"The use of TEE as the primary imaging technique for guiding transapical TAVI was associated with clinical and hemodynamic results similar to those of angiographic guidance," Dr. Josep Rodés-Cabau from Laval University, Quebec City, Quebec, Canada, told Reuters Health in an e-mail. "Also, there was a significant reduction in the use of contrast media during the procedures, and this might have major clinical implications with respect to the occurrence of postprocedural contrast nephropathy."
Dr. Rodés-Cabau and colleagues compared TEE with angiography in a total of 100 consecutive patients, the first 25 of whom underwent transapical TAVI with angiography as the primary imaging technique and the last 75 of whom had TEE as the primary imaging technique.
These patients generally had severe symptomatic aortic stenosis deemed inoperable or at very high surgical risk.
Procedural success didn't differ between the two imaging groups, but procedural time was significantly shorter and contrast amount was significantly lower in the TEE group than in the angiography group.
Valve malposition needing a second valve due to transvalvular or paravalvular severe aortic regurgitation occurred in one patient (4%) in the angiography group and in four patients (5.3%) in the TEE group.
There were no cases of valve embolization, valve malposition, or coronary obstruction in the 18 patients who underwent transapical TAVI completely under guidance of TEE and fluoroscopy (with no angiography).
Six patients (one in the angiography group and five in the TEE group) required hemodynamic support with cardiopulmonary bypass (p = 1.0).
Thirty-day mortality didn't differ significantly between the angiography (12%) and TEE (13.3%) groups, and there were no differences between the groups in the reduction in mean aortic gradient and increase in aortic valve area.
Survival at one-year follow-up was 84% in the angiography group and 75% in the TEE group.
Dr. Rodés-Cabau said, "Although an operating room with hybrid facilities is the optimal scenario to perform TAVI procedures, our results suggest the feasibility and safety of performing transapical TAVI procedures in a regular operating room."
"The confirmation of these findings in future studies might have important logistic and financial implications in the near future, when a rapid expansion of TAVI procedures worldwide is expected and many new centers, most of them with no hybrid operating rooms, will want to start a transapical TAVI program."
"The only potential benefit from using TEE alone is that of cost and possibly to avoid the complication of renal failure, although none occurred in their radiographic group and only one occurred in the TEE group," write Dr. Lars G. Swensson and colleagues from Cleveland Clinic Foundation, Cleveland, Ohio, in a related editorial.
"We have been strong advocates of the team approach for percutaneous valve insertion, and this applies also to imaging," they explain. "We consider both TEE and radiographic techniques to be essential."
"Although it is provocative to rely on only one imaging modality, it does not make practical sense to close 'one eye' to assess whether the cup is half full during the procedure in the environment where we are trying to perfect a new technique and potentially make it applicable for low-risk patients," the editorial concludes. "It would be prudent to use all our imaging power to make the procedure as safe as possible for the current devices, particularly in centers that are commencing their use."
"We agree that the complementary use of the two techniques (angiography and TEE) is the best option for guiding TAVI," Dr. Rodés-Cabau said. "However, the very final decision regarding valve positioning and implantation has usually been based on angiography. Our study suggests that TEE might be as good as angiography to guide the very final positioning of the valve prosthesis."
"We are increasing our experience with this approach," Dr. Rodés-Cabau added. "We plan to evaluate the usefulness of 3D echocardiography in this setting, and we are further determining the potential benefits of reducing the contrast media use during transapical TAVI procedures."
By Will Boggs, MD
J Am Coll Cardiol Img 2011;4:115-124,125-127.
Last Updated: 2011-02-15 15:08:22 -0400 (Reuters Health)
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