Over the past decade, transcatheter aortic valve implantation (TAVI) emerged as preferred treatment for high-risk patients with severe aortic stenosis (AS), expanding towards lower risk patients. Chronic kidney disease (CKD) is one of the most frequent comorbidity. Preprocedural screening includes application of contrast media [computed tomography (CT)], followed by repeated contrast during procedure (coronary angiography, aortic root angiography, and peripheral angiography), increasing risk of acute kidney injury (AKI). AKI in presence of CKD increases the incidence of kidney disorders after TAVI up to 30%. Efforts to abolish periprocedural contrast appear therefore beneficial, like the use of EchoNavigator (Philips, the Netherlands). An 80-year-old male patient with low-flow, low-gradient severe AS (mean aortic valve area 0.6 cmq, mean gradient 29 mmHg, LVEF 10%) and pre-dialytic CKD (creatinine 5.5 mg/dL) was scheduled for no contrast TAVI, under general anaesthesia and fusion guidance. The aortic valve (AV) plane was identified with EchoNavigator and three fiducial markers were placed in correspondence of the nadir of the cusps (Panels A and B), in X-plane view. By superimposing the echo images, the AV and the root become visible on the fluoroscopic screen and the angulation of C-arm was gradually adjusted to co-align the three markers on correct plane (Panel C). The overlayed 3D echo fusion allowed successful implantation of a Sapien 3 26 mm (Edwards Lifesciences, USA), without contrast and preoperative CT (Supplementary data online, Video S1). At transthoracic echo at discharge, only a trivial paravalvular leak was detected (Panel D). In high-risk patients with CKD, use of EchoNavigator as a measure to minimize the risk of AKI during TAVI appears extremely beneficial. (Panels A and B) The three markers, placed at the level of the nadir cusp, are overlayed on fluoroscopy and aligned to reach the coaxial planar projection. Using the echo 3D modality, it is possible to crop thickness of soft tissues, obtaining clearcut imaging of the aortic root (asterisks) and of the valvular plane itself (arrow). (Panel C) During TAVI implantation, the translucency of overlayed 3D tissues is reduced through a specific tool, making catheters and device well visible. (Panel D) Trivial paravalvular leak at 8 o’clock at discharge transthoracic echo. View largeDownload slide View largeDownload slide Supplementary data are available at European Heart Journal - Cardiovascular Imaging online. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2018. For permissions, please email: firstname.lastname@example.org. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
European Heart Journal – Cardiovascular Imaging – Oxford University Press
Published: Mar 22, 2018
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