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

Whitener, George

McKenzie, Jeff

Akushevich, Igor

White, William D

Dhakal, Ishwori B

Nicoara, Alina

Swaminathan, Madhav

United States

2017-06-05T19:10:12Z

2017-06-05T19:10:12Z

2016-04

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.

https://www.ncbi.nlm.nih.gov/pubmed/26649912

1526-7598

https://hdl.handle.net/10161/14814

eng

Ovid Technologies (Wolters Kluwer Health)

Anesth Analg

10.1213/ANE.0000000000001099

Aged

Aged, 80 and over

Aortic Valve Stenosis

Cardiopulmonary Bypass

Echocardiography, Transesophageal

Female

Heart Valve Prosthesis Implantation

Humans

Male

Middle Aged

Retrospective Studies

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

Journal article

Nicoara, Alina|0000-0002-3814-6182

Swaminathan, Madhav|0000-0001-9136-8609

https://www.ncbi.nlm.nih.gov/pubmed/26649912

953

958

4

Anesthesiology

Anesthesiology, Cardiothoracic

Clinical Science Departments

Duke

Duke Population Research Institute

Institutes and Provost's Academic Units

Physics

Sanford School of Public Policy

School of Medicine

Social Science Research Institute

Trinity College of Arts & Sciences

University Institutes and Centers

Published

122