Intraprocedural echocardiographic guidance in transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis across all surgical risk groups. Traditionally performed under general anesthesia with transesophageal echocardiography (TEE) guidance, TAVI has evolved toward a minimalist approach using local anesthesia and conscious sedation (LACS), supported by transthoracic echocardiography (TTE) or fluoroscopy alone. Despite this shift, intraprocedural imaging remains valuable as it offers real-time imaging guidance throughout the procedures, allowing for rapid and accurate assessment of complication and procedural results. Echocardiographic modalities used during TAVI include TTE, TEE (adult-, mini-, or micro-TEE) and intracardiac echocardiography (ICE), each with its own advantages and limitations. While TTE is widely used in uncomplicated cases, its image quality may be suboptimal, leading to missing complications and underestimation of paravalvular leak (PVL). In contrast, TEE provides superior spatial resolution, enabling comprehensive real-time assessment and improved PVL detection and other complications. Moreover, 3D TEE offers accurate assessment of the aortic annulus and aids in sizing of the prosthesis when computed tomography is suboptimal or unavailable. ICE is an attractive alternative as it provides real-time high-resolution images and can be performed under LACS by the same operator, although it is costly with single use and requires additional venous access. ICE may be particularly helpful in patients with challenging TTE windows, or in those with contraindications for TEE. We propose an upfront intraprocedural TEE strategy in patients with high-risk anatomies undergoing TAVI, and those with poor TTE window or renal impairment in whom minimal contrast usage is preferred. Mini-TEE (with a smaller probe) is the preferred modality for intraprocedural guidance, which has 3D imaging with good resolution, and is well tolerated under LACS. In conclusion, imaging strategies in TAVI should be individualized. While minimalist approaches are feasible, TEE remains indispensable in complex cases to optimize outcomes and minimize complications.