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

Authors

  • Pranav Loyalka, MD Houston Heart, HCA Houston Healthcare, Houston, TX, USA; 2HCA Research Institute, Nashville, TN, USA
  • Faisal H. Cheema, MD University of Houston College of Medicine, Houston, TX, USA
  • Pratap Singh, MBBS Division of Cardiology, Department of Internal Medicine, University of Texas-Houston McGovern Medical School, Houston, TX, USA
  • Charles C. Miller III, PhD Department of Cardiovascular and Thoracic Surgery, University of Texas-Houston McGovern Medical School, Houston, TX, USA
  • Roy Sheinbaum, MD Department of Anesthesiology, University of Texas-Houston McGovern Medical School, Houston, TX, USA
  • Anthony L. Estrera, MD Department of Cardiovascular and Thoracic Surgery, University of Texas-Houston McGovern Medical School, Houston, TX, USA
  • Hazim J. Safi, MD Department of Cardiovascular and Thoracic Surgery, University of Texas-Houston McGovern Medical School, Houston, TX, USA
  • Keshava Rajagopal, MD, PhD University of Houston College of Medicine, Houston, TX, USA

DOI:

https://doi.org/10.1532/hsf.3139

Keywords:

aortic stenosis, echocardiography, cardiac catheterization, hemodynamics, valve replacement, transcatheter

Abstract

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.

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Published

2020-11-10

How to Cite

Loyalka, P., Cheema, F. H., Singh, P., Miller, C. C., Sheinbaum, R., Estrera, A. L., Safi, H. J., & Rajagopal, K. . (2020). 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. The Heart Surgery Forum, 23(6), E837-E844. https://doi.org/10.1532/hsf.3139

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