Editorial comment
Three-dimensional transesophageal echocardiography in the prevention of transcatheter aortic valve implantation-related stroke: Another brick in the wall?
ETE-3D na prevenção do AVC peri-TAVI: uma nova arma?
Nuno Cardim
Multimodality Cardiac Imaging Department, Hospital da Luz, Lisbon, Portugal
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<span class="elsevierStyleSup">b</span> discontinuation due to minor bleeding.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Luís Silva Miguel, Jorge Ferreira" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Luís" "apellidos" => "Silva Miguel" ] 1 => array:2 [ "nombre" => "Jorge" "apellidos" => "Ferreira" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0870255115003182" "doi" => "10.1016/j.repc.2015.09.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255115003182?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916000398?idApp=UINPBA00004E" "url" => "/21742049/0000003500000003/v1_201603180035/S2174204916000398/v1_201603180035/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204916000386" "issn" => "21742049" "doi" => "10.1016/j.repce.2015.09.012" "estado" => "S300" "fechaPublicacion" => "2016-03-01" "aid" => "771" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2016;35:133-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2225 "formatos" => array:3 [ "EPUB" => 156 "HTML" => 1692 "PDF" => 377 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Echogenic mobile images in intraprocedural three-dimensional transesophageal echocardiographic monitoring during percutaneous aortic valve implantation: Incidence, characteristics and clinical implications" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "133" "paginaFinal" => "138" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Monitorização de imagens ecogénicas móveis intraprocedimento pela ecocardiografia transesofágica 3 D durante a implantação valvular aórtica percutânea: incidência, características e implicações clínicas" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1295 "Ancho" => 1781 "Tamanyo" => 200227 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">An 85-year-old woman with a history of severe aortic stenosis who was accepted for transfemoral valve replacement. 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Ulises" "apellidos" => "Ramírez" ] 9 => array:2 [ "nombre" => "Rosa" "apellidos" => "Gonzalez Davia" ] 10 => array:2 [ "nombre" => "Ignacio" "apellidos" => "Plaza" ] 11 => array:2 [ "nombre" => "José María" "apellidos" => "Mesa" ] 12 => array:2 [ "nombre" => "Jose Luis" "apellidos" => "López-Sendón" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255116000147" "doi" => "10.1016/j.repc.2015.09.023" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255116000147?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916000386?idApp=UINPBA00004E" "url" => "/21742049/0000003500000003/v1_201603180035/S2174204916000386/v1_201603180035/en/main.assets" ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Three-dimensional transesophageal echocardiography in the prevention of transcatheter aortic valve implantation-related stroke: Another brick in the wall?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "139" "paginaFinal" => "140" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Nuno Cardim" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Nuno" "apellidos" => "Cardim" "email" => array:1 [ 0 => "ncardim@hospitaldaluz.pt" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Multimodality Cardiac Imaging Department, Hospital da Luz, Lisbon, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "ETE-3D na prevenção do AVC peri-TAVI: uma nova arma?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The introduction of transcatheter aortic valve implantation (TAVI) has changed the classical treatment of patients with severe aortic stenosis (AS). Nowadays, TAVI is recommended for patients with severe symptomatic AS who are considered unsuitable for conventional surgery, according to an evaluation performed by a heart team (in high-risk patients, but still candidates for surgical valve replacement, the decision remains individualized).</p><p id="par0010" class="elsevierStylePara elsevierViewall">As a rapidly evolving technique, with significant technical improvements leading to higher success rates, long-term durability and fewer complications, patient selection criteria and clinical indications for TAVI are likely to expand in the future to non-high-risk surgical candidates (in intermediate-risk patients randomized trials with appropriate scoring systems to assess outcomes and durability are needed).</p><p id="par0015" class="elsevierStylePara elsevierViewall">TAVI requires a multidisciplinary heart team approach, involving clinical and interventional cardiologists, cardiac surgeons, anesthesiologists, and cardiovascular imaging specialists. Imaging plays a central role during TAVI implementation, since it is essential at several stages of the procedure, including patient selection, choice of procedural access, prosthesis type and sizing, intraprocedural guidance, and detection of early and late complications.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Though intraprocedural guidance is usually performed with transesophageal echocardiography (TEE), it is still a matter of debate whether the added value of TEE imaging during TAVI is worth the price of general anesthesia, compared to conventional fluoroscopy (with the associated lack of spatial resolution and increased contrast load and ionizing radiation). Though alternative imaging modalities without general anesthesia, such as intracardiac echocardiography and transnasal TEE, are being explored, they appear to provide inferior quality imaging compared to TEE, and there are concerns with the safety of intracardiac echography.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Compared with the two-dimensional (2D) approach, three-dimensional (3D) TEE appears better for visualizing balloon-expandable valves (though 3D TEE expertise is needed), and also provides a better characterization of cardiac and noncardiac structures involved in the procedure. In the near future, fusion imaging with real-time synchronization of echocardiography and fluoroscopy images using 2D or 3D echocardiography will minimize radiation exposure and may improve outcomes.</p><p id="par0030" class="elsevierStylePara elsevierViewall">During TAVI, periprocedural monitoring with TEE plays an important role. Its advantages include assessment of aortic root morphology and valve leaflet behavior both during balloon valvuloplasty (visualization of the balloon in the aortic annulus, assessment of the space within the sinuses to accommodate the calcified leaflets, imaging of coronary ostia to determine risk of obstruction, and detection of severe regurgitation post valvuloplasty) and during valve deployment (correction of valve positioning post deployment, avoiding complications arising from low and high positioning and allowing correction of position and post-dilatation).</p><p id="par0035" class="elsevierStylePara elsevierViewall">Additionally, TEE is essential in the early detection and treatment of major classical TAVI complications (aortic regurgitation, myocardial ischemia, mitral regurgitation, pericardial effusion, aortic dissection or root rupture, and stroke).</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although TAVI is considered an effective and safe therapeutic option for patients with AS and high surgical risk, the 30-day and in-hospital mortality of patients undergoing this procedure is still variable, between 5 and 10%.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–3</span></a> This mortality is mainly associated with procedure-related complications such as vascular complications, device embolization and stroke.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Periprocedural stroke<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1–4</span></a> is in fact a major issue in TAVI. Though its frequency is highly variable (rates ranging from 0 to 10%), it is associated with poor prognosis, 30-day mortality being about 40%, compared to around 5% in patients without stroke.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The pathophysiology of peri-interventional ischemic stroke is multifactorial, and many possible sources are detectable by TEE: thromboembolism from catheters (atherosclerotic material displaced from the arterial tree during valve delivery or catheter advancement), post-valvuloplasty valve remains (embolization of aortic cusp fragments), erosion of ascending aorta and aortic arch plaques, aortic arch dissection extending into the supra-aortic vessels, thrombosis of the implanted valve, air embolism, spontaneous echo contrast in the left atrium, atrial fibrillation, and prolonged hypotension.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In this issue of the <span class="elsevierStyleItalic">Journal</span>, Arroyo-Úcar et al.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> specifically investigate the incidence and clinical relevance of the presence of mobile echogenic images (MEI) as potential embolic sources, detected with 3D TEE during TAVI procedures. Though they identified MEI in 11% of TAVI procedures (in most cases thrombus attached to catheters or remains of former valve structures), they did not observe an increased incidence of periprocedural stroke in patients with MEI. Additionally, in 45% of cases, the MEI disappeared during the procedure without a higher incidence of periprocedural stroke.</p><p id="par0060" class="elsevierStylePara elsevierViewall">From these results some important issues arise:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0065" class="elsevierStylePara elsevierViewall">Thorough preprocedural screening by multiple invasive and noninvasive imaging techniques is imperative for TAVI candidates, in order to fully characterize the aortic annulus, the adjacent aorta and the vascular tree, and to define the optimal route for arterial access in order to minimize ischemic stroke.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0070" class="elsevierStylePara elsevierViewall">The role of peri-interventional TEE in the identification of potential causes of stroke (particularly embolization of aortic cusp fragments and thromboembolism from catheters) is crucial. The identification and characterization of MEI can help operators to modify their strategy, avoiding and correcting specific precipitating factors (for instance heparin dosage and type of arterial access), minimizing the risk of embolism. This probably partially explains the disappearance of MEI without stroke in 45% of the patients, though small subclinical microembolic stroke and minor non-cerebral embolism should also have been systematically excluded.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0075" class="elsevierStylePara elsevierViewall">The potential incremental role of 3D TEE (over the 2D approach) seems to be particularly useful in correct characterization of the embolic source, since the real-time 3D image provides high-quality information on its location, time of onset, mechanism and relation to cardiac structures and devices used during the procedure.</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">In conclusion, the paper by Arroyo-Úcar et al. raises a number of important issues, though many of them remain unanswered. Accordingly, the results of this study should be confirmed in further studies in multiple centers, with large number of patients and with different designs and aims. These should assess the clinical impact of MEI detection on operators’ strategy in order to modify potential stroke-precipitating factors and their clinical consequences in patient outcomes. The presence of minor subclinical microembolism, cerebral and non-cerebral, should also be systematically excluded. Finally, generalization of the results to other available TAVI systems should also be addressed in future studies.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0085" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cardim N. ETE-3D na prevenção do AVC peri-TAVI: uma nova arma?. Rev Port Cardiol. 2016;35:139–140.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of availability of transcatheter aortic-valve replacement on clinical practice" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Reinöhl" 1 => "K. Kaier" 2 => "H. 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Kodali" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2011.08.024" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2011" "volumen" => "58" "paginaInicial" => "2143" "paginaFinal" => "2150" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22078419" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Echogenic mobile images in intraprocedural three-dimensional transesophageal echocardiography monitoring during percutaneous aortic valve implantation: incidence, characteristics and clinical implications" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Arroyo-Úcar" 1 => "R. Moreno" 2 => "S. del Prado" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2015.09.023" "Revista" => array:7 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2016" "volumen" => "35" "numero" => "3" "paginaInicial" => "133" "paginaFinal" => "138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26919889" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003500000003/v1_201603180035/S2174204916000404/v1_201603180035/en/main.assets" "Apartado" => array:4 [ "identificador" => "9917" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003500000003/v1_201603180035/S2174204916000404/v1_201603180035/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204916000404?idApp=UINPBA00004E" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 3 | 9 |
| 2024 October | 33 | 26 | 59 |
| 2024 September | 43 | 23 | 66 |
| 2024 August | 41 | 22 | 63 |
| 2024 July | 26 | 32 | 58 |
| 2024 June | 27 | 18 | 45 |
| 2024 May | 29 | 18 | 47 |
| 2024 April | 27 | 23 | 50 |
| 2024 March | 21 | 20 | 41 |
| 2024 February | 28 | 32 | 60 |
| 2024 January | 25 | 33 | 58 |
| 2023 December | 13 | 22 | 35 |
| 2023 November | 31 | 22 | 53 |
| 2023 October | 25 | 16 | 41 |
| 2023 September | 17 | 21 | 38 |
| 2023 August | 27 | 12 | 39 |
| 2023 July | 20 | 10 | 30 |
| 2023 June | 20 | 7 | 27 |
| 2023 May | 27 | 22 | 49 |
| 2023 April | 12 | 3 | 15 |
| 2023 March | 34 | 27 | 61 |
| 2023 February | 27 | 25 | 52 |
| 2023 January | 12 | 7 | 19 |
| 2022 December | 17 | 26 | 43 |
| 2022 November | 29 | 18 | 47 |
| 2022 October | 21 | 19 | 40 |
| 2022 September | 22 | 35 | 57 |
| 2022 August | 32 | 38 | 70 |
| 2022 July | 28 | 29 | 57 |
| 2022 June | 16 | 14 | 30 |
| 2022 May | 18 | 35 | 53 |
| 2022 April | 20 | 21 | 41 |
| 2022 March | 22 | 25 | 47 |
| 2022 February | 22 | 21 | 43 |
| 2022 January | 15 | 12 | 27 |
| 2021 December | 12 | 33 | 45 |
| 2021 November | 28 | 34 | 62 |
| 2021 October | 21 | 33 | 54 |
| 2021 September | 18 | 31 | 49 |
| 2021 August | 21 | 34 | 55 |
| 2021 July | 16 | 17 | 33 |
| 2021 June | 21 | 24 | 45 |
| 2021 May | 17 | 35 | 52 |
| 2021 April | 60 | 35 | 95 |
| 2021 March | 54 | 17 | 71 |
| 2021 February | 32 | 9 | 41 |
| 2021 January | 29 | 11 | 40 |
| 2020 December | 24 | 10 | 34 |
| 2020 November | 28 | 13 | 41 |
| 2020 October | 18 | 11 | 29 |
| 2020 September | 36 | 10 | 46 |
| 2020 August | 20 | 10 | 30 |
| 2020 July | 31 | 12 | 43 |
| 2020 June | 21 | 13 | 34 |
| 2020 May | 33 | 4 | 37 |
| 2020 April | 30 | 6 | 36 |
| 2020 March | 23 | 10 | 33 |
| 2020 February | 48 | 13 | 61 |
| 2020 January | 27 | 6 | 33 |
| 2019 December | 32 | 7 | 39 |
| 2019 November | 22 | 7 | 29 |
| 2019 October | 23 | 4 | 27 |
| 2019 September | 25 | 11 | 36 |
| 2019 August | 19 | 4 | 23 |
| 2019 July | 28 | 7 | 35 |
| 2019 June | 31 | 10 | 41 |
| 2019 May | 39 | 6 | 45 |
| 2019 April | 23 | 15 | 38 |
| 2019 March | 22 | 8 | 30 |
| 2019 February | 29 | 7 | 36 |
| 2019 January | 21 | 9 | 30 |
| 2018 December | 25 | 11 | 36 |
| 2018 November | 46 | 7 | 53 |
| 2018 October | 70 | 20 | 90 |
| 2018 September | 30 | 12 | 42 |
| 2018 August | 18 | 6 | 24 |
| 2018 July | 20 | 7 | 27 |
| 2018 June | 27 | 8 | 35 |
| 2018 May | 42 | 8 | 50 |
| 2018 April | 23 | 0 | 23 |
| 2018 March | 37 | 9 | 46 |
| 2018 February | 26 | 5 | 31 |
| 2018 January | 22 | 7 | 29 |
| 2017 December | 39 | 12 | 51 |
| 2017 November | 15 | 12 | 27 |
| 2017 October | 24 | 10 | 34 |
| 2017 September | 20 | 14 | 34 |
| 2017 August | 24 | 16 | 40 |
| 2017 July | 20 | 13 | 33 |
| 2017 June | 30 | 8 | 38 |
| 2017 May | 25 | 26 | 51 |
| 2017 April | 18 | 11 | 29 |
| 2017 March | 11 | 24 | 35 |
| 2017 February | 19 | 7 | 26 |
| 2017 January | 17 | 2 | 19 |
| 2016 December | 30 | 11 | 41 |
| 2016 November | 18 | 8 | 26 |
| 2016 October | 19 | 8 | 27 |
| 2016 September | 21 | 12 | 33 |
| 2016 August | 4 | 1 | 5 |
| 2016 July | 21 | 5 | 26 |
| 2016 June | 11 | 6 | 17 |
| 2016 May | 14 | 14 | 28 |
| 2016 April | 20 | 1 | 21 |
| 2016 March | 37 | 13 | 50 |
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