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Recommendations for Transesophageal Echocardiographic Screening in Transcatheter Aortic Valve Replacement: Insights for the Cardiothoracic Anesthesiologist

2023; Elsevier BV; Volume: 37; Issue: 5 Linguagem: Inglês

10.1053/j.jvca.2023.01.021

1532-8422

Emily Methangkool, Lisa Q. Rong, Peter J. Neuburger,

Aortic Disease and Treatment Approaches

IN A RECENT Journal of the American Society of Echocardiography issue, Hahn et al. introduced a focus topic on "Recommended Standards for the Performance of Transesophageal Echocardiographic Screening for Structural Heart Intervention."1Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar This manuscript, pertaining to preprocedural workup, received endorsement from numerous prominent cardiology societies. However, although one cardiothoracic anesthesiologist contributed as an author, the subspecialty was, overall, a minority voice in this collaborative effort. This may have been because cardiothoracic anesthesiologists do not frequently acquire outpatient images or report the study results for these patients. Yet, as cardiothoracic anesthesiologists increasingly gain ground as perioperative echocardiographers and develop clinical expertise, especially with transesophageal echocardiography (TEE), these recommendations are highly relevant to those in the field. Of all structural heart interventions, this is perhaps most true for transcatheter aortic valve replacement (TAVR). The global burden of aortic stenosis (AS) continues to increase dramatically, as the aging population is expected to triple, from 137 million in 2017 to 425 million in 2050 for those older than 80.2United Nations. World population projected to reach 9.8 billion in 2050, and 11.2 billion in 2100. Available at: https://www.un.org/en/desa/world-population-projected-reach-98-billion-2050-and-112-billion-2100. Accessed January 8, 2023.Google Scholar Transcatheter aortic valve replacement has been shown recently to provide a safe alternative to surgical aortic valve replacement (SAVR), with comparable short- and long-term outcomes in low-, intermediate-, and high-risk patients,3Leon MB Smith CR Mack M et al.Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363: 1597-1607Crossref PubMed Scopus (5612) Google Scholar, 4Leon MB Smith CR Mack MJ et al.Transcatheter or surgical aortic-valve replacement in intermediate-risk patients.N Engl J Med. 2016; 374: 1609-1620Crossref PubMed Scopus (3448) Google Scholar, 5Mack MJ Leon MB Thourani VH et al.Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380: 1695-1705Crossref PubMed Scopus (2682) Google Scholar, 6Smith CR Leon MB Mack MJ et al.Transcatheter versus surgical aortic-valve replacement in high-risk patients.N Engl J Med. 2011; 364: 2187-2198Crossref PubMed Scopus (4939) Google Scholar and the volume of TAVR procedures has grown exponentially, exceeding the numbers of isolated SAVR.7Carroll JD Mack MJ Vemulapalli S et al.STS-ACC TVT registry of transcatheter aortic valve replacement.Ann Thorac Surg. 2021; 111: 701-722Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Despite not regularly having "hands on the probe" in the screening clinic, cardiothoracic anesthesiologists are tasked with interpreting the workup at Heart Team meetings in order to help determine the appropriateness of intervention. They also are called upon to reassess the suitability of TAVR during the periprocedural echocardiogram and, when warranted, given the power to revise the procedural plan. As valued members of the Heart Team and experienced structural imagers, the role of cardiothoracic anesthesiologists in the structural heart arena is more important than ever. Accordingly, this editorial reviews recently published guidelines from the American Society of Echocardiography on TEE screening in structural heart interventions,1Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar with a focus on preprocedural imaging for TAVR. It is important to recognize that the screening guidelines by Hahn et al. for TAVR may have limited utility for preprocedural evaluation, as they only reported recommendations for TEE. The majority of TAVR patients will not undergo this imaging test and instead undergo the less-invasive transthoracic echocardiography to confirm the severity of AS. Once the diagnosis is made, multidetector computed tomography (MDCT) has become the "gold standard" for evaluation of the aortic root and aortic annulus for device sizing and femoral vasculature for access.8Achenbach S Delgado V Hausleiter J et al.SCCT expert consensus document on computed tomography imaging before transcatheter aortic valve implantation (TAVI)/transcatheter aortic valve replacement (TAVR).J Cardiovasc Comput Tomogr. 2012; 6: 366-380Abstract Full Text Full Text PDF PubMed Scopus (483) Google Scholar Two-dimensional (2D) TEE is associated with an increased incidence of patient-prosthesis mismatch and postprocedure paravalvular regurgitation,3Leon MB Smith CR Mack M et al.Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery.N Engl J Med. 2010; 363: 1597-1607Crossref PubMed Scopus (5612) Google Scholar and also tends to underestimate the aortic annulus in patients with a smaller annulus, and overestimate in patients with a larger annulus, whereas three-dimensional (3D) TEE tends to be more accurate for annular sizing.9Tsuneyoshi H Komiya T Shimamoto T. Accuracy of aortic annulus diameter measurement: comparison of multi-Detector CT, two- and three-dimensional echocardiography.J Card Surg. 2016; 31: 18-22Crossref PubMed Scopus (18) Google Scholar A recent meta-analysis and systematic review found that 3D TEE annular measurements had a strong correlation with MDCT, and 3D TEE was able to predict paravalvular regurgitation with similar accuracy to MDCT.10Rong LQ Hameed I Salemi A et al.Three-dimensional echocardiography for transcatheter aortic valve replacement sizing: A systematic review and meta-analysis.J Am Heart Assoc. 2019; 8e013463Crossref Scopus (19) Google Scholar There remain several advantages to preprocedural screening TEE over MDCT, including the evaluation of other valvular structures, diastolic function, and right ventricular systolic pressures. In TAVR, moderate or severe postprocedure mitral regurgitation is associated with higher early and 1-year mortality,11Bedogni F Latib A De Marco F et al.Interplay between mitral regurgitation and transcatheter aortic valve replacement with the CoreValve Revalving System: A multicenter registry.Circulation. 2013; 128: 2145-2153Crossref PubMed Scopus (101) Google Scholar, 12Nombela-Franco L Ribeiro HB Urena M et al.Significant mitral regurgitation left untreated at the time of aortic valve replacement: A comprehensive review of a frequent entity in the transcatheter aortic valve replacement era.J Am Coll Cardiol. 2014; 63 (2643-584)Crossref PubMed Scopus (126) Google Scholar, 13Zahn R Gerckens U Linke A et al.Predictors of one-year mortality after transcatheter aortic valve implantation for severe symptomatic aortic stenosis.Am J Cardiol. 2013; 112: 272-279Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar and, thus, a preprocedure assessment is necessary to determine baseline risk. Significant tricuspid regurgitation can be associated with right ventricular dysfunction and pulmonary hypertension; even mild pulmonary hypertension is associated with higher mortality after TAVR.14Sinning JM Hammerstingl C Chin D et al.Decrease of pulmonary hypertension impacts on prognosis after transcatheter aortic valve replacement.EuroIntervention. 2014; 9: 1042-1049Crossref PubMed Scopus (64) Google Scholar Patients with AS routinely have a significant degree of left ventricular hypertrophy, which can be associated with diastolic dysfunction, and in the long term, pulmonary hypertension due to left-sided heart disease. The degree of pulmonary hypertension may influence the choice of anesthetic (monitored anesthesia care versus general anesthesia), as well as vasopressor support during the procedure. Assessment of systolic function is also necessary, as patients with a depressed ejection fraction may need mechanical circulatory support during transcatheter valve implantation. In addition, the assessment of left ventricular stroke volume is necessary to identify patients with low-flow, low-gradient AS, which may be associated with worse outcomes after TAVR.15Kataoka A Watanabe Y Kozuma K et al.Prognostic impact of low-flow severe aortic stenosis in small-body patients undergoing TAVR: The OCEAN-TAVI registry.JACC Cardiovasc Imaging. 2018; 11: 659-669Crossref PubMed Scopus (40) Google Scholar Finally, TEE may provide valuable information about the presence or absence of calcifications in the left ventricular outflow tract (LVOT); moderate or severe LVOT calcification is associated with an increased risk of annular rupture, especially with balloon-expandable valves.16Okuno T Asami M Heg D et al.Impact of left ventricular outflow tract calcification on procedural outcomes after transcatheter aortic valve replacement.JACC Cardiovasc Interv. 2020; 13: 1789-1799Crossref PubMed Scopus (52) Google Scholar Transesophageal echocardiography evaluation of the LVOT may, therefore, change the choice of device or suggest avoidance of pre- and postdeployment balloon dilation, and if calcifications are present in the aortic root, it may change the operative strategy completely (eg, from a TAVR to a SAVR). A 2017 expert consensus decision pathway from the American College of Cardiology stated that TEE was "somewhat invasive" in the frail TAVR population and is "not recommended for routine pre-TAVR valve sizing."17Otto CM Kumbhani DJ Alexander KP et al.2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis: A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents.J Am Coll Cardiol. 2017; 69: 1313-1346Crossref PubMed Scopus (363) Google Scholar However, TAVR is being performed increasingly in younger patients with fewer comorbidities, and, thus, the performance of TEE under sedation may not confer substantial additional risk. Although MDCT is less invasive, TEE can provide the evaluation of other cardiac structures as well as accurate aortic annular and root measurements for patients who may have contraindications to MDCT (eg, severe renal dysfunction) or when MDCT is unable to determine the annular size for device selection (eg, measurements fall in between 2 sizes). In patients in whom MDCT assessment is inadequate, TEE placed immediately preintervention can supplement evaluation, as well as provide the most current assessment of systolic, diastolic, and valvular functions. Therefore, MDCT and 3D TEE can and should be used in a complementary fashion. Preprocedural TEE imaging should be focused on identifying the mechanism of valvular dysfunction, severity of disease, as well as appropriate anatomy for device selection.1Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Comprehensive 2D and 3D images should be obtained, with a focus on 3D optimization of images for evaluation of the aortic valve structures. This manuscript provides some simple yet effective pearls in this regard, as follows: mid-esophageal (ME) short-axis images (40°-60°) from both the aortic side and ventricular should be used to identify unfavorable aortic pathology.1Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Not emphasized were the ME long-axis views (110°-140°), which are required to evaluate leaflet and subaortic pathology, as well as the basal ventricular septum. Although real-time imaging (live 3D) can provide rapid visualization of the aortic valve, multibeat imaging should be used whenever possible to improve both spatial and temporal resolution. The authors' recommendations demonstrate their high level of expertise in 3D imaging. They provide excellent guidance concerning the limitations of various 3D techniques, including how dropout, blurring, blooming, railroad shape, and reverberations and shadowing impact the assessment of the native or artificial valve and catheters and wires during the intervention.1Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar The manuscript cautions against measurement directly on the 3D image due to parallax error, and instead suggests that when precise measurements are needed (eg, aortic annular dimensions), multibeat spliced images should not be used, as undetectable splice artifacts may affect the measurement.1Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar The authors of this document are experienced interventional echocardiographers well-versed in aortic annular sizing by TEE, which was performed commonly before MDCT became the gold standard. This section should be read carefully and practiced in the cardiac operating room, as there are fewer opportunities to master this skill in the structural heart setting. Accurate measurements of the aortic annulus are critical—oversizing can lead to frame distortion or catastrophes such as annular rupture, whereas undersizing can lead to significant paravalvular regurgitation or even valve embolization.18Athappan G Patvardhan E Tuzcu EM et al.Incidence, predictors, and outcomes of aortic regurgitation after transcatheter aortic valve replacement: Meta-analysis and systematic review of literature.J Am Coll Cardiol. 2013; 61: 1585-1595Crossref PubMed Scopus (634) Google Scholar, 19Barbanti M Yang TH Rodès Cabau J et al.Anatomical and procedural features associated with aortic root rupture during balloon-expandable transcatheter aortic valve replacement.Circulation. 2013; 128: 244-253Crossref PubMed Scopus (414) Google Scholar, 20Détaint D Lepage L Himbert D et al.Determinants of significant paravalvular regurgitation after transcatheter aortic valve implantation: Impact of device and annulus discongruence.JACC Cardiovasc Interv. 2009; 2: 821-827Crossref PubMed Scopus (340) Google Scholar Hahn et al. recommended a zoomed-in ME long-axis view of the aortic valve, with the LVOT aligned with the aortic root. The paper provided a great image of 3D multiplanar quantification describing where the annulus should be drawn (during midsystole, defined by a line bisecting the valve between the noncoronary and left coronary cusps posteriorly and right coronary cusp anteriorly).1Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar This measurement should still be performed manually, as the document cautioned that newer automatic programs have yet to be validated. The LVOT diameter is key for the calculation of aortic valve area and stroke volume, and should be measured at the annulus for the greatest accuracy from the right coronary cusp hinge anteriorly to the posterior aortic root at the base of the interleaflet trigone.1Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Coronary artery obstruction is a known risk of TAVR, and typically occurs from displacement of the calcified coronary cusps toward the ostia of the coronary arteries.21Ribeiro HB Nombela-Franco L Urena M et al.Coronary obstruction following transcatheter aortic valve implantation: A systematic review.JACC Cardiovasc Interv. 2013; 6: 452-461Crossref PubMed Scopus (222) Google Scholar A length of ≤10 mm from the aortic annulus to the coronary ostia is associated with a higher risk of coronary artery obstruction after TAVR.22Corrigan 3rd, FE Gleason PT Condado JF et al.Imaging for predicting, detecting, and managing complications after transcatheter aortic valve replacement.JACC Cardiovasc Imaging. 2019; 12: 904-920Crossref PubMed Scopus (13) Google Scholar The distance from the annulus to the coronary ostia, as well as the length of the aortic valve cusps, should be measured from 2D-reconstructed images from a 3D-zoomed volume. Most cardiothoracic anesthesiologists are comfortable with the assessment of AS severity as determined by calculation of pressure gradients and aortic valve area via Doppler echocardiography, which is reviewed in this document. However, the recommendations regarding aortic regurgitation (AR) quantification may be new. Although most cardiothoracic anesthesiologists are comfortable imaging and assessing AR pressure half-time, velocity-time integral, and jet density in the deep transgastric 5-chamber views, these guidelines suggest proximal isovelocity surface area (PISA) as an integral assessment of the severity of AS. Although PISA is not a new concept, the use of PISA for AR may be relatively new and should be reviewed in detail. With increasing TAVR volumes across the globe, cardiothoracic anesthesiologists may be increasingly expected to participate in preprocedural evaluation of patients as part of the Heart Team. Consequently, it is imperative to have an expert understanding of the aortic valve and root anatomy and measurement. Even if the cardiothoracic anesthesiologist is not involved in procedural decision-making, it is important to understand preprocedural imaging and prepare for the potential complications after TAVR, including the risk of paravalvular regurgitation, permanent pacemaker implantation, coronary artery obstruction, and device embolization. The guidelines provided by Hahn et al., although comprehensive, failed to address a few pertinent areas of aortic valve assessment. There is increasing debate over whether implantable valve size should be determined by perimeter; as the aortic valve becomes increasingly stenotic, it becomes more oval, and the area reduces disproportionately to the perimeter, leading to potential underestimation of the true annular dimensions and undersizing.23Bleakley C Monaghan MJ. The pivotal role of imaging in TAVR procedures.Curr Cardiol Rep. 2018; 20: 9Crossref PubMed Scopus (24) Google Scholar The guidelines did not provide detailed recommendations for the measurement of membranous septum length, which is an important determinant of the risk of complete heart block and the need for a permanent pacemaker. Finally, Hahn et al. made no mention of the advantage that screening TEE can provide over MDCT in the precise localization of calcium deposits in the aortic annulus, cusps, LVOT, and root, which can be risk factors for postintervention paravalvular leak.24Bhushan S Huang X Li Y et al.Paravalvular leak after transcatheter aortic valve implantation its incidence, diagnosis, clinical implications, prevention, management, and future perspectives: A review article.Curr Probl Cardiol. 2022; 47100957Crossref PubMed Scopus (13) Google Scholar Accurate aortic annular and root measurements are critical to appropriate device selection in TAVR. Pre-interventional imaging is key to procedural success. Both MDCT and 3D TEE have been shown to be accurate in measuring the aortic annulus, and can be used in a complementary fashion. The cardiothoracic anesthesiologist may be increasingly involved in preprocedural planning, given the growth of the TAVR procedure. Preprocedural TEE imaging should focus on the optimization of 3D images, with intimate knowledge and acquisition of annular and root dimensions, along with evaluation of biventricular systolic and diastolic function and mitral and tricuspid pathology. In this regard, the recommendations by Hahn et al. are a valuable guide for cardiothoracic anesthesiologists and all members of the Heart Team. E. Methangkool receives consultant fees from Edwards LifeSciences and author royalties from UpToDate, Inc. L. Rong is funded by NIH grant K23HL153836.