SHA24/087003

Edwin G. Avery IV, M.D.

Chief, Division of Cardiac Anesthesia Associate Professor of Anesthesiology University Hospitals Case Medical Center Case Western Reserve University School of Medicine

Covidien: consultant, speaker’s bureau, funded research

Medtronic: funded research, Co-invesitgator Core Valve trial

Separating from bypass is facilitated by using TEE to confirm: An optimal surgical result has been achieved To rule out iatrogenic injury TEE is useful to asses cardiac performance in real time

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Do a quick check of the AV/aorta prior to CPB separation Assess the valve integrity (i.e. leaflet motion, AI, residual gradient, paravalular leak)

Aortic root edema lasting several months is the rule following surgical AVR but is not seen with TAVIs It is mandatory to attempt to obtain a gradient or EOA to rule out patient prosthesis mismatch

Zoghbi WA, et al. JASE 2009;22(9);975-1014

AV leaflet mobility and integrity appear excellent while the anticipated aortic root edema is noted (Freestyle AV + myectomy)

C.O. = 4.4 L/min

LVOTDiam = 2.1 cm C.1. = 2.3 VTILVOT = 14 2 L/min/m cm/sec HR = 90 bpm BSA = 1.9 m2 Peak & Mean gradients = 6 and 2 mmHg, respectively

EOA = SV/VTIPrV

EOA = (πr2 • VTILVOT) / 19.3 cm = 2.5 cm2

Low gradients or EOA >0.8 cm2 help to rule patient prosthesis mismatch but calculating EOA is preferred for this assessment

Zoghbi WA, et al. JASE 2009;22(9);975-1014

Determining a transvalvular gradient or EOA with TEE is essential to document procedural success. Concurrent cardiac function should be noted.

Paravalvular leak may be common with traditional valves that contain a rigid sewing ring (and Core AV) but is not seen with Freestyle valves Severe paravalvular leak in a bi-leaflet tilting disc valve

Agrifoglio M, et al. JCTS 2011;6(60) http://www.readcube.com/articles/10.1186/1749-8090-6-60

Paravalvular leak may be common with traditional valves that contain a rigid sewing ring (and Core AV) but is not seen with Freestyle valves Core Valve Images

Washing jets or “physiologic regurgitation� is normal for mechanical valve prostheses Washing Jets

Eichinger WB, et al. JTCVS 2010;140(3):611-16 Zoghbi WA, et al. JASE 2009;22(9);975-1014

Checking the proximal left main and right coronary artery with color flow Doppler and a low nyquist limit can demonstrate absence of proximal flow obstructuion.

Ruling out aortic dissection is a must for case involving aortic manipulation – aortic dissection?

Freestyle Subcoronary Implantation Technique

R L N

Space behind here is not a dissection and should not have flow with color Doppler Suture lines continue to noncoronary sinus into native root tissue

Do a quick check of neighboring structures Assess the valve integrity (i.e. leaflet motion, MR, residual gradient, paravalular leak, SAM) It is mandatory to attempt to obtain a gradient or EOA (PHT not valid in prosthetic valves) to rule out patient prosthesis mismatch

Do a quick check of neighboring structures Pre-CPB

On-CPB (just prior to separation)

On-CPB (just prior to separation)

Ruling out SAM can be facilitated by pre-CPB measurements

C-Sept distance Anterior leaflet Posterior leaflet LVOT diameter Maximal SWT PWT (TG SAX view) Calculate SWT:PWT ( 竕･ 1.3 meets ASH criteria) JACC 1999; 34:2096

竊全AM Risk: 窶｢AL/PL < 1.0 窶｢C-sept < 2.5 cm

TEE presentation of ASH → SWT:PWT ≥ 1.3 LV long axis

SWT = 34 mm

Distance to maximal septal thickness from aortic annulus

(SWT measured perpendicular to LV long axis)

SWT:PWT = 34 / 21 = 1.62

End Diastole

Doppler evaluation of LVOT for C.O. (preferred) Tissue Doppler imaging of mitral annulus (S’) Simpson’s MOD (difficult w/TEE) Fractional Area Change or Fractional Shortening

Doppler evaluation of LVOT for C.O.

Measure in mid- systole for determining LVOT diameter for C.O.

PW Doppler of LVOT just before annulus

CSALVOT = π•(r=1.1 cm)2 VTI = 11.1 cm HR = 70 C.O. = 3.0 L/min = CSALVOT x VTILVOT x HR

Zoghbi WA, et al. JASE 2009;22(9);975-1014

Doppler evaluation of LVOT for C.O.

Tissue Doppler imaging of lateral mitral annulus (S’) LV S’ > 5.4 cm/sec correlates well with EF > 50%

LV S’ Gulati VK, et al. Am J Cardiol 1996;77(11):979-84

Fractional Shortening FS Reference Ranges: Females 27 - 45%

ED = 52 mm

Males 25 - 43%

ES = 38 mm

FS = [(LVED â&#x20AC;&#x201C; LVES)/LVED] x 100 = 27%

Right heart function is challenged by the unusual geometry of the structure. Modalities that have been used to assess RV function include the following: RVSWI† (right ventricular stroke work index) Gross assessment of 2D/3D echocardiographic images Fractional area change (FAC)‡ Tricuspid annular plane systolic excursion (TAPSE) ‡ Tricuspid annular plane tissue velocity (RV S’)₰,λ 3D Magnetic resonance imaging based assessment Gross† dynamics in CVP:PAD (i.e. increased ratio) 2002 Circulation 106[suppl I]; I98-202 ₰ 2006 J Amer Soc Echocard 19; 329-34 λ 2001 Eur Heart J 22; 340-8 ‡ 2010 J Amer Soc Echocard 23;685-713

Gross assessment of 2D echocardiographic images

Fractional Area Change or Fractional Shortening Tricuspid Annular Plane Systolic Excursion (TAPSE) Tissue Doppler imaging of tricuspid annulus (RV Sâ&#x20AC;&#x2122;)

Right ventricular fractional area change (FAC) ‡ (EDA – ESA) / EDA = FAC

End Diastole

End Systole

ASE 2010 RH Guidelines* 2010 JAbnormal Amer Soc Echocard 23;685-713 < 35%

*

‡

2005 J Amer Soc Echocard 18;1440-63

Tricuspid annular plane systolic excursion (TAPSE)‡ 58 mm – 43 mm = 15 mm

43 mm

58 mm End Diastole

End Systole

Normative TAPSE ≥ 16 mm ‡ ‡

2010 J Amer Soc Echocard 23;685-713

Tricuspid annular plane systolic excursion (TAPSE)‡

24.7 mm

TEE: use deep TG or TG RV inflow at 120-140º

Normative TAPSE ≥ 16 mm ‡ ‡

2010 J Amer Soc Echocard 23;685-713

Tricuspid annular plane systolic velocity (RV S’)‡ Deep Transgastric RV view

17 cm/sec S’

E’

Normative RV S’ ≥ 10 cm/sec ₰ ‡

2006 J Amer Soc Echocard 19; 329-34 2010 J Amer Soc Echocard 23;685-713

A’

Skubas n, Perrino A. Comprehensive Textbook of Periop TEE. 2012. Chap. 26

Estimating Pulmonary Artery Systolic Pressure Est. PAS = †RAP + (4VmaxTRjet)2 = 5 mmHg + 4(3.1 m/sec)2 = 43 mmHg

Est PAS = 43 mmHg

†

Assumes no pulmonary valular stenosis (i.e., RVSP = PAS) Skubas n, Perrino A. Comprehensive Textbook of Periop TEE. 2012. Chap. 26

Estimating Left Atrial Pressure Est. LAP = †SBP – (4VmaxMRjet)2 = 95 mmHg - 4(4.3 m/sec)2 = 21 mmHg

Est LAP = 21 mmHg

†

Assumes no aortic stenosis (i.e., SBP = LVSP) Skubas n, Perrino A. Comprehensive Textbook of Periop TEE. 2012. Chap. 26

TEE has become an extremely useful adjunct in the perioperative setting With some practice skill with the TEE probe can replace the use of the PA catheter Pre & Post-CPB hemodynamics and cardiac function can be accurately assessed with TEE

Outstanding Reference Text

Thank you

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