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← Section VI · Miscellaneous Topics (Role of Echo)
VI.J

Interventional Echocardiography

7 cards

Notes

Role of echo in structural interventions

  • Pre-procedural: patient selection, anatomy characterization.
  • Intra-procedural: real-time guidance for device deployment.
  • Post-procedural: assessment of results, complications.
  • 3D TEE is central to structural procedures.

TAVR

  • Pre-op: annulus sizing (CT is primary), AV pathology characterization, coronary height.
  • Intra-op: valve deployment, positioning, paravalvular leak assessment.
  • Post-op: baseline gradients, paravalvular AR, coronary flow.
  • Paravalvular leak > mild is a risk factor for mortality.

MitraClip / edge-to-edge repair

  • Pre-op: leaflet anatomy (A2/P2 landing zone), MV area (avoid iatrogenic MS), sub-valvular tethering.
  • Real-time 3D TEE guidance for transseptal puncture (high-posterior, superior), clip alignment perpendicular to coaptation line, grasp confirmation.
  • Post-clip: assess residual MR, mean transmitral gradient (target < 5 mmHg), avoid single-orifice / double-orifice MS.
  • Contraindications: leaflet calcification at the device landing zone, extensive fibrosis, insufficient leaflet length.

LAA closure (Watchman / Amulet)

  • Pre-op: LAA morphology (chicken wing, cauliflower, cactus, wind sock).
  • Intra-op: TEE-guided transseptal puncture, device positioning, deployment.
  • Post-op: 45-day TEE to confirm complete seal; peri-device leak > 5 mm is significant.
  • Anticoagulation transitioned after complete endothelialization.

ASD / PFO closure

  • Pre-op: rim measurement (need ≥ 5 mm rim of tissue around defect for device seat).
  • Intra-op: TEE-guided balloon sizing, device deployment.
  • Post-op: assess residual shunt and device position.

Percutaneous pulmonary valve (Melody, Sapien)

  • Pre-op: RVOT anatomy, calcification, PA sizing.
  • Intra-op: valve deployment, RV outflow gradient.

Transseptal puncture

  • Guided by TEE - optimal site is high-posterior and superior for LAA closure; different sites for MitraClip and ASD closure.
  • Confirm needle tenting on interatrial septum before advancing.
  • Best A-P alignment: short-axis view at the level of the aortic root.

Alcohol septal ablation (HCM)

  • Contrast injection into a septal perforator during dobutamine echo confirms correct target zone.
  • Assess for peri-procedural VSD.

Cards

  • basicVI.J-001
    Following TAVR, what is the primary echocardiographic complication associated with worse long-term outcomes?
    → Paravalvular aortic regurgitation greater than mild. Also assess for coronary ostial obstruction and neo-annular thrombus.
  • basicVI.J-002
    What is the maximum acceptable post-MitraClip mean transmitral gradient to avoid iatrogenic mitral stenosis?
    → < 5 mmHg. Deploying multiple clips or extensive leaflet grasping can create relative mitral stenosis.
  • basicVI.J-003
    State two absolute contraindications to MitraClip.
    → 1) Leaflet calcification at the device landing zone (typically A2/P2). 2) Insufficient leaflet length or extensive fibrosis. 3) Severe pulmonary hypertension precluding the procedure. Mitral annular calcification alone is NOT a contraindication.
  • basicVI.J-004
    For LAA closure, what peri-device leak size at 45-day TEE follow-up is considered significant?
    → > 5 mm. Persistent leaks larger than this typically warrant continuation of therapeutic anticoagulation.
  • basicVI.J-005
    Which TEE view is best for A-P orientation during transseptal puncture?
    → Short-axis (mid-esophageal ~45–60°) at the level of the aortic root. The needle should be manipulated posterior to the aorta.
  • basicVI.J-006
    What rim size is generally required for percutaneous ASD closure?
    → ≥ 5 mm of tissue rim around the defect on all sides — this provides adequate seating for the closure device.
  • basicVI.J-007
    Common complication of alcohol septal ablation for HCM to screen for on echo?
    → Iatrogenic VSD from septal necrosis, complete heart block (from septal Purkinje damage), and residual dynamic LVOT obstruction. Post-procedure baseline gradient should be documented.