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Invasive Versus Echocardiographic Evaluation of Transvalvular Gradients Immediately Post-Transcatheter Aortic Valve Replacement

2019; Lippincott Williams & Wilkins; Volume: 12; Issue: 7 Linguagem: Inglês

10.1161/circinterventions.119.007973

ISSN

1941-7632

Autores

Amr E. Abbas, Ramy Mando, George Hanzel, Michael J. Gallagher, Robert D. Safian, Ivan Hanson, Steven Almany, Philippe Pîbarot, Pratik Dalal, Alessandro Vivacqua, Marc Sakwa, Francis Shannon,

Tópico(s)

Cardiac pacing and defibrillation studies

Resumo

HomeCirculation: Cardiovascular InterventionsVol. 12, No. 7Invasive Versus Echocardiographic Evaluation of Transvalvular Gradients Immediately Post-Transcatheter Aortic Valve Replacement Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBInvasive Versus Echocardiographic Evaluation of Transvalvular Gradients Immediately Post-Transcatheter Aortic Valve ReplacementDemonstration of Significant Echocardiography-Catheterization Discordance Amr E. Abbas, MD, Ramy Mando, MD, George Hanzel, MD, Michael Gallagher, MD, Robert Safian, MD, Ivan Hanson, MD, Steven Almany, MD, Philippe Pibarot, DVM, PhD, Pratik Dalal, MD, Alessandro Vivacqua, MD, Marc Sakwa, MD and Francis Shannon, MD Amr E. AbbasAmr E. Abbas Amr E Abbas, MD, FACC, Beaumont Health, Royal Oak, MI, 3601 W 13 Mile Rd, Royal Oak, MI 48073. Email E-mail Address: [email protected] Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI (A.E.A., R.M., G.H., M.G., R.S., I.H., S.A., P.D., A.V. M.S. F.S.) Department of Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A., G.H., M.G., R.S., I.H., S.A., A.V. M.S. F.S.) , Ramy MandoRamy Mando Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI (A.E.A., R.M., G.H., M.G., R.S., I.H., S.A., P.D., A.V. M.S. F.S.) , George HanzelGeorge Hanzel Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI (A.E.A., R.M., G.H., M.G., R.S., I.H., S.A., P.D., A.V. M.S. F.S.) Department of Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A., G.H., M.G., R.S., I.H., S.A., A.V. M.S. F.S.) , Michael GallagherMichael Gallagher Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI (A.E.A., R.M., G.H., M.G., R.S., I.H., S.A., P.D., A.V. M.S. F.S.) Department of Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A., G.H., M.G., R.S., I.H., S.A., A.V. M.S. F.S.) , Robert SafianRobert Safian Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI (A.E.A., R.M., G.H., M.G., R.S., I.H., S.A., P.D., A.V. M.S. F.S.) Department of Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A., G.H., M.G., R.S., I.H., S.A., A.V. M.S. F.S.) , Ivan HansonIvan Hanson Department of Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A., G.H., M.G., R.S., I.H., S.A., A.V. M.S. F.S.) , Steven AlmanySteven Almany Department of Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A., G.H., M.G., R.S., I.H., S.A., A.V. M.S. F.S.) , Philippe PibarotPhilippe Pibarot Department of Medicine, Laval University, Quebec, Canada (P.P.). , Pratik DalalPratik Dalal Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI (A.E.A., R.M., G.H., M.G., R.S., I.H., S.A., P.D., A.V. M.S. F.S.) , Alessandro VivacquaAlessandro Vivacqua Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI (A.E.A., R.M., G.H., M.G., R.S., I.H., S.A., P.D., A.V. M.S. F.S.) Department of Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A., G.H., M.G., R.S., I.H., S.A., A.V. M.S. F.S.) , Marc SakwaMarc Sakwa Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI (A.E.A., R.M., G.H., M.G., R.S., I.H., S.A., P.D., A.V. M.S. F.S.) Department of Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A., G.H., M.G., R.S., I.H., S.A., A.V. M.S. F.S.) and Francis ShannonFrancis Shannon Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, MI (A.E.A., R.M., G.H., M.G., R.S., I.H., S.A., P.D., A.V. M.S. F.S.) Department of Medicine, Oakland University William Beaumont School of Medicine, Auburn Hills, MI (A.E.A., G.H., M.G., R.S., I.H., S.A., A.V. M.S. F.S.) Originally published5 Jul 2019https://doi.org/10.1161/CIRCINTERVENTIONS.119.007973Circulation: Cardiovascular Interventions. 2019;12:e007973Transcatheter aortic valve replacement (TAVR) for severe native aortic valve stenosis (native-TAVR) and valve-in-valve TAVR by balloon-expanding and self-expanding platforms is available.1,2 Studies report post-TAVR mean gradients (MG) obtained by aortic valve continuous wave Doppler on echocardiography (echocardiography MG,4V22), without adjusting for noninvasive mean pressure recovery (PRmean) or left ventricular outflow tract MG (LVOT MG,4V12), or invasive MG (catheterization MG) comparison.1,2Catheterization/echocardiography MG discrepancies exist in aortic valve stenosis due to PR3 and inherent Bernoulli-equation limitations.4 Equations adjusting for these differences are described.3,4 We hypothesized that echocardiography will overestimate post-TAVR MG compared with catheterization.Institutional Review Board approved the study; authors elect not to make data publicly available.We retrospectively compared consecutive post-TAVR catheterization and echocardiography MG obtained almost simultaneously (September 2015–September 2018) and studied the impact of LVOT MG and PRmean.Post-TAVR, a pigtail catheter was reintroduced in the left ventricle for left ventricular pressure. A second transducer was connected to the side-arm of the balloon-expanding TAVR sheath, or the long sheath after removing the self-expanding TAVR valve, for aortic pressure with the sheath-tip positioned in the distal descending aorta to obtain catheterization MG. Echocardiography was performed within 1 to 2 minutes following catheterization measurement.Ascending aorta (AA) diameter was measured from baseline echocardiography to derive:AA area=(AA diameter/2)2 × πPRmean=echocardiography MG×2×AA area/effective orifice area×(1−AA area/effective orifice area).3Definitions AND RESULTSEchocardiography MG: aortic valve continuous wave Doppler tracingEchocardiography MG PR: echocardiography MG−PRmeanEchocardiography MG PROX: echocardiography MG−LVOT MGEchocardiography MG PR/PROX: echocardiography MG−PRmean−LVOT MGEchocardiography and catheterization MGs were presented as mean±SD, median, and range based on their respective distribution. Using IBM SPSS Statistical Software Package Version 25, Mann-Whitney U (nonparametric) compared catheterization MG with echocardiography MG, echocardiography MG PROX, echocardiography MG PR, and echocardiography MG PR/PROX, as catheterization MG did not fit normal distribution. Differences and agreement between catheterization and echocardiography MG and echocardiography MG PR/PROX were represented through Bland-Altman by plotting the difference of the 2 measurements against their means. For all tests, a 2-sided P value of 10 mm Hg discordance (left to right).ECHO MG PR=ECHO MG−PRmean, ECHO MG PROX=ECHO MG−LVOT MG, and ECHO MG PR/PROX=ECHO MG−PRmean−LVOT MG.NativeCatheterization/echocardiography discordance existed in all (median 0, range 0–14 mm Hg versus median 5, range 1–30 mm Hg; P<0.000001), with progressive improved discordance between catheterization MG and echocardiography MG, echocardiography MG PROX, echocardiography MG PR, and echocardiography MG PR/PROX. Catheterization MG and echocardiography MG PR/PROX remained statistically, albeit less clinically different (median 0 versus 0.95 mm Hg, P<0.0001, Z=−10.3). Bland-Altman confirmed poor comparisons of catheterization MG versus echocardiography MG (mean 5.2±3.4; 95% CI, 4.8–5.6; P<0.0001) that improved versus echocardiography MG PR/PROX (mean 1.1±2.8; 95% CI, 0.7–1.4; P<0.0001). Catheterization/echocardiography MG discordance was ≥5 mm Hg in 151 out of 259 (58%) and ≥10 mm Hg in 24 out of 259 (9%). Catheterization/echocardiography MG PR/PROX discordance improved to 19 out of 259 (7%) ≥5 mm Hg and none ≥10 mm Hg.Valve-in-ValveCatheterization/echocardiography discordance existed in all (median 0.5 versus 9.5 mm Hg; P<0.000001) with progressive improved discordance between catheterization MG and echocardiography MG, echocardiography MG PROX, echocardiography MG PR, and echocardiography MG PR/PROX. Catheterization MG and echocardiography MG PR/PROX remained statistically and clinically different (median 0.5 versus 5 mm Hg; P<0.007; Z=−2.7). Bland-Altman confirmed poor comparisons of catheterization MG versus echocardiography MG (mean 6.5± 6.3; 95% CI, 4.4–8.6; P<0.0001) that improved versus echocardiography MG PR/PROX (mean 2±6.3; 95% CI −0.13 to 4.2; P<0.0001). Catheterization/echocardiography MG discordance was ≥5 mm Hg in 24 out of 36 (67%) and ≥10 mm Hg in 9 out of 36 (25%). Catheterization/echocardiography MG PR/PROX discordance improved to 11 out of 36 (31%) ≥5 mm Hg and 3 out of 36 (8%) ≥10 mm Hg.This study demonstrates (1) post-TAVR, echocardiography MG is significantly higher than catheterization MG. (2) After accounting for LVOT MG and PRmean, echocardiography MG and catheterization MG remain statistically, albeit not clinically different post–native-TAVR, whereas post–valve-in-valve TAVR, they remain statistically and clinically different.Discordance occurs secondary to PR3 or inherent simplified Bernoulli-equation limitations.4 PR occurs beyond the aortic valve due to recovery of a portion of lost pressure as flow decelerates when turbulent vortices rejoin central laminar flow and is only accounted for by catheterization MG.Bernoulli-equation assumes laminar flow and no PR and omits:Flow acceleration, which is not negligible with pulsatility or normal TAVR valves.Viscous losses.LVOT MGPost-TAVR, catheterization MG is required, especially post–valve-in-valve and elevated echocardiography MG requires further study while accounting for LVOT MG and PRmean. Elevated echocardiography MG not confirmed on catheterization, questions the true percentage of prosthesis-patient mismatch5 because PR and Bernoulli limitations may be the culprit.This is a single center study with known inherent limitations. However, careful attention to the fidelity of measurements under similar hemodynamic conditions was conducted. Patients were supine, and echocardiography MG may be underestimated, thus echocardiography-catheterization discordance may be higher.Echocardiography remains important in extended follow-up of post-TAVR MG and aortic regurgitation because repeat catheterization is impractical.DisclosuresDr Abbas has received research grants and honoraria from Edwards Life Sciences, and Dr Pibarot received grants and honoraria from Medtronic and Edwards Life Sciences. The other authors report no conflicts.FootnotesAmr E Abbas, MD, FACC, Beaumont Health, Royal Oak, MI, 3601 W 13 Mile Rd, Royal Oak, MI 48073. Email [email protected]eduReferences1. Adams DH, Popma JJ, Reardon MJ, Yakubov SJ, Coselli JS, Deeb GM, Gleason TG, Buchbinder M, Hermiller J, Kleiman NS, Chetcuti S, Heiser J, Merhi W, Zorn G, Tadros P, Robinson N, Petrossian G, Hughes GC, Harrison JK, Conte J, Maini B, Mumtaz M, Chenoweth S, Oh JK; U.S. CoreValve Clinical Investigators. Transcatheter aortic-valve replacement with a self-expanding prosthesis.N Engl J Med. 2014; 370:1790–1798. doi: 10.1056/NEJMoa1400590CrossrefMedlineGoogle Scholar2. Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ; PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med. 2011; 364:2187–2198. doi: 10.1056/NEJMoa1103510CrossrefMedlineGoogle Scholar3. Baumgartner H, Stefenelli T, Niederberger J, Schima H, Maurer G. "Overestimation" of catheter gradients by doppler ultrasound in patients with aortic stenosis: a predictable manifestation of pressure recovery.J Am Coll Cardiol. 1999; 33:1655–1661.CrossrefMedlineGoogle Scholar4. Firstenberg MS, Abel EE, Papadimos TJ, Tripathi RS. Nonconvective forces: a critical and often ignored component in the echocardiographic assessment of transvalvular pressure gradients.Cardiol Res Pract. 2012; 383217:1–4. doi: 10.1155/2012/383217CrossrefGoogle Scholar5. Herrmann HC, Daneshvar SA, Fonarow GC, Stebbins A, Vemulapalli S, Desai ND, Malenka DJ, Thourani VH, Rymer J, Kosinski AS. Prosthesis-patient mismatch in patients undergoing transcatheter aortic valve replacement: from the STS/ACC TVT registry.J Am Coll Cardiol. 2018; 72:2701–2711. doi: 10.1016/j.jacc.2018.09.001CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Hatoum H, Samaee M, Sathananthan J, Sellers S, Kuetting M, Lilly S, Ihdayhid A, Blanke P, Leipsic J, Thourani V and Dasi L (2022) Comparison of performance of self-expanding and balloon-expandable transcatheter aortic valves, JTCVS Open, 10.1016/j.xjon.2022.04.015, 10, (128-139), Online publication date: 1-Jun-2022. Esmailie F, Razavi A, Yeats B, Sivakumar S, Chen H, Samaee M, Shah I, Veneziani A, Yadav P, Thourani V and Dasi L (2022) Biomechanics of Transcatheter Aortic Valve Replacement Complications and Computational Predictive Modeling, Structural Heart, 10.1016/j.shj.2022.100032, 6:2, (100032), Online publication date: 1-Jun-2022. Généreux P, Kipperman R, Placido Disla J, Aldaia L, Koulogiannis K, Marcoff L, Mediratta A, Slater J, Zaku B, Redfors B, Abdelfattah O and Gillam L (2022) Evaluation of the OpSens OptoWire III and Novel TAVR Algorithm to Measure Pressure Gradient During TAVR, Journal of the Society for Cardiovascular Angiography & Interventions, 10.1016/j.jscai.2022.100309, (100309), Online publication date: 1-May-2022. Barker M, Abbas A, Webb J, Pibarot P, Sathananthan J, Brunner N, Wang D, Wang J, Leon M and Wood D (2021) Standardized Invasive Hemodynamics for Management of Patients With Elevated Echocardiographic Gradients Post-Transcatheter Aortic Valve Replacement at Midterm Follow-Up, Circulation: Cardiovascular Interventions, 15:1, Online publication date: 1-Jan-2022. Naidu S, Chen T, Fiorilli P, Li R, Desai N, Szeto W, Giri J, Kobayashi T, Atluri P and Herrmann H (2022) Measuring TAVR Prosthesis Gradient Immediately Post-Procedure May Underestimate its Significance, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2021.09.012, 15:1, (120-121), Online publication date: 1-Jan-2022. Herrmann H, Abdel-Wahab M, Attizzani G, Batchelor W, Bleiziffer S, Verdoliva S, Chang Y, Gada H, Gillam L, Guerrero M, Mahoney P, Petronio A, Rogers T, Rovin J, Szerlip M, Whisenant B, Mehran R and Tchetche D (2022) Rationale and design of the SMall Annuli Randomized To Evolut or SAPIEN Trial (SMART Trial), American Heart Journal, 10.1016/j.ahj.2021.09.011, 243, (92-102), Online publication date: 1-Jan-2022. Guzzetti E, Côté N, Clavel M and Pibarot P (2022) Ventricular–arterial coupling and arterial load in aortic valve disease Textbook of Arterial Stiffness and Pulsatile Hemodynamics in Health and Disease, 10.1016/B978-0-323-91391-1.00037-6, (591-607), . 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Reddy Y, Miranda W and Nishimura R (2021) Measuring Pressure Gradients After Transcatheter Aortic Valve Implantation: Rethinking the Bernoulli Principle, Journal of the American Heart Association, 10:19, Online publication date: 5-Oct-2021.Abbas A, Mando R, Kadri A, Khalili H, Hanzel G, Shannon F, Al‐Azizi K, Waggoner T, Kassas S, Pilgrim T, Okuno T, Camacho A, Selberg A, Elmariah S, Bavry A, Ternacle J, Christensen J, Gheewala N, Pibarot P and Mack M (2021) Comparison of Transvalvular Aortic Mean Gradients Obtained by Intraprocedural Echocardiography and Invasive Measurement in Balloon and Self‐Expanding Transcatheter Valves, Journal of the American Heart Association, 10:19, Online publication date: 5-Oct-2021. Leone P, Fazzari F, Cannata F, Sanz-Sanchez J, Mangieri A, Monti L, Cozzi O, Stefanini G, Bragato R, Colombo A, Reimers B and Regazzoli D (2021) Clinical and Technical Challenges of Prosthesis–Patient Mismatch After Transcatheter Aortic Valve Implantation, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2021.670457, 8 Kaneko T, Makkar R, Krishnaswamy A, Hermiller J, Greenbaum A, Babaliaros V, Shah P, Bailey S, Bapat V, Kapadia S and Abbas A (2021) Valve-in-Surgical-Valve With SAPIEN 3 for Transcatheter Aortic Valve Replacement Based on Society of Thoracic Surgeons Predicted Risk of Mortality, Circulation: Cardiovascular Interventions, 14:5, Online publication date: 1-May-2021. Ternacle J, Abbas A and Pibarot P (2021) Prosthesis-Patient Mismatch After Transcatheter Aortic Valve Replacement, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2021.03.039, 14:9, (977-980), Online publication date: 1-May-2021. Leon M, Mack M, Hahn R, Thourani V, Makkar R, Kodali S, Alu M, Madhavan M, Chau K, Russo M, Kapadia S, Malaisrie S, Cohen D, Blanke P, Leipsic J, Williams M, McCabe J, Brown D, Babaliaros V, Goldman S, Herrmann H, Szeto W, Genereux P, Pershad A, Lu M, Webb J, Smith C and Pibarot P (2021) Outcomes 2 Years After Transcatheter Aortic Valve Replacement in Patients at Low Surgical Risk, Journal of the American College of Cardiology, 10.1016/j.jacc.2020.12.052, 77:9, (1149-1161), Online publication date: 1-Mar-2021. Ternacle J, Guimaraes L, Vincent F, Côté N, Côté M, Lachance D, Clavel M, Abbas A, Pibarot P and Rodés-Cabau J (2020) Reclassification of prosthesis–patient mismatch after transcatheter aortic valve replacement using predicted vs. measured indexed effective orifice area, European Heart Journal - Cardiovascular Imaging, 10.1093/ehjci/jeaa235, 22:1, (11-20), Online publication date: 1-Jan-2021. Abbas A (2020) Letter by Abbas Regarding Articles, "Balloon-Expandable Versus Self-Expanding Transcatheter Aortic Valve Replacement: A Propensity-Matched Comparison From the FRANCE-TAVI Registry" and "Impact of Sapien 3 Balloon-Expandable Versus Evolut R Self-Expandable Transcatheter Aortic Valve Implantation in Patients With Aortic Stenosis: Data From a Nationwide Analysis", Circulation, 141:24, (e908-e909), Online publication date: 16-Jun-2020. Aalaei-Andabili S, Park K, Choi C, Manning E, Stinson W, Van Woerkom R, Pilgrim T, Kumbhani D and Bavry A (2020) Relationship between Invasive and Echocardiographic Transvalvular Gradients after Transcatheter Aortic Valve Replacement, Cardiology and Therapy, 10.1007/s40119-020-00161-y, 9:1, (201-206), Online publication date: 1-Jun-2020. Pibarot P, Salaun E, Dahou A, Avenatti E, Guzzetti E, Annabi M, Toubal O, Bernier M, Beaudoin J, Ong G, Ternacle J, Krapf L, Thourani V, Makkar R, Kodali S, Russo M, Kapadia S, Malaisrie S, Cohen D, Leipsic J, Blanke P, Williams M, McCabe J, Brown D, Babaliaros V, Goldman S, Szeto W, Généreux P, Pershad A, Alu M, Xu K, Rogers E, Webb J, Smith C, Mack M, Leon M and Hahn R (2020) Echocardiographic Results of Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients, Circulation, 141:19, (1527-1537), Online publication date: 12-May-2020. Abbas A (2020) Prosthesis–Patient Mismatch Following Transcatheter Aortic Valve Replacement, JACC: Cardiovascular Interventions, 10.1016/j.jcin.2019.10.027, 13:1, (138), Online publication date: 1-Jan-2020. Abbas A (2019) Valve-in-Valve Transcatheter Aortic Valve Replacement, Journal of the American College of Cardiology, 10.1016/j.jacc.2019.06.070, 74:11, (1516-1517), Online publication date: 1-Sep-2019. July 2019Vol 12, Issue 7 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.119.007973PMID: 31272227 Originally publishedJuly 5, 2019 Keywordscatheterizationtranscatheter aortic valve replacementaortic valve stenosisaortic valveechocardiographyPDF download Advertisement SubjectsAortic Valve Replacement/Transcatheter Aortic Valve ImplantationCatheter-Based Coronary and Valvular InterventionsComputerized Tomography (CT)Echocardiography

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