Demonstration of Left Ventricular Outflow Tract Eccentricity by Real Time 3D Echocardiography: Implications for the Determination of Aortic Valve Area

Doddamani, Sanjay; Bello, Ricardo; Friedman, Mark A.; Banerjee, Anita; Bowers, James H.; Kim, Bette; Vennalaganti, Prashant R.; Ostfeld, Robert J.; Gordon, Garet M.; Malhotra, Divya; Spevack, Daniel M.

doi:10.1111/j.1540-8175.2007.00479.x

Cited by 127 publications

(105 citation statements)

References 11 publications

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“…It is possible that a 3-dimensional echocardiographic or computed tomography assessment of the outflow tract dimensions or invasive hemodynamic assessment could lead to different values and conclusions. 5,29,30 The velocity-time integral assessed by LV outflow tract flow may also be directly affected by the presence of aortic regurgitation and indirectly by mitral regurgitation, both of which differed in prevalence at baseline between LF and NF subjects. Nonetheless, neither aortic nor mitral regurgitation had an independent predictive value for subsequent mortality.…”

Section: Limitationsmentioning

confidence: 99%

Predictors of Mortality and Outcomes of Therapy in Low-Flow Severe Aortic Stenosis

et al. 2013

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Background-The prognosis and treatment of patients with low-flow (LF) severe aortic stenosis are controversial. Methods and Results-The Placement of Aortic Transcatheter Valves (PARTNER) trial randomized patients with severe aortic stenosis to medical management versus transcatheter aortic valve replacement (TAVR; inoperable cohort) and surgical aortic valve replacement versus TAVR (high-risk cohort). Among 971 patients with evaluable echocardiograms (92%), LF (stroke volume index ≤35 mL/m 2 ) was observed in 530 (55%); LF and low ejection fraction (<50%) in 225 (23%); and LF, low ejection fraction, and low mean gradient (<40 mm Hg) in 147 (15%). Two-year mortality was significantly higher in patients with LF compared with those with normal stroke volume index (47% versus 34%; hazard ratio, 1.5; 95% confidence interval, 1.25-1.89; P=0.006). In the inoperable cohort, patients with LF had higher mortality than those with normal flow, but both groups improved with TAVR (46% versus 76% with LF and 38% versus 53% with normal flow; P<0.001). In the high-risk cohort, there was no difference between TAVR and surgical aortic valve replacement. In patients with paradoxical LF and low gradient (preserved ejection fraction), TAVR reduced 1-year mortality from 66% to 35% (hazard ratio, 0.38; P=0.02). LF was an independent predictor of mortality in all patient cohorts (hazard ratio, ≈1.5), whereas ejection fraction and gradient were not. Conclusions-LF

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Section: Limitationsmentioning

confidence: 99%

Predictors of Mortality and Outcomes of Therapy in Low-Flow Severe Aortic Stenosis

et al. 2013

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“…5 These inconsistencies have been attributed to stroke volume variability, despite normally appearing left ventricular (LV) function, small LV size, diastolic dysfunction, chronic afterload changes from hypertension, and underestimation of AVA secondary to the erroneous assumption that the left ventricular outflow tract (LVOT) is a circle rather than an ellipse. [6][7][8][9][10][11][12] Inconsistent AS grading is problematic because misinterpretation of grading parameters may delay surgical intervention and negatively affect patients. [1][2][3] AS severity is defined by the following echocardiographic parameters: peak velocity, ΔP m , AVA by continuity equation, dimensionless index, and indexed AVA (Table 1).…”

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confidence: 99%

Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography

Whitener

McKenzie

Akushevich

et al. 2016

Anesthesia &Amp; Analgesia

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Discordance in Grading Aortic Stenosis by Pre-CPB TEE aortic valve. For this reason, AVA calculation is prone to error compared with a ΔP m measurement.Although inconsistencies for grading AS with AVA and ΔP m are well known for preoperative TTE, they are routinely used for grading AS in the pre-cardiopulmonary bypass (pre-CPB) context. In this study, we investigate the frequency of discordance between grading AS with ΔP m measurements and AVA calculations during pre-CPB transesophageal echocardiography (TEE) to provide insight into their reliability for pre-CPB assessment of AS severity. Conventional AS severity cutoffs were derived from TTE studies performed in awake, spontaneously breathing patients.14-18 However, cardiac anesthesiologists perform pre-CPB TEE in anesthetized patients receiving positive pressure ventilation. Because general anesthesia and positive pressure ventilation may influence cardiac loading conditions, we hypothesized that grading discordance by pre-CPB TEE would be higher than previously reported for TTE by others. METHODSWe obtained Duke University IRB approval, which granted waiver of consent to perform a retrospective database study for information collected between January 1, 2000, and December 31, 2012. This study was an investigator-initiated, single-center, retrospective review of the Duke University, Department of Anesthesiology perioperative echocardiography-reporting database. This database includes all adult patients who have undergone cardiac surgery at Duke University Medical Center and had a TEE report generated electronically since January 1, 2000. The Duke Health Information Technologies Solutions (DHTS) Perioperative Development Group (PDG) maintains the reporting system. A cardiothoracic anesthesiology fellow, attending, or both, generated TEE reports as part of a dedicated perioperative echocardiography training program. All imaging and reports were subsequently reviewed offline by an independent cardiothoracic anesthesiologist to confirm the accuracy of the report. Subject SelectionWe reviewed all patients in the database, who underwent AVR with or without coronary artery bypass grafting from January 1, 2000, until December 31, 2012. Patients were included if the echocardiographer reported both a pre-CPB ΔP m and an AVA. Patients were excluded if they had emergency surgery or repeat sternotomy. Patients were also excluded if they had an ejection fraction <55%, moderate or severe mitral regurgitation (MR), or severe aortic insufficiency (AI). Definitions of Variables Statistical AnalysisIRB approval was obtained in early 2013; therefore, we collected retrospective data as far as possible, up through December 31, 2012. Pre-CPB TEE ΔP m and AVA values were extracted for all patients meeting clinical inclusion criteria. These values were grouped according to AS severity (mild, moderate, and severe) and compared for discordance rates based on current grading guidelines for ΔP m and AVA. Values were considered "discordant" if there was disagreement between severities bas...

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“…(24) Although the sizing guidelines are straightforward the measurement of the aortic annulus diameter by non-invasive imaging is not as simple as might be implied. Studies using 3-D imaging modalities including MSCT, CMRI and 3-D TTE/TEE have shown that the aortic annulus is not round but oval in shape (10,12,13,25) (Figure 3). In one study using MSCT to evaluate the aortic root in 75 patients who were candidates for TAVI an oval annulus was seen in approximately 78% of patients.…”

Section: Sizingmentioning

confidence: 99%

Multislice computer tomography (MSCT) for the optimisation of transcatheter aortic valve implantation (TAVI)

Schultz

Jaegere

2017

SAHJ

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Multislice computer tomography (MSCT) for the optimisation of transcatheter aortic valve implantation (TAVI) and 3-D TEE can evaluate all anatomical aspects of the aortic root. (6)(7)(8) MSCT is particularly attractive for the evaluation of anatomy because it provides the user with a 3-D virtual representation that can be viewed from any angle or cut-plane after acquisition. What follows is a review of the role of MSCT pre-and post-TAVI. DIAGNOSIS OF SEVERE AORTIC STENOSISThe diagnosis of severe aortic stenosis is typically based on demonstrated that the LVOT is oval shaped, a fact which cannot be appreciated on 2-D echocardiography. (10,12,13,) In 3 separate studies the assumption of circularity of the LVOT was abandoned when using the continuity equation and instead the LVOT area measured on MSCT was used to replace the LVOT diameter from TTE for the calculation of AVA. (14,15,16)

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Demonstration of Left Ventricular Outflow Tract Eccentricity by Real Time 3D Echocardiography: Implications for the Determination of Aortic Valve Area

Cited by 127 publications

References 11 publications

Predictors of Mortality and Outcomes of Therapy in Low-Flow Severe Aortic Stenosis

Predictors of Mortality and Outcomes of Therapy in Low-Flow Severe Aortic Stenosis

Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography

Multislice computer tomography (MSCT) for the optimisation of transcatheter aortic valve implantation (TAVI)

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