Role of Rest and Stress Echocardiography in Transcatheter Aortic Valve Implantation



Rest and stress echocardiography plays a pivotal role in the evaluation of valvular heart disease. In aortic stenosis (AS), rest echocardiographic analysis is characterized by a stepwise integrated approach, starting from aortic valve morphology and followed by transvalvular aortic gradient and aortic valve area (AVA) using continuity equation or planimetric approach. The presence of any of the following three criteria, an AVA <1.0 cm2, a peak velocity ≥4.0 m/s, or a mean gradient ≥40 mmHg, is suggestive of severe AS. Sometimes, we can have an AVA <1 cm2 in the presence of peak velocity <4.0 m/s, or a mean gradient <40 mmHg. In this condition, the reduced transvalvular flow can occur in the presence of left ventricular (LV) systolic dysfunction, with a reduced LV ejection fraction (LVEF <50%): this pathophysiological condition is known as “classical” low-flow low-gradient AS. On the other hand, the reduced transvalvular flow can occur also with a normal LVEF (>50%): this pathophysiological condition is defined as low-flow low-gradient “paradoxical” AS with preserved LVEF. Stress echocardiography (SE) has an established role in the evaluation of LV contractile reserve in low-flow low-gradient classical AS with reduced LVEF but also in identifying pseudo-severe AS from truly severe AS.

Echocardiographic study plays an important role throughout all stages of the procedure of transcatheter aortic valve implantation (TAVI). In the selection of the AS patients, detailed characteristics of the aortic valve and accurate sizing of aortic annular dimension should be described. It is also important to evaluate concomitant mitral valve disease, LV function, and the presence of septal hypertrophy that it may be related to severe left ventricular outflow tract (LVOT) obstruction. Transesophageal echocardiography may be used during TAVI procedure; however, the need for general anesthesia reduces its use. Immediately after the release of aortic valve prosthesis, echocardiographic evaluation is used to confirm satisfactory positioning and function of the prosthesis but also to exclude acute complications. Echocardiographic follow-up post-TAVI is similar to that of postsurgical aortic valve replacement: particular attention should be used to evaluate the presence of paravalvular leaks. In patients with low-flow low-gradient classical AS without LV contractile reserve, TAVI may provide a good alternative to surgery.


Aortic stenosis Echocardiography Stress echocardiography Left ventricular contractile reserve Transcatheter aortic valve implantation 


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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of CardiologyFatebenefratelli HospitalBeneventoItaly
  2. 2.Division of CardiologySan Giuseppe Moscati HospitalAvellinoItaly

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