Feasibility of aortic diameter measurement by multiplane transesophageal echocardiography for preoperative selection and preparation of homograft aortic valves

A simplified cardiac damage staging predicts the outcome of patients undergoing TAVR-A multicenter analysis

BACKGROUND

A significant number of patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) suffer from extra-aortic cardiac damage. Few studies have investigated strategies to quantify cardiac damage and stratify patients accordingly in different risk groups. The aim of this retrospective multicenter study was to provide a user-friendly simplified staging system based on the proposed classification system of Généreux et al. as a tool to evaluate the prognosis of patients undergoing TAVR more easily. Moreover, we analyzed changes in cardiac damage after TAVR.

METHODS

We assessed cardiac damage in patients, who underwent TAVR at the Heart Center Bonn or Düsseldorf, using pre- and postprocedural transthoracic echocardiography. Patients were assigned to the staging system proposed by Généreux et al. according to the severity of their baseline cardiac damage. Based on the established system, we created a simplified staging system to facilitate improved applicability. Finally, we compared clinical outcomes between the groups and evaluated changes in cardiac damage after TAVR.

RESULTS

A total of 933 TAVR patients were included in the study. We found a significant association between cardiac damage and 1-year all-cause mortality (stage 0: 0% vs. stage 1: 3% vs. stage 2: 6.6%; p < 0.009). In multivariate analysis, cardiac damage was an independent predictor of 1-year all-cause mortality (hazard ratio: 2.0, 95% confidence interval: 1.1-3.8; p = 0.03).

CONCLUSIONS

In patients undergoing TAVR, cardiac damage is associated with enhanced mortality. A simplified staging system can help identify patients at high risk for an adverse outcome.

Accuracy and usefulness of aortic annular measurement using real-time three-dimensional transesophageal echocardiography: Comparison with direct surgical sizing

BACKGROUND

There is a paucity of data that demonstrates a clinical impact of anatomical measurements of the aortic annulus by three-dimensional (3D) transesophageal echocardiography (TEE) on surgical aortic valve replacement (AVR). The aim of this study is to validate the accuracy of 3D TEE measurements compared with the direct intraoperative annular diameter and to investigate an impact of 3D TEE on a prediction of AVR with aortic annular enlargement (AAE).

METHODS AND RESULTS

We retrospectively enrolled 61 patients who underwent both two-dimension (2D) and 3D TEE and transthoracic echocardiography (TTE) before AVR. The annular diameters were measured noninvasively with 2D TEE (D_2D) and TTE (D_TTE) in a classical manner and the area- and perimeter-derived annular diameters (D_area, D_perim) were measured from using 3D TEE analysis. Intraoperative annular diameter was measured with the manufacture's sizer (D_intraope). D_area showed the best agreement with D_intraope in the Bland-Altman analysis. D_area, D_perim, D_2D, and D_TTE correlated well with D_intraope (r=0.821, 0.820, 0.532, and 0.610, respectively; all p<0.001). Three patients underwent AVR with AAE and the specificity of D_perim for prediction of AAE was significantly higher than D_2D (p=0.008).

CONCLUSIONS

3D TEE measurement of aortic annular diameter showed better agreement with the direct intraoperative measurement than 2D TEE and TTE measurements. 3D TEE measurement could predict AVR with AAE more accurately than 2D TEE and TTE measurements.

Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve

The books and articles devoted to the anatomy of the aortic valvar complex are numerous. Until now, however, little consideration has been given to understanding the anatomy with percutaneous valvar replacement in mind. It is axiomatic that knowledge of the anatomy of the valve is fundamental in understanding key principles involved in valvar replacement.Such an appreciation of the anatomy helps better understand the optimal positioning for the prosthetic valve within the root of the aorta with respect to the coronary arteries, mitral valve, and the conduction system and may circumvent complications that can arise during its implantation [corrected] In this review, therefore, we describe the anatomy of the trifoliate aortic valvar complex and its implications for percutaneous valvar replacement.

Does intraoperative transesophageal echocardiography predict pulmonary valve dysfunction during the Ross procedure?

OBJECTIVE

To determine the value of intraoperative transesophageal echocardiography for the assessment of the pulmonary valve anatomy and the pulmonary autograft performance in patients undergoing the Ross procedure.

DESIGN

Open, prospective, observational survey.

SETTING

Favaloro Foundation, single institution.

PARTICIPANTS

Consecutive patients undergoing elective Ross procedure (n = 87).

INTERVENTIONS

Pulmonary valve function and anatomy were assessed by transesophageal echocardiography and the surgeon. Pulmonary autograft function was assessed after implantation. Regurgitation was considered mild (+/4), moderate (++/4), moderate-to-severe (+++/4), and severe (++++/4). Patients were restudied during midterm follow-up.

MEASUREMENTS AND MAIN RESULTS

The Ross procedure was done in 74 patients (85%). Overall mortality was 3.4%. Mean follow-up was 24 +/- 13 months. The Ross procedure was not done in 13 patients (15%): 6 patients had a bicuspid pulmonary valve, 6 patients had >3 mm fenestrations, and 1 patient had regurgitation. The surgeon diagnosed anomalies in the pulmonary valve through direct observation. Transesophageal echocardiography was not sensitive enough to diagnose pulmonary valve defects in 12 of 13 patients with anomalies. Pulmonary valve regurgitation was identified by intraoperative transesophageal echocardiography in only 1 patient. Autograft regurgitation was 1.07 +/- 0.35 at postoperative evaluation. At 1, 6, and 12 months, it was 1.25 +/- 0.7 (p = 0.18), 1.27 +/- 0.9 (p = 0.185), and 1.29 +/- 0.8 (p = 0.17). The difference in values was not statistically significant. Four patients (5.4%) showed an increase in regurgitation during the first transthoracic autograft control.

CONCLUSION

Intraoperative transesophageal echocardiography allows assessment of autograft performance after implantation. This method is not helpful, however, in detecting pulmonary valve anatomic anomalies.

Aortic Stenosis: The Role of Transesophageal Echocardiography

Noninvasive assessment of aortic valve area by echocardiography has become the standard of practice over the past few years. The advent of transesophageal echocardiography (TEE) has provided a new method for the assessment of aortic valve area (AVA) using planimetry by two-dimensional imaging. Clear visualization of the anatomy of the valve, as well as accuracy of AVA assessment, makes TEE an invaluable tool for the evaluation of aortic valve stenosis. TEE is especially helpful in clinical settings when there is a discrepancy between the AVA obtained by transthoracic echocardiography and cardiac catheterization. TEE is particularly helpful in the assessment of the aortic valve during intraoperative echocardiography. This review discusses the techniques, imaging planes, and details for assessing AVA by TEE. The role of TEE in AVA assessment is described, with specific clinical case examples cited.

Role of intraoperative transesophageal echocardiography in determining aortic annulus diameter in homograft insertion

The sizing of aortic valve (AV) homografts for optimum function requires an accurate measurement of the aortic annulus. Typically, this measurement is obtained directly with sizers in the open aorta. We describe the use of intraoperative transesophageal echocardiography (IOTEE) to measure the aortic annulus and select the appropriate AV homograft before cardiopulmonary bypass and aortic cross-clamping. Thirty-two patients underwent AV homograft insertion between March 1993 and March 1996 and had IOTEE. There were 13 women and 19 men. Mean age was 58 +/- 14 years. IOTEE measurements were satisfactory in sizing in all patients, and no extraordinary surgical measures were necessary to insert the AV homografts. Early postoperative follow-up showed trivial or mild regurgitation of all homografts. Prebypass IOTEE is reliable in guiding the selection of optimal AV homografts.