Severe AS is conventionally defined as an aortic jet velocity 4 m/s, a mean gradient 40 mmHg/peak >64 mmHg and/or an aortic valve area < 1.0 cm2. In addition there are anatomical variants such as bicuspid aortic valve (seen here) and prosthetic valve degeneration which may require aortic valve replacement. Conventional surgical replacement of the aortic valve is available for patients able to survive a very challenging operation.
TEE windows are used not just for deployment and assessment of the valve but for assessing for coexisting valvular disease, biventricular function/filling and hemodynamic management. As well complications are ruled out at the conclusion of the procedure including tamponade, new wall motion abnormality and aortic dissection.
Using the deep transgastric view, the velocity across the valve represents the gradient using the simplified Bernoulli equation, Gradient=(Velocity x velocity) x 4. A gradient greater than 64 mmHg represents severe aortic stenosis, although a lower gradient may be present in some cases such as low EF.
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Along with fluoroscopy TEE is very useful (though not essential in skilled hands) in placing the TAVR in the aortic annulus. The wire is followed up the descending aorta then picked up in the ascending aorta. The prosthetic valve is followed up the descending aorta over the wire then positioned in the annulus. Larger institutions are now using only fluoroscopy with post-TTE assessment for TAVR;'s with conscious sedation.
Role of Transesohageal Echocardiography
Midesophageal Aortic Valve Short Axis Demonstrating ovoid shape without leak.
Midesophageal Long Axis view demonstrating correct TAVR position without paravalvilar leak.
Deep Transgastric Long Axis View Demonstrating Nominal Gradient (< 20 mmHg) with no Paravalvular Leak
ME AV SAX with Paravalvular Leak around New Aortic Valve
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Deep Transgastric View with Paravalvular Leak, high but still nominal gradient across valve but regurgitant flow with mild AR based on PHT
Common scenario requiring assessment and intervention
Apparent with TEE and fluoroscopy
ECG picks it up first, verified by TEE but takes up to 17 views
Widened mediastinum on fluoroscopy, TEE and hemodynamic effects are typically obvious.
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