Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography.
Abstract
BACKGROUND: Current guidelines define severe aortic valve stenosis (AS) as an aortic
valve area (AVA) ≤1.0 cm by the continuity equation and mean gradient (ΔPm) ≥ 40 mm
Hg. However, these measurements can be discordant when classifying AS severity. Approximately
one-third of patients with normal ejection fraction and severe AS by AVA have nonsevere
AS by ΔPm when measured by preoperative transthoracic echocardiography (TTE). Given
the use of positive pressure ventilation and general anesthesia in the pre-cardiopulmonary
bypass (pre-CPB) period, we hypothesized that discordance between ΔPm and AVA during
pre-CPB transesophageal echocardiography (TEE) would be higher than previously reported
by TTE. METHODS: We retrospectively examined pre-CPB TEE data for patients who had
aortic valve replacement, with or without coronary artery bypass grafting, from 2000
to 2012. Patients were excluded if they had ejection fraction <55%, emergency surgery,
repeat sternotomy, moderate or severe mitral regurgitation, or severe aortic regurgitation.
Only patients with both pre-CPB AVA and ΔPm measurements were included. Patients were
grouped according to severity (mild, moderate, and severe) by AVA or ΔPm. Discordance
was defined as disagreement between severities based on either parameter. RESULTS:
A total of 277 patients met inclusion criteria. There were 227 patients with AVA ≤
1.0 cm. The proportion of these patients with a ΔPm < 40 mm Hg was 54% (95% confidence
interval, 47%-61%). The rate of discordance was significantly higher than the rate
(37%; P < 0.001) found in previously reported analyses using TTE. Of the patients
with a ΔPm ≥ 40 mm Hg, only 8% (n = 9/113) had a discordant AVA. In contrast, of the
patients with ΔPm < 40 mm Hg, 80% (n = 131/164) had a discordant AVA. CONCLUSIONS:
We confirmed our hypothesis that grading AS by ΔPm and AVA during pre-CPB TEE exhibits
higher discordance than reported for TTE by others. It remains unclear whether these
discrepancies reflect the effect of general anesthesia, imaging modality (TTE versus
TEE) differences, inaccuracies in AS grading cutoffs when applied to pre-CPB TEE,
or selection bias of the surgical population.
Type
Journal articleSubject
AgedAged, 80 and over
Aortic Valve Stenosis
Cardiopulmonary Bypass
Echocardiography, Transesophageal
Female
Heart Valve Prosthesis Implantation
Humans
Male
Middle Aged
Retrospective Studies
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https://hdl.handle.net/10161/14814Published Version (Please cite this version)
10.1213/ANE.0000000000001099Publication Info
Whitener, George; McKenzie, Jeff; Akushevich, Igor; White, William D; Dhakal, Ishwori
B; Nicoara, Alina; & Swaminathan, Madhav (2016). Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal
Echocardiography. Anesth Analg, 122(4). pp. 953-958. 10.1213/ANE.0000000000001099. Retrieved from https://hdl.handle.net/10161/14814.This is constructed from limited available data and may be imprecise. To cite this
article, please review & use the official citation provided by the journal.
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Show full item recordScholars@Duke
Igor Akushevich
Research Professor in the Social Science Research Institute
Alina Nicoara
Associate Professor in Anesthesiology
Madhav Swaminathan
Professor of Anesthesiology
My overall goal is to elucidate mechanisms of and risk factors for perioperative acute
kidney injury in patients undergoing heart surgery with emphasis the role of early
recovery of kidney function. A special area of interest is the phenomenon of left
ventricular diastolic dysfunction. We have successfully developed an algorithm to
help simplify the detection of diastolic dysfunction using echocardiography during
heart surgery. A future goal is to explore interventions that help prevent or reduc
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