TEE-Guided TAVI Without Contrast - Viable Alternative in CKD
TEE-Guided TAVI Without Contrast - Viable Alternative in CKD
AKI stage II-III has been associated with a higher short-term and long-term mortality after TAVR. In patients enrolled in the PARTNER trial, the all-cause mortality at 1 year was 6 times higher in patients who developed AKI stage II-III versus those who did not. The etiology of AKI after TAVR has not been fully understood, but contrast-media associated nephropathy has been implicated as one of the mechanisms.
There are many ways to minimize contrast load during a TAVR procedure. Preprocedure hydration modulation based on preprocedure filling pressures minimizes the deleterious effects of contrast media. The contrast volume for aortic root angiography can be diluted 50%. A preprocedure computed tomography angiography can help further by identifying the right angle of deployment for the valve. A clear understanding of the annulus size by three-dimensional TEE minimizes the need for an angiogram during balloon valvuloplasty for annuli in the grey zone. The contrast load can be reduced with operator and site experience, but elimination of use of contrast altogether has never been described in the literature and requires expertise and confidence in real-time imaging provided by 3D-TEE.
Discussion
AKI stage II-III has been associated with a higher short-term and long-term mortality after TAVR. In patients enrolled in the PARTNER trial, the all-cause mortality at 1 year was 6 times higher in patients who developed AKI stage II-III versus those who did not. The etiology of AKI after TAVR has not been fully understood, but contrast-media associated nephropathy has been implicated as one of the mechanisms.
There are many ways to minimize contrast load during a TAVR procedure. Preprocedure hydration modulation based on preprocedure filling pressures minimizes the deleterious effects of contrast media. The contrast volume for aortic root angiography can be diluted 50%. A preprocedure computed tomography angiography can help further by identifying the right angle of deployment for the valve. A clear understanding of the annulus size by three-dimensional TEE minimizes the need for an angiogram during balloon valvuloplasty for annuli in the grey zone. The contrast load can be reduced with operator and site experience, but elimination of use of contrast altogether has never been described in the literature and requires expertise and confidence in real-time imaging provided by 3D-TEE.
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