Clinically Important Misclassification of Aortic Valve Stenosis Severity Using Non-Invasive Techniques: Simultaneous Echocardiography and Cardiac Catheterization During Transcatheter Aortic Valve Implantation in Awake Patients
Keywords:aortic stenosis, echocardiography, cardiac catheterization, hemodynamics, valve replacement, transcatheter
Background: Suitability for transcatheter aortic valve (AV) implantation (TAVI) is determined by using transthoracic echocardiography (TTE), although left-sided cardiac catheterization (LCC) provides directly measured pressure data. TAVI in awake patients permits simultaneous comparison of TTE and LCC under physiologically relevant left ventricular loading conditions. We hypothesized that clinically important discrepancies between TTE and LCC would be identified.
Methods and results: TAVI was performed in 108 awake patients undergoing intra-procedural TTE and LCC between January 1, 2016 and December 31, 2016, based upon pre-procedure TTE data. Intra-procedural assessments simultaneously were performed before and after prosthesis implantation. Based upon mean trans-AV systolic ejection pressure gradient (MSEPG), AS was graded as: mild (<20 mm Hg; grade 1), moderate (20 - <40 mm Hg; grade 2), or severe (≥40 mm Hg; grade 3). In 79 of the 108 (73.1%) patients, intra-procedural TTE and LCC assessments were concordant. In 2 of the 108 (1.9%) patients, TTE overestimated AS severity by ≥1 grade. In 27 of the 108 (25.0%) patients, TTE underestimated AS severity by ≥1 grade. In total, AS severity reclassification occurred in 29 (26.9%) patients. Overall, TTE underestimated MSEPG by 8.9 ± 1.2 mm Hg (TTE MSEPG versus LCC MSEPG; P < .001).
Conclusion: Current TTE criteria appear to frequently and importantly underestimate AS severity. Because decision-making regarding TAVI often exclusively is based upon TTE data, these findings suggest either a continued role for LCC in the diagnostic assessment of AS in patients who do not meet standard TTE criteria or lowering TTE cutoffs for TAVI.
Adams DH, Popma JJ, Reardon MJ, et al. 2014. U.S. CoreValve Clinical Investigators. Transcatheter aortic valve replacement with a self-expanding prosthesis. New Engl J Med. 370(19):1790-1798.
Andell P, Li X, Martinsson A, et al. 2017. Epidemiology of valvular heart disease in a Swedish nationwide hospital-based register study. Heart. 103(21):1696-1703.
Braunwald E. 2018. Aortic stenosis: then and now. Circulation. May 15;137(20):2099-2100.
Carabello BA, Barry WH, Grossman W. 1979. Changes in arterial pressure during left heart pullback in patients with aortic stenosis: a sign of severe aortic stenosis. Am J Cardiol. 44(3):424-427.
Currie PJ, Seward JB, Reeder GS, et al. 1985. Continuous-wave Doppler echocardiographic assessment of severity of calcific aortic stenosis: a simultaneous Doppler-catheter correlative study in 100 patients. Circulation. 71(6):1162-1169.
Ford LE, Feldman T, Chiu YC, Carroll JD. 1990. Hemodynamic resistance as a measure of functional impairment in aortic valvular stenosis. Circ Res. 66(1):1-7.
Gertz ZM, Raina A, O’Donnell W, et al. 2012. Comparison of invasive and non-invasive assessment of aortic stenosis severity in the elderly. Circ Cardiovasc Interv. 5(3): 406-414.
Johnson NP, Zelis JM, Tonino PAL, et al. 2018. Pressure gradient vs. flow relationships to characterize the physiology of a severely stenotic aortic valve before and after transcatheter valve implantation. Eur Heart J. 39(28): 2646-2655.
Lauck SB, Wood DA, Achtem L, et al. 2014. Risk stratification and clinical pathways to optimize length of stay after transcatheter aortic valve replacement. Can J Cardiol. 30(12):1583-1587.
Leon MB, Smith CR, Mack M, et al. 2010. PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. New Engl J Med. 363(17):1597-1607.
Oh JK, Taliercio CP, Holmes Jr DR, et al. 1988. Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients. J Am Coll Cardiol. 11(6): 1227-1234.
Otto CM, Davis KB, Holmes DR Jr, et al. 1992. Methodologic issues in clinical evaluation of stenosis severity in adults undergoing aortic or mitral balloon valvuloplasty. The NHLBI Balloon Valvuloplasty Registry. Am J Cardiol. 69(19):1607-1616.
Otto CM, Kumbhani DJ, Alexander KP, et al. 2017. 2017 ACC expert consensus decision pathway for transcatheter aortic valve replacement in the management of adults with aortic stenosis: a report from the American College of Cardiology Taskforce on Clinical Expert Consensus Documents. J Am Coll Cardiol. 69(10): 1313-1346.
Parameswaran AC, Reisner D, Amanullah A. 2009. Discrepancy between gradients derived by cardiac catheterization and by Doppler echocardiography in aortic stenosis: how often does pressure recovery play a role? Echocardiography. 26(9):1000-1005.
Popma JJ, Adams DH, Reardon MJ, et al. 2014. CoreValve United States Clinical Investigators. Transcatheter aortic valve replacement using a self-expanding bioprosthesis in patients with severe aortic stenosis at extreme risk for surgery. J Am Coll Cardiol. 63(19):1972-1981.
Reineke D, Gisler F, Englberger L, Carrel T. 2016. Mechanical versus biological aortic valve replacement strategies. Expert Rev Cardiovasc Ther. 14(4):423-430.
Rijsterborgh H, Roelandt J. 1987. Doppler assessment of aortic stenosis: Bernoulli revisited. Ultrasound Med Biol. 13(5):241-248.
Sacchi S, Dhutia NM, Shun-Shin MJ, et al. 2018. Doppler assessment of aortic stenosis: a 25-operator study demonstrating why reading the peak velocity is superior to the velocity-time integral. Eur Heart J Cardiovasc Imaging. e-pub ahead of print.
Smith CR, Leon MB, Mack MJ, et al. 2011. PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients. New Engl J Med. 364(23):2187-2198.
Stamm RB, Martin RP. 1983. Quantification of pressure gradients across stenotic valves by Doppler ultrasound. J Am Coll Cardiol. 2(4):707-718.
Svihlova H, Hron J, Malek J, Rajagopal KR, Rajagopal K. 2016. Determination of pressure data from velocity with a view toward its application in cardiovascular mechanics. Part 1. Theoretical considerations. Int J Eng Sci. 105(1): 108-127.
Svihlova H, Hron J, Malek J, Rajagopal KR, Rajagopal K. 2017. Determination of pressure data from velocity with a view toward its application in cardiovascular mechanics. Part 2. A study of aortic valve stenosis. Int J Eng Sci. 114(1):1-15.
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).