Imaging Guidance for Transcatheter Aortic Valve Replacement: Is Transoesophageal Echocardiography the Gold Standard?

Transcatheter aortic valve replacement (TAVR) is traditionally performed under cardiac imaging guidance. In the early TAVR experience, intra-procedural transoesophageal echocardiography (TOE) is recommended to guide device deployment, in the context of general anaesthesia (GA). Intra-procedural TOE imaging is particularly useful during TAVR deployment as a contrast-saving strategy for patients with renal impairment. Evidence has emerged recently demonstrating that in selected patients, transthoracic echocardiography (TTE) can be used to provide intra-procedural guidance for TAVR. Additionally, there is a growing body of evidence supporting the performance of TAVR using fluoroscopy alone, without additional cardiac imaging. This article aims to provide a contemporary review of the various procedural imaging approaches for TAVR guidance, comparing the relative strengths and weaknesses of each approach (Table 1).