 21,Online Video 22); this complication frequently re-solves with removal of the wire. In the settingof leaflet eversion and before a valve-in-valve pro-cedure, placement of a pigtail catheter in each of thesinuses of the TAVR valve may help in amelioratingthe central insufficiency by causing the evertedleaflet to close normally. Again, with later iterationsof the balloon-expandable valve, the leaflet designprevents this eversion from occurring. Althoughrarely performed (2.4% of cases in the PARTNER 1trial), the majority (88.5%) of repeat valves wereperformed immediately. When valve-in-valve is per-formed in the setting of PAR, the etiology was mostcommonly malpositioning.





FIGURE 20 Malposition of the THV and Central Aortic Regurgitation

Severe tilting/canting of the transcatheter valve (yellow arrows) occurred in the setting of

operator-independent motion of the valve during balloon inflation (A). This malpositioning

prevents normal closure of the valve, resulting in severe central aortic regurgitation (B, red

arrows). After placement of a second transcatheter valve (valve-in-valve salvage), there

was no central regurgitation but moderate paravalvular regurgitation was seen (C, blue

arrows). Abbreviation as in Figure 8.


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Perforation. Perforation of the ventricle can occurfrom any of the wires or catheters that enter thecavity. Right ventricular perforation from the pacingwire may go undetected until removal of the wire. InFigure 22 (Online Videos 23 and 24), rapid but focalaccumulation of pericardial blood was seen on intra-procedural imaging only after removal of the pacingwire, emphasizing the need for continuous imagingthroughout the procedure. Perforation of the leftventricle is typically seen immediately, with accu-mulation of relatively echodense pericardial blood,associated with tamponade physiology (compressionof the ventricular or atrial chambers) and hemody-namic collapse. Figure 23A shows an initially unde-tected left ventricular (LV) perforation in the settingof a transaortic TAVR. This patient was stable forweeks before presenting with progressive dyspneaand a large pseudoaneurysm. Figure 23B shows a LVperforation that occurred in the setting of cardiopul-monary resuscitation after a long pacing run beforeBAV; perforation likely occurred secondary to theBAV catheter being pushed through the left ventricleduring chest compressions. Both TAVR migration andcompression have been reported after cardiopulmo-nary resuscitation. Figure 24 shows an example of theinitial circular shape of the THV (Figures 24A and 24B)in a patient with acute rupture requiring chest com-pressions. Subsequent images reveal a flattening THV(Figures 24C [Online Video 25] and 24D [Online Video26]), and color Doppler suggested turbulent trans-aortic flow.

Perforation of the cardiac tissue at the proximal ordistal border of the THV can lead to unusual intra-cardiac communications. These perforations arelikely related to significant calcific protrusions nearthe edge of the stent. The most common intracardiacshunt is a ventricular septal defect which occurs atthe proximal edge of the THV; the offending calciumextends into the LVOT from the right coronary cusp orcommissure between the right coronary cusp and thenoncoronary cusp (Figure 25, Online Videos 27 and 28)(95–98). Because rupture of the septum in this regionwill likely also result in malapposition of the edge ofthe THV, PAR may accompany this complication.Spectral Doppler flow profiles for this unusual ven-tricular septal defect may thus have prominent dia-stolic flow, as well as typical systolic flow (Figure 26).The diastolic flow is a result of PAR; flow fromthe aorta crosses the ventricular septal defect. Thesystolic flow is a result of the typical ventricularleft-to-right flow. Intraprocedural treatment of thiscomplication is limited given the proximity to thenew THV; however, transcatheter paravalvular leakclosure may reduce the diastolic flow.

Rare cases of muscular ventricular septal de-fects have also been reported after transapical im-plantation of the THV (99,100). This complication isdue to direct perforation by the apical cannula andcan be avoided with imaging of the cannulation sitebefore apical puncture. Using TEE imaging, the sur-geon can determine the optimal position of cannula-tion, avoiding the right ventricle and interventricular








FIGURE 21 Severe Central Aortic Regurgitation

In these color compare images a transcatheter valve leaflet has been pinned open (A, yellow arrows) (Online Video 22) resulting in severe

central aortic regurgitation (A and B, red arrows). This may be due to the stiff wire (B, green arrows), which can respond to removal or

manipulation of the wire.



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septum as well as avoiding the mitral valve apparatus(see Complications unique to transapical TAVR insubsequent text).Coronary occlusion. Coronary obstruction is related tothe displacement of a calcified native AV leaflet intothe coronary ostium. A recent meta-analysis (41) re-ported a <1% incidence of coronary occlusion (range0.0% to 4.1%). Most of the reported 24 cases pre-sented with persistent severe hypotension (87.5%),although ST-segment changes and ventricular ar-rhythmias also occurred. The majority of occlusionsoccurred immediately after valve implantation(83.3%) due to displacement of the calcified nativecusp over the coronary ostium. Rarely patients

presented within the first few hours after the proce-dure (8.3%), or within the first 2 days after theprocedure (8.3%). Coronary obstruction occurredmore frequently in the left coronary artery (LCA)(83.3%) and was successfully treated with percuta-neous coronary intervention in 91.3% of cases. Riskfactors appeared to be female sex and no previousbypass surgery. The height of the left main above theannulus was on average 10.3 mm (range 7 to >12 mm),and w60% of occlusions occurred with a coronaryheight >10 mm. A narrow aortic root with shallowsinuses of Valsalva (leaving little room to accommo-date the calcified native aortic leaflets after valvedeployment) may also be an important factor.


FIGURE 22 Acute Right Ventricular Perforation

After successful TAVR with no evidence of conduction abnormalities, the pacing wire was removed with immediate accumulation of blood seen

by simultaneous multiplane imaging within the pericardial space (A) (Online Video 23) adjacent to the right ventricle (*). This resulted in

obstruction to the tricuspid valve flow (B) (Online Video 24) and ensuing tamponade physiology. Abbreviation as in Figure 5.

FIGURE 23 Ventricular Perforation

(A) A small, undetected left ventricular perforation occurred in the setting of a transaortic TAVR. On follow-up imaging, a ventricular pseu-

doaneurysm was seen (A) with flow from the left ventricle (yellow arrow) to the pericardial space (green asterisk). (B) An example of a BAV

catheter (blue arrow) through the left ventricle at open repair. This complication occurred during cardiopulmonary resuscitation with chest

compressions. Abbreviations as in Figures 2 and 5.


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FIGURE 24 Crushed THV After CPR

(A) The short axis view, and (B) the long axis view after initial deployment of the THV. Chest compressions were subsequently necessary in the

setting of an aortic rupture and short-axis (C) (Online Video 25) and long-axis (D) (Online Video 26) views show narrowing of the anterior-

posterior dimension of the THV. Abbreviation as in Figure 8.

FIGURE 25 Ventricular Septal Rupture

Ectopic calcification may extend into the LVOT along the membranous septum (A, yellow arrow). After TAVR, deep gastric long axis views may

be the best views for imaging the defect in the membranous septum (B, blue arrow) (Online Video 27) with color Doppler (C) (Online Video 28)

showing systolic flow across a traumatic ventricular septal defect. Abbreviations as in Figures 5 and 7.



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FIGURE 26 Atypical Doppler of Ventricular Septal Rupture From TAVR

(A) A typical continuous wave Doppler across a ventricular septal defect after TAVR. On follow-up transthoracic continuous wave Doppler (B),

there is prominent phasic but pan-cyclic flow representing aortic–to–right ventricular systolic and diastolic shunt. Abbreviation as in Figure 5.


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Left Main Occlusion. Characterizing “at-risk” anatomyis of paramount importance in avoiding the compli-cation of left main occlusion. Because the LCA lies inthe coronal plane, routine 2D echocardiography im-aging cannot typically allow measurement of LCAheight above the annulus or left coronary cusp length.

FIGURE 27 Coronary Occlusion

LM coronary occlusion can be imaged immediately after TAVR (yellow a

hemodynamic collapse (Online Video 29). Abbreviations as in Figures 4

One method for predicting left main coronary occlu-sion is to image the coronary artery during the BAVprocedure (as discussed earlier) (Figure 5). If the LCAor right coronary artery ostia become occluded by thebulky calcium of the associated coronary cusp duringBAV, pre-emptive measures should be considered

rrow) and is accompanied by acute left ventricular dysfunction and

and 5.


FIGURE 28 Acute Mitral Valve Regurgitation

At baseline, mitral chordae appear intact (A) (Online Video 30) with trace mitral regurgitation (B). After stiff wire insertion and balloon aortic

valvuloplasty, a ruptured mitral ruptured chordae (C, yellow arrow) (Online Video 31) results in moderate mitral regurgitation (D).

FIGURE 29 SAM of the Mitral Leaflet After TAVR

(A) A hypertrophied basal septum but without systolic anterior motion (yellow arrow) and no significant mitral regurgitation (B) (Online Video 32)

before TAVR. After valve implantation, there is prominent systolic anterior motion (SAM) (C, blue arrow)with turbulent LVOT flow (D, blue arrow)

(Online Video 33) and mitral regurgitation (*). Abbreviations as in Figures 4 and 7.



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FIGURE 30 Papillary Muscle Transection Secondary to Transapical Cannulation

(A) The transapical cannula in a slightly posterior position (Online Video 34), with associated new-onset severe mitral regurgitation (B). Deep

gastric short axis (C) (Online Video 35) and long-axis (D) views of the left ventricle (LV) confirm that the cannula has passed through the

posteromedial papillary muscle head (yellow arrows).


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which enable rapid treatment of an occluded coro-nary following TAVR. These measures may includepositioning a wire or crimped stent in the LCA. Im-mediate post-TAVR imaging of coronary occlusion byusing 2D echocardiography and color Doppler(Figure 27, Online Video 29) with associated regionalwall motion abnormalities may prompt confirmationwith coronary angiography.

The etiologies of delayed coronary occlusion aretheoretical. Late embolization of calcium or low flowwith thrombus formation seem plausible. One authorpostulated that after TAVR, a periaortic hematomamay have formed and resulted in right coronary ar-tery occlusion (101).Mitral valve regurgitation (acute). MV ApparatusCompromise (Perforation and Chordal Rupture). Arecent study of Cohort A of the PARTNER I trial showedthat among 30-day survivors who had TAVR,moderateto severe mitral regurgitation had improved in 57.7%,was unchanged in 36.5%, and worsened in 5.8% (102).Although the cause of worsening mitral regurgitation

could not be delineated in that study, both rupturedchordae resulting in flail leaflets, and mitral leafletperforation have been reported. The latter may bepredicted by a careful assessment of dystrophiccalcification on the anterior mitral leaflet andavoidance of a low implantation. Acute but reversiblechanges in mitral regurgitation may also occur,mainly under 2 circumstances: primary alteration inmitral morphology from wire entanglement (Figure 1)or ruptured chordae (Figure 28, Online Videos 30 and31) and secondary changes in annular morphologydue to severe ventricular dysfunction (i.e., diffuseischemia after long pacing runs) or dilation (i.e.,acute severe aortic regurgitation).

Significant LVOT gradients may occur in up to 14%of patients after surgical AV replacement (103–107),with a similar hemodynamic disturbance having beenreported after TAVR (108) (Figure 29, Online Videos 32and 33). The mechanism is thought to be related to asmall, hypertrophied ventricle and the developmentof systolic anterior motion of the mitral leaflet.








FIGURE 31 Confirmation of Apical Cannulation Site

After limited thoracotomy, the surgeon indicates the intended site of cannulation with an apical poke, which is easily identified in 2 orthogonal

views with simultaneous multiplane imaging (A [Online Video 36]). When appropriately identified, wires pass freely into the LV and across the

AV (B [Online Video 37]). Abbreviation as in Figures 18 and 30.



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Associated with this finding is significant mitralregurgitation. Patients at risk for this finding includethose with a small, hypertrophied ventricle, the useof catecholamines, narrowing of the LVOT, reducedcirculating blood volume, and septal hypertrophy.Because of the association with hypotension andincreased mortality (105,106), it is important torecognize this entity and avoid inotropes or afterloadreduction.

Complications unique to transapical TAVR. Transapicalaortic valve implantation of the balloon-expandableTHV is performed through a mini left anterior thora-cotomy (47,109,110). Fluoroscopic and TEE guidanceare recommended to locate the optimal cannulationsite as well as guide the procedure. A recent meta-analysis of transapical TAVR studies revealed thefollowing incidence of major adverse events: 30-daymortality (4.7% to 20.8%), cerebrovascular accident(0.0% to 16.3%), major tachyarrhythmia (0.0% to48.8%), bradyarrhythmia requiring permanent pace-maker insertion (0.0% to 18.7%), cardiac tamponade(0% to 11%), major bleeding (1% to 17%), myocardial

infarction (0% to 6%), aortic dissection/rupture (0%to 5%), moderate to severe paravalvular leak (0.7% to24.0%), cardiopulmonary bypass support (0% to 15%);conversion to surgery (0.0% to 9.5%), and valve-in-valve implantation (0.6% to 8.0%) (111). Numerousstudies suggest that the learning curve in this proce-dure may play a significant role in outcomes(47,112,113).

There are a number of complications that areunique to the transapical approach. Malpositioning ofthe apical cannulation site risks perforation of theright ventricle, ventricular septum, or papillarymuscle (Figure 30, Online Videos 34 and 35). Thesecomplications can be avoided by using intra-procedural imaging. Figure 31 shows an example ofthe surgeon confirming the intended cannulationsite. After a limited thoracotomy, the surgeon in-dicates the site with an apical poke, which is easilyidentified in 2 orthogonal views with simultaneousmultiplane imaging (Figure 31A, Online Video 36).When appropriately identified, wires pass freely intothe left ventricle and across the AV (Figure 31B, OnlineVideo 37).








FIGURE 32 Indirect Obstruction of Distal Coronary Flow After Cannula Removal and Apical Closure Due to Tension From the

Purse-String Sutures

Marked apical hypokinesis involving more than the immediate cannulation site is shown in this diastolic (A) and systolic (B) (Online Video 38)

multiplane (Online Video 38, short-axis and long-axis) deep gastric views of the LV. Abbreviation as in Figure 30.


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Acute myocardial infarction may occur by eitherdirect or indirect compromise of distal coronary flow.The location of the apical cannulation site is in partdictated by the location of the left anterior descendingaorta or associated coronary artery bypass grafts.Perforation of the vessel is thus unlikely given theability to directly visualize the vessel. However, indi-rect obstruction of distal coronary flow after cannularemoval and apical closure can occur due to tensionfrom the purse-string sutures (114). This rare compli-cation can be first detected by intraprocedural TEE,which shows marked apical hypokinesis involvingmore than the immediate cannulation site (Figure 32,Online Video 38). Treatment by implanting a coronarystent may be warranted.

Because of the direct cannulation through theventricular apex, acute laceration and hemorrhageare possible. Direct visualization of the apex duringclosure should reduce the likelihood of this compli-cation; nonetheless, persistent bleeding and peri-cardial tamponade may occur. Development of apseudoaneurysm may result from incomplete closureof the apical cannulation site but may not be detecteduntil well after the procedure (Figure 33, OnlineVideos 39 and 40).

Malpositioning of the transcatheter valve. Althoughoperator-independent motion of the balloon-expandable valve is usually predictable and has beenwell described for the first generation and secondgeneration balloon-expandable valves (67), there israrely an unexpected extreme motion of the valve.Embolization of the valve into the aorta may itselfresult in aortic trauma, but if not, intentional reposi-tioning of the valve into the descending aorta beyondthe great arteries (Figure 34) may be necessary beforeattempted deployment of a second valve at the aorticannulus. Translocation of the valve into the ventriclecan also occur when the initial position of the valve istoo low (Figure 35, Online Videos 41 and 42). Thiscomplication typically requires open retrieval of thetranscatheter valve.

CONCLUSIONS

This imaging compendium from the PARTNER trials isa compilation of intraprocedural complications ofballoon-expandable THV implantation imaged by us-ing intraprocedural TEE. Although newer iterations ofthe balloon-expandable valve, as well as other valvedesigns, may significantly reduce the rate of some









FIGURE 33 Apical Pseudoaneurysm Formation After Transapical Cannulation

This patient complained of an expanding chest wall mass (A, red asterisk) 6 months after transapical TAVR (yellow arrows show the mini-

thoracotomy scar). Transthoracic imaging revealed a pseudoaneurysm, best seen from the apical views (C, red asterisk) (Online Video 39) with

systolic flow detected on color Doppler (D, blue arrow) (Online Video 40). The finding was confirmed by both echocardiographic intravenous

contrast study as well as chest computed tomography (CT) (B). Abbreviation as in Figure 5.

FIGURE 34 Distal Migration of the THV

Migration of the THV into the aortic arch (A, red arrow)may occur with high positioning of the THV. In this patient, with placement of a covered

stent (B, yellow dashed arrows) was performed to exclude the valve component of the THV. Abbreviation as in Figure 8.



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FIGURE 35 Translocation of the THV into the Ventricle

Migration of the THV into the LV can occur when the initial position of the valve is too low. The simultaneous multiplane image (A) (Online

Video 41), with the long-axis view of the transcatheter valve on the left and the short-axis view on the right, shows the low position of the

transcatheter valve (blue arrows) with significant native leaflet overhang (red arrows). Translocation of the transcatheter valve is seen by

both 2-dimensional (B) and 3-dimensional (C) (Online Video 42) imaging. Abbreviations as in Figures 8 and 30.


315

complications such as PAR, recognizing, predicting, oreffectively reacting to all complications remains animportant aspect of improving the safety of TAVR. Asthe field progresses and lower risk patients are treated,early recognition of complications will remain animportant advantage of intraprocedural imaging.

REPRINT REQUESTS AND CORRESPONDENCE: Dr.Rebecca T. Hahn, Columbia University MedicalCenter, New York-Presbyterian Hospital, 177 FortWashington Avenue, New York, New York 10032.E-mail: [email protected].

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KEY WORDS aortic stenosis,echocardiography, transcatheter aorticvalve replacement

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