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TEE-Guided Transcatheter Aortic Valve Implantation With Zero Contrast - A Viable Alternative for Patients with Chronic Kidney Disease

Ashish Pershad, MD1;  Ghassan Fraij, MD2;  Sudhakar V. Girotra, MD2;  H. Kenith Fang, MD3,4;  George Gellert, MD1,5


Ashish Pershad, MD1;  Ghassan Fraij, MD2;  Sudhakar V. Girotra, MD2;  H. Kenith Fang, MD3,4;  George Gellert, MD1,5


Abstract: Acute kidney injury (AKI) stage II-III has been associated with a higher short-term and long-term mortality after transcatheter aortic valve replacement (TAVR). We present a patient with AKI where fluoroscopic landmarks and TEE imaging were used exclusively, sparing the patient a contrast load, and describe patient-tailored modifications.

J INVASIVE CARDIOL 2015;27(2):E25-E26

Key words: transcatheter aortic valve replacement, contrast media


Transesophageal echocardiography (TEE) and intraoperative angiography are complementary imaging techniques in a transcatheter aortic valve replacement (TAVR) procedure. In this case, fluoroscopic landmarks and TEE imaging were used exclusively, sparing the patient a contrast load. Subtle iterations and patient-tailored modifications of this procedure are described.

Case Report

An 85-year-old male patient presented with subacute class-IV heart failure. Work-up revealed normal coronary arteries and severe left ventricular dysfunction with an ejection fraction of 20% and severe aortic stenosis with a mean gradient of 38 mm Hg, with valve area of 0.76 cm2. He had an estimated glomerular filtration rate of 32 mL/min. 

Due to poor access vessels, the patient was considered for transapical (TA) TAVR procedure with an Edwards Sapien valve (Edwards Lifesciences) by the heart team. His annulus was 24.5 mm, and a 26 mm Sapien valve was used. 

Six Fr femoral sheaths were used to place pacer and pigtail catheters via the right femoral vein and artery. Typically, a root angiogram is performed at this point to align the cusps and to confirm the optimal angle of valve deployment obtained. This was deferred because the plan was to deploy the valve using TEE guidance exclusively. After TA access, an Ascendra sheath was placed in the left ventricle. Balloon aortic valvuloplasty (BAV) was performed with a 23 mm V8 balloon (InterValve) with the assistance of rapid right ventricular pacing. The V8 balloon is a newer valvuloplasty balloon that has radiopaque markers; alignment of the second marker to the bottom of the pigtail catheter facilitates its accurate positioning (Figure 1). The balloon design and structural components offer the following potential advantages over currently used balloons: (1) the figure-eight design provides a waist that locks into the valve anatomy and prevents displacement during BAV and potentially mitigates the need for rapid pacing; (2) balloon design results in enhanced leaflet hyperextension with potentially larger post-BAV valve areas; (3) non-compliant balloon material prevents undue balloon growth and potential for annular or balloon rupture; (4) rapid inflation and deflation times minimize pacing need and valve occlusion time; and (5) low device profile permits use of a 12 Fr system for all balloon sizes. 

A 26 mm Sapien valve was then advanced across the aortic valve. TEE imaging was used for placement, and final fine-tuning was done during rapid pacing of the right ventricle and TEE guidance in the long axis view of the left ventricle (Videos 1 and 2). 

Final deployment positioning was confirmed with TEE. Final echocardiographic measurements were performed, confirming the absence of aortic insufficiency and an aortic valve area of 2.4 cm². The apex was repaired in the usual manner. No contrast was used during the procedure.

The postoperative course was uneventful, barring a slight bump in his postoperative creatinine to 2.7 mg/dL on day 4 that returned to baseline by day 6. This is the first reported case in the literature where a transcatheter valve was deployed successfully without the use of any contrast media.  


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.1 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.2 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. 


  1. Généreux P, Kodali SK, Green P. Incidence and effect of acute kidney injury after transcatheter aortic valve replacement using the new Valve Academic Research Consortium criteria. Am J Cardiol. 2013;111(1):100–105.
  2. Brar SS. POSEIDON: sliding scale hydration for the prevention of contrast-induced AKI. Presented at SCAI 2013, Orlando, FL.

From the 1Cavanagh Heart Center; 2Banner Good Samaritan Interventional Cardiovascular Fellowship Program; 3Phoenix Cardiac Surgery; 4Banner Good Samaritan Division of Cardiac Surgery; and 5the Division of Interventional Echocardiography, Banner Good Samaritan Medical Center, Phoenix, Arizona.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Fang reports consulting fees from Edwards Lifesciences. Dr Gellert reports speakers bureau and consulting fees from Phillips Healthcare. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript submitted May 9, 2014, provisional acceptance given May 27, 2014, final acceptance given June 2, 2014.

Address for correspondence: Ashish Pershad, MD, FACC, FSCAI, Cavanagh Heart Center, 1300 N. Edwards Plaza Suite 407, Phoenix AZ 85006. Email: