1. Transcatheter Aortic Valve Replacement
Andrej Alfirevic, MD, Anand R. Mehta, MD, Lars G. Svensson, MD 
Anesthesiology Clinics 
Volume 31, Issue 2, Pages (June 2013)
DOI: /j.anclin
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2. Fig. 1
Six different approaches used for transcatheter aortic valve replacement (TAVR) with a stent-valve. (A) Retrograde transfemoral arterial approach from femoro-iliac vessels. (B) Antegrade left ventricular transapical approach via anterolateral mini-thoracotomy. (C) Antegrade transfemoral venous approach, used during initial experience. (D) Retrograde transaortic approach via mini–anterior thoracotomy. (E) Retrograde trans-subclavian artery approach via surgical cut-down. (F) Retrograde trans-axillary artery approach via percutaneous Seldinger method.
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3. Fig. 2
Edwards SAPIEN aortic valve prosthesis. The prosthesis is crimped onto the expandable balloon and positioned via the retrograde arterial approach at the level of the aortic valve annulus.
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4. Fig. 3
CoreValve aortic valve prosthesis. This valve is self-expandable, with 2 anchoring points at the annulus and the sinotubular junction.
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5. Fig. 4
Catheterization laboratory modified for the purpose of performing the TAVR procedure. Note the location of the anesthesia equipment and its relationship with the patient’s table, floor-mounted biplane fluoroscopy machine, and positioning of the rest of the multidisciplinary team members. ARKS, Anesthesia Record-Keeping System; IV, intravenous.
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6. Fig. 5
Hybrid operating room and location of the anesthesia equipment, and its relationship with the patient’s table and single-plane fluoroscopy machine coming in from the patient’s right-hand side. LIJ, left internal jugular; PAC, pulmonary artery catheter; TEE, transesophageal echocardiography.
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7. Fig. 6
Mid-esophageal long-axis view depicting properly positioned balloon (arrow) during the act of valvuloplasty. Note the electrocardiogram tracing during the rapid ventricular pacing. LA, left atrium; LV, left ventricle; AV, aortic valve.
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8. Fig. 7
Mid-esophageal long-axis view depicting properly positioned Edwards SAPIEN stent-valve before deployment. The stent-valve is positioned approximately 50/50 at the annulus. The measurement represents the length of the stent-valve (≈16 mm for the 26-mm size valve). Note the difficulty of 2-dimensional echocardiography in depicting accurate coaxial alignment between the axis of crimped stent-valve and left ventricular outflow tract axis/aortic valve axis. Also note the shadowing of the anterior aortic valve annulus by the deployment device and stent-valve, representing potential difficulty in positioning of the stent-valve perpendicular to the annulus.
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9. Fig. 8
Two orthogonal mid-esophageal (LAX, long-axis; SAX, short-axis) views with color-flow Doppler depicting the paravalvular insufficiency after stent-valve deployment.
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10. Fig. 9
Mid-esophageal short-axis view of the aortic valve with a color-flow Doppler demonstrating area percentage measurements of the paravalvular insufficiency jets compared with the stent-valve circumferential area. Note the multiple paravalvular jets with crescent-shaped irregular origin. The calculated ratio of measures areas is greater than 20%, suggesting moderate paravalvular insufficiency. Treatment options will include reexpansion and/or deployment of the second stent-valve (valve-in-valve).
(Modified from Bloomfield GS, Gillam LD, Hahn RT, et al. A practical guide to multimodality imaging of transcatheter aortic valve replacement. JACC Cardiovasc Imaging 2012;5:441–55, with permission.)
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