Intracardiac Doppler Echocardiography for Monitoring of Pulmonary Artery Pressures in High-Risk Patients Undergoing Transcatheter Aortic Valve Replacement

Silvana Müller; Corinna Velik-Salchner; Michael Edlinger; Nikolaos Bonaros; Anneliese Heinz; Gudrun Feuchtner; Thomas Bartel

doi:10.1016/j.echo.2015.09.003

Intracardiac Doppler Echocardiography for Monitoring of Pulmonary Artery Pressures in High-Risk Patients Undergoing Transcatheter Aortic Valve Replacement

J Am Soc Echocardiogr. 2016 Jan;29(1):83-91. doi: 10.1016/j.echo.2015.09.003. Epub 2015 Oct 20.

Authors

Silvana Müller¹, Corinna Velik-Salchner², Michael Edlinger³, Nikolaos Bonaros⁴, Anneliese Heinz⁴, Gudrun Feuchtner⁵, Thomas Bartel⁶

Affiliations

¹ Division of Cardiology, Department of Internal Medicine III, Innsbruck University Medical School, Innsbruck, Austria.
² Department of Anesthesiology, Innsbruck University Medical School, Innsbruck, Austria.
³ Department of Medical Statistics, Informatics and Health Economics, Innsbruck University Medical School, Innsbruck, Austria.
⁴ Department of Cardiac Surgery, Innsbruck University Medical School, Innsbruck, Austria.
⁵ Department of Radiology II, Innsbruck University Medical School, Innsbruck, Austria.
⁶ Department of Cardiology, Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates. Electronic address: bartelt@clevelandclinicabudhabi.ae.

PMID: 26494418
DOI: 10.1016/j.echo.2015.09.003

Abstract

Background: Uncontrolled pulmonary hypertension may cause worse outcomes after transcatheter aortic valve replacement (TAVR), while hemodynamic monitoring is desirable for risk control. Pulmonary artery pressure (PAP) readings obtained by intracardiac Doppler echocardiography were evaluated.

Methods: In 114 patients with symptomatic aortic stenosis and median Society of Thoracic Surgeons scores of 10.5% (interquartile range, 7.7%-15.0%), transfemoral and transapical TAVR was guided by intracardiac Doppler echocardiography. The continuous-wave Doppler beam interrogated the jet of tricuspid regurgitation from the "home view" position. Systolic PAP (PAPs) was estimated as the sum of the pressure gradient derived from the maximum transtricuspid regurgitation jet velocity and the central venous pressure. Mean PAP (PAPm) was calculated by the mean gradient method (1) and the Chemla formula (2). Measurements were obtained immediately before and after TAVR.

Results: Pre- and postinterventional readings showed marginal pressure underestimation in comparison with measurements derived from right-heart catheterization: PAPs, -2.7 (95% CI, -3.3 to 2.1) and -1.4 (95% CI, -1.9 to -0.9); PAPm by the mean gradient method, -1.9 (95% CI, -2.2 to -1.6) and -0.1 (95% CI, -0.4 to 0.2). Agreement (95% limits) for PAPs was -8.6 to 3.2 and -6.8 to 4.0; agreement for PAPm by the mean gradient method was -5.4 to 1.6 and -3.4 to 3.2. The repeatability coefficient (95% limits of agreement) for PAPs was excellent: 3.4 (-4.2 to 2.5) and 5.5 (-5.3 to 5.8); repeatability for PAPm was higher by the mean gradient method than by the Chemla method. In ≥ 85% of patients with pulmonary hypertension, PAPm improved after valve deployment.

Conclusions: Intracardiac Doppler echocardiography-derived monitoring of PAP by the mean gradient method is accurate and well applicable to high-risk TAVR candidates for intraprocedural risk control.

Keywords: Aortic stenosis; Hemodynamic monitoring; Intracardiac echocardiography; Pulmonary hypertension; Transcatheter aortic valve replacement.

MeSH terms

Aged, 80 and over
Aortic Valve Stenosis / diagnostic imaging
Aortic Valve Stenosis / physiopathology
Aortic Valve Stenosis / surgery*
Echocardiography, Doppler / methods*
Female
Humans
Male
Monitoring, Intraoperative / methods*
Pulmonary Artery / diagnostic imaging
Pulmonary Artery / physiopathology*
Pulmonary Wedge Pressure / physiology*
Risk Factors
Transcatheter Aortic Valve Replacement / methods*
Ultrasonography, Interventional / methods*