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Aortic valve homograft regurgitation: Perivalvular or not?
Aortic Valve Homograft Regurgitation: Perivalvular or Not? Marty L. Ericksen, MD, Daniel P. Vezina, MD, FRCPC, and Raul A. Peragallo, MD
Fig 1. TEE. Midesophageal aortic valve short-axis view.
Fig 2. TEE. Zoom of midesophageal aortic valve short-axis view
A
76-YEAR-OLD woman with a 1-year history of aortic homograft valve replacement was admitted with recent onset of shortness of breath, fatigue, and congestive heart failure. Preoperative evaluation included transthoracic echo-
From the Department of Anesthesiology, University of Utah, Salt Lake City, UT. Address correspondence and reprint requests to Daniel P. Vezina, MD, FRCPC, Department of Anesthesiology, University of Utah Medical Center, 30 North 1900 East, Salt Lake City, UT 84132. Copyright 2003, Elsevier Science (USA). All rights reserved. 1053-0770/03/1701-0026$30.00/0 doi:10.1053/jcan.2003.27 Key words: Transesophageal echocardiography, aortic regurgitation, homograft, prosthetic valve dysfunction, infective endocarditis 134
cardiography (TTE) and transesophageal echocardiography (TEE). TTE showed an aortic homograft with moderate aortic regurgitation. Doppler mean aortic valve gradient was noted to be less than 10 mmHg. TEE revealed the presence of an aortic homograft with a notable central jet of aortic regurgitation as well as a broad circumferential perivalvular jet. Also found on TEE was diastolic flow reversal in the descending aorta. The patient was taken to the operating room for a redo aortic valve replacement. Intraoperative TEE performed before cardiopulmonary bypass showed the images displayed in Figs 1 and 2. Both of these images were taken during the same pre– cardiopulmonary bypass examination. What is the diagnosis? Is the regurgitation central, perivalvular, or both?
Journal of Cardiothoracic and Vascular Anesthesia, Vol 17, No 1 (February), 2003: pp 134-135
AORTIC VALVE HOMOGRAFT REGURGITATION
Fig 3. TEE. Midesophageal aortic valve long-axis view, with lines 1 and 2 depicting the 2 planes at which Figs 1 and 2 were cut.
DIAGNOSIS: CENTRAL AORTIC REGURGITATION WITH AN ECCENTRIC JET IN THE LEFT VENTRICULAR OUTFLOW TRACT
The 2 echocardiograms are midesophageal aortic valve short-axis views. Fig 1 is a short-axis view below the leaflet tips in the left ventricular outflow tract, showing the eccentrically directed jet. Fig 2 is a midesophageal aortic valve short-axis view at the aortic valve leaflet tips, showing the origin of the central aortic regurgitant jet. Fig 3 is a midesophageal aortic valve long-axis view that shows the aortic regurgitant jet originating at the aortic valve leaflet tips and then becoming eccentric as it runs retrograde into the left ventricular outflow tract. Lines 1 and 2 in Fig 3 show the 2 planes at which Figs 1 and 2 were cut. The midesophageal aortic valve short-axis view is useful to measure the length of the free edges of the aortic valve cusps, and the area of the aortic valve can also be measured by planimetry in this view. If color-flow Doppler is applied in the cross-section of the aortic valve, aortic regurgitation can be detected, along with the size and location of the regurgitant orifice.1 When obtaining a short-axis view of the aortic valve, it is important to advance and withdraw the TEE probe until it is in the short-axis plane, which correctly shows the pathology of interest. As with any TEE study, multiple-image planes are needed to make the correct diagnosis. When faced with prosthetic homograft aortic valve dysfunction, it is important to differentiate between a central regurgitant jet and a perivalvular regurgitant jet. Central regurgitation jets are usually caused by progressive tissue degeneration with fibrocalcific changes of the leaflets and, if severe, require replacement of the prosthesis. Perivalvular regurgitation jets, which occur postoperatively, are most often because of loss of suture material in the setting of fibrocalcific disease in the valvular annulus. On the other
135
hand, if perivalvular regurgitation occurs late after surgery, it can be a sign of infective endocarditis and requires a higher index of suspicion to detect complications and perivalvular extensions such as abscesses, pseudoaneurysms, and fistulas, all of which are best detected by TEE.2 All this information is important when planning the operative procedure. Abscesses may occur in native valve endocarditis, particularly of the aortic valve, but are detected most often in patients with prosthetic valve endocarditis, in whom infections tend to involve the periannular structures. Pseudoaneurysm may develop as abscesses progress to communicate with one or more cardiac chambers. Fistulas and intracardiac shunts are the later end of the spectrum of infective heart disease. Endocarditis is a clinical diagnosis and can be managed medically most of the time with appropriate antimicrobial treatment. Unfortunately, some of the patients with endocarditis will need surgical intervention. The following TEE findings indicate the potential need for surgical intervention3: (1) the presence of a complicated vegetation defined as a persistent vegetation after systemic embolization or a large mitral valve leaflet vegetation (⬎10 mm) and despite appropriate antimicrobrial therapy, one or more embolic events, or an increased vegetation size; (2) valvular dysfunction caused by acute aortic or mitral regurgitation and valvular dysfunction resulting in heart failure unresponsive to medical therapy; and (3) perivalvular extension causing valvular dehiscence, rupture, fistula, new heart block, large abscess, or extension of abscess despite appropriate antimicrobial therapy. In summary, a comprehensive TEE examination is critical for the assessment of prosthetic valve dysfunction. In the presence of prosthetic valve regurgitation, the precise localization of the leak is important for planning the operative repair. Multiplane imaging should be obtained to correctly delineate the origin and direction of the regurgitant jets. Relying on just one image can be misleading. REFERENCES 1. Shanewise JS, Cheung AT, Aronson S, et al: ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 89:870-84, 1999 2. Afridi I, Apostolidou MA, Saad RM, et al: Pseudoaneurysms of the mitral-aortic intervalvular fibrosa: Dynamic characterization using transesophageal echocardiographic and Doppler techniques. J Am Coll Cardiol 25:137-145, 1995 3. Bayer AS, Bolger AF, Taubert KA, et al: Diagnosis and management of infective endocarditis and its complications. Circulation 98: 2935-2948, 1998
Fig 1. TEE. Midesophageal aortic valve short-axis view.
Fig 2. TEE. Zoom of midesophageal aortic valve short-axis view
A
76-YEAR-OLD woman with a 1-year history of aortic homograft valve replacement was admitted with recent onset of shortness of breath, fatigue, and congestive heart failure. Preoperative evaluation included transthoracic echo-
From the Department of Anesthesiology, University of Utah, Salt Lake City, UT. Address correspondence and reprint requests to Daniel P. Vezina, MD, FRCPC, Department of Anesthesiology, University of Utah Medical Center, 30 North 1900 East, Salt Lake City, UT 84132. Copyright 2003, Elsevier Science (USA). All rights reserved. 1053-0770/03/1701-0026$30.00/0 doi:10.1053/jcan.2003.27 Key words: Transesophageal echocardiography, aortic regurgitation, homograft, prosthetic valve dysfunction, infective endocarditis 134
cardiography (TTE) and transesophageal echocardiography (TEE). TTE showed an aortic homograft with moderate aortic regurgitation. Doppler mean aortic valve gradient was noted to be less than 10 mmHg. TEE revealed the presence of an aortic homograft with a notable central jet of aortic regurgitation as well as a broad circumferential perivalvular jet. Also found on TEE was diastolic flow reversal in the descending aorta. The patient was taken to the operating room for a redo aortic valve replacement. Intraoperative TEE performed before cardiopulmonary bypass showed the images displayed in Figs 1 and 2. Both of these images were taken during the same pre– cardiopulmonary bypass examination. What is the diagnosis? Is the regurgitation central, perivalvular, or both?
Journal of Cardiothoracic and Vascular Anesthesia, Vol 17, No 1 (February), 2003: pp 134-135
AORTIC VALVE HOMOGRAFT REGURGITATION
Fig 3. TEE. Midesophageal aortic valve long-axis view, with lines 1 and 2 depicting the 2 planes at which Figs 1 and 2 were cut.
DIAGNOSIS: CENTRAL AORTIC REGURGITATION WITH AN ECCENTRIC JET IN THE LEFT VENTRICULAR OUTFLOW TRACT
The 2 echocardiograms are midesophageal aortic valve short-axis views. Fig 1 is a short-axis view below the leaflet tips in the left ventricular outflow tract, showing the eccentrically directed jet. Fig 2 is a midesophageal aortic valve short-axis view at the aortic valve leaflet tips, showing the origin of the central aortic regurgitant jet. Fig 3 is a midesophageal aortic valve long-axis view that shows the aortic regurgitant jet originating at the aortic valve leaflet tips and then becoming eccentric as it runs retrograde into the left ventricular outflow tract. Lines 1 and 2 in Fig 3 show the 2 planes at which Figs 1 and 2 were cut. The midesophageal aortic valve short-axis view is useful to measure the length of the free edges of the aortic valve cusps, and the area of the aortic valve can also be measured by planimetry in this view. If color-flow Doppler is applied in the cross-section of the aortic valve, aortic regurgitation can be detected, along with the size and location of the regurgitant orifice.1 When obtaining a short-axis view of the aortic valve, it is important to advance and withdraw the TEE probe until it is in the short-axis plane, which correctly shows the pathology of interest. As with any TEE study, multiple-image planes are needed to make the correct diagnosis. When faced with prosthetic homograft aortic valve dysfunction, it is important to differentiate between a central regurgitant jet and a perivalvular regurgitant jet. Central regurgitation jets are usually caused by progressive tissue degeneration with fibrocalcific changes of the leaflets and, if severe, require replacement of the prosthesis. Perivalvular regurgitation jets, which occur postoperatively, are most often because of loss of suture material in the setting of fibrocalcific disease in the valvular annulus. On the other
135
hand, if perivalvular regurgitation occurs late after surgery, it can be a sign of infective endocarditis and requires a higher index of suspicion to detect complications and perivalvular extensions such as abscesses, pseudoaneurysms, and fistulas, all of which are best detected by TEE.2 All this information is important when planning the operative procedure. Abscesses may occur in native valve endocarditis, particularly of the aortic valve, but are detected most often in patients with prosthetic valve endocarditis, in whom infections tend to involve the periannular structures. Pseudoaneurysm may develop as abscesses progress to communicate with one or more cardiac chambers. Fistulas and intracardiac shunts are the later end of the spectrum of infective heart disease. Endocarditis is a clinical diagnosis and can be managed medically most of the time with appropriate antimicrobial treatment. Unfortunately, some of the patients with endocarditis will need surgical intervention. The following TEE findings indicate the potential need for surgical intervention3: (1) the presence of a complicated vegetation defined as a persistent vegetation after systemic embolization or a large mitral valve leaflet vegetation (⬎10 mm) and despite appropriate antimicrobrial therapy, one or more embolic events, or an increased vegetation size; (2) valvular dysfunction caused by acute aortic or mitral regurgitation and valvular dysfunction resulting in heart failure unresponsive to medical therapy; and (3) perivalvular extension causing valvular dehiscence, rupture, fistula, new heart block, large abscess, or extension of abscess despite appropriate antimicrobial therapy. In summary, a comprehensive TEE examination is critical for the assessment of prosthetic valve dysfunction. In the presence of prosthetic valve regurgitation, the precise localization of the leak is important for planning the operative repair. Multiplane imaging should be obtained to correctly delineate the origin and direction of the regurgitant jets. Relying on just one image can be misleading. REFERENCES 1. Shanewise JS, Cheung AT, Aronson S, et al: ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: Recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 89:870-84, 1999 2. Afridi I, Apostolidou MA, Saad RM, et al: Pseudoaneurysms of the mitral-aortic intervalvular fibrosa: Dynamic characterization using transesophageal echocardiographic and Doppler techniques. J Am Coll Cardiol 25:137-145, 1995 3. Bayer AS, Bolger AF, Taubert KA, et al: Diagnosis and management of infective endocarditis and its complications. Circulation 98: 2935-2948, 1998