Grading Aortic Stenosis With Mean Gradient and Aortic Valve Area: A Comparison Between Preoperative Transthoracic and Precardiopulmonary Bypass Transesophageal Echocardiography.

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2016-10

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Abstract

OBJECTIVE: The authors hypothesized that average precardiopulmonary bypass (pre-CPB) transesophageal echocardiographic (TEE) mean gradient (PGm) and aortic valve area (AVA) values would be significantly different from preoperative transthoracic (TTE) values in the same patients and that these changes would affect pre-CPB TEE grading of aortic stenosis (AS). DESIGN: Retrospective, observational design. SETTING: Single university hospital. PARTICIPANTS: The study comprised 92 patients who underwent aortic valve replacement with or without coronary artery bypass grafting between 2000 and 2012 at Duke University Hospital and who had PGm and AVA values recorded in both pre-CPB TEE and preoperative TTE reporting databases. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: PGm with pre-CPB TEE was lower by 6.6 mmHg (95% confidence interval, -4.0 to -9.3 mmHg; p<0.001), whereas AVA was higher by 0.10 cm(2) (95% confidence interval, 0.04 to 0.15 cm(2); p<0.001), compared with preoperative TTE values. When using PGm, pre-CPB TEE generated an AS severity 1 grade lower 39.1% of the time and revealed no difference 55.4% of the time compared to preoperative TTE. When using AVA by continuity, pre-CPB TEE generated an AS severity 1 grade lower 14.1% of the time and revealed no difference 81.5% of the time compared to preoperative TTE. When using either PGm or AVA, preoperative TTE exhibited moderate or severe AS for all study patients, whereas, pre-CPB TEE demonstrated mild AS in 5.4% (n = 92) of patients. CONCLUSIONS: The authors confirmed their hypothesis that pre-CPB TEE generates different PGm and AVA values compared with preoperative TTE. These differences often underestimate AS severity. Hemodynamic standardizations or adjustments of pre-CPB TEE PGm and AVA values may be necessary in anesthetized patients before assigning an AS grade using these parameters.

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10.1053/j.jvca.2016.05.012

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Whitener, George, Joseph Sivak, Igor Akushevich, Zainab Samad and Madhav Swaminathan (2016). Grading Aortic Stenosis With Mean Gradient and Aortic Valve Area: A Comparison Between Preoperative Transthoracic and Precardiopulmonary Bypass Transesophageal Echocardiography. J Cardiothorac Vasc Anesth, 30(5). pp. 1254–1259. 10.1053/j.jvca.2016.05.012 Retrieved from https://hdl.handle.net/10161/14813.

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Scholars@Duke

Igor Akushevich

Research Professor in the Social Science Research Institute
Samad

Zainab Samad

Adjunct Associate Professor in the Department of Medicine

Dr. Zainab Samad is chairwoman of the Department of Medicine at Aga Khan University (AKU) in Pakistan and currently serves as an Adjunct Associate Professor of Medicine at Duke University. 

She attended Medical School at the Aga Khan University Medical College in Karachi, Pakistan and thereafter completed her residency training in Internal Medicine and fellowship in Cardiology at Duke University Medical Center in Durham, North Carolina. Additionally, she completed advanced training in cardiovascular imaging, specifically in clinical echocardiography, cardiac MRI and SPECT-myocardial perfusion imaging. She is also trained in quantitative methods with a Master of Health Sciences in Clinical Research degree from the National Institutes of Health- Duke Clinical Research Training Program. She served on faculty in the Division of Cardiology, Department of Medicine for nine years before accepting the position at AKU in 2018. She resides full-time in Karachi.

Swaminathan

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 reduce the severity of diastolic dysfunction postoperatively.


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