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Percutaneous aortic balloon valvuloplasty under transesophageal echocardiographic guidance
Percutaneous
Aortic Balloon Valvuloplasty Under Echocardiographic Guidance R.Joseph
Transesophageal
Isner, MD, and James A. DiNardo, MD
P
ERCUTANEOUS BALLOON valvuloplasty is a procedure normally carried out in cardiac catheterization laboratories under fluoroscopic guidance. Improvement of aortic stenosis with balloon valvuloplasty is typically shortlived and the procedure is often reserved for patients who are poor surgical candidates. lx2This report documents the use of transesophageal echocardiography to both aid the execution of valvuloplasty and to confirm its efficacy in a patient for whom aortic valve replacement was deemed prohibitively dangerous after induction of anesthesia. CASE REPORT
The patient was a 56-year-old man with aortic stenosis who presented for aortic valve replacement. He had previously undergone coronary artery bypass grafting and had received extensive external beam radiation to his left chest as treatment for lymphoma. His preoperative peak aortic valve gradient as measured by transthoracic echocardiography was 55 mmHg. The patient had a history of syncope, angina, and congestive heart failure. Following induction of anesthesia, a biplane transesophageal echocardiography probe was inserted without difficulty. Initial findings included a peak pressure gradient across the aorticvalve of 58 mmHg without evidence of aortic insufficiency. Median sternotomy was performed and significant hemorrhage noted resulting from transection of the innominate vein. The patient was placed on partial femoral bypass and the transsected vein repaired, but further dissection resulted in disruption of the right ventricular wall and massive hemorrhage. After this bleeding was controlled, the surgeons decided further dissection would be potentially fatal. Because of the severity of the patient’s aortic stenosis, however, it was believed that intervention was necessary. Percutaneous aortic valvuloplasty was undertaken in the operating room by a cardiologist using a left femoral artery approach. Initially, a guidewire was passed across the aortic valve with transesophageal echocardio-
graphic (TEE) guidance. The wire and its position were readily identified by two-dimensional (2D) echocardiography using a long-axis view of the left ventricular outflow tract and aortic root (Fig 1). An Amplatz balloon valvuloplasty catheter was then passed over the guidewire. The distal tip of the catheter itself was less easily localized by TEE, but the use of agitated saline given as sonographic contrast through the distal catheter port helped confirm that the tip of the catheter had crossed the aorticvalve (Fig 2). Once the catheter was in place, serial balloon inflations were performed. The dilated balloon was easily seen with TEE (Fig 3). Once the dilations were completed, efficacy of the valvuloplasty was confirmed by comparing postvalvuloplasty aortic annulus diameter (2.8 cm) with preoperative values (2.4 cm) using a 2D long-axis view of the left ventricular outflow tract and aortic root. Postdilatation Doppler measurement of flow velocity across the aortic valve was compared with values obtained immediately following induction of anesthesia using a transgastric longitudinal view of the aortic valve. Baseline (immediate postinduction) peak flow velocity was 3.8 m/s, corresponding to a pressure gradient of 58 mmHg across the aortic valve (Fig 4). Postoperative peak flow velocity was 3.0 m/s, corresponding to a 36 mmHg pressure gradient (Fig 5). DISCUSSION
The TEE probe used in this case was a biplane instrument with both transverse and longitudinal probes. This is
From the Department of Anesthesiology, University of Arizona Health Sciences Center, Tucson, AZ. Reprints are not available. Copyright 0 1994 by W.B. Saunders Company 1053-0770/94/0801-0018$03.00/0 Key words:percutaneous aortic valvuloplasty, transesophageal echocardiography
Fig 1. Longitudinal view of left ventricular outflow tract (right), aecending aorta (left). and aortic valve. Guidewire is seen crossing the aortic valve.
Journalof Cardiothoracic and VascularAnesthesia, Vol8, No 1 (February), 1994: pp 81-83
81
ISNER AND DiNARDO
Fig 2. Agitated saline injected as sonographiceontrast through the distal balloon catheter port confirms that the catheter has crossed the aortic valve.
important because without a longitudinal probe 2D and Doppler examinations of the aortic valve and aortic root are more difficult and less informative. Two-dimensional views of the aortic root used to aid retrograde guidewire and catheter placement and to confirm a change in aortic valve annulus size were obtained in the following manner.’ The transducer elements were positioned posterior to the left atrium, approximately 25 cm from the incisors. The tip of the endoscope was flexed leftward (laterally) and the endoscope was rotated slightly to the right (medially) until optimal views of the left ventricular outflow tract, aortic valve, and aortic root were obtained. Though this technique offers excellent 20 views of these structures, it is subopti-
Fig 3. Longitudinal view of inflated balloon catheter.
ma1 for Doppler assessment of aortic valve disease. For this portion of the examination, the transducer was advanced into the transgastric position (approximately 35 to 40 cm from the incisors) by observing the transverse probe and adjusting the endoscope depth until a transgastric shortaxis view was obtained. Switching to the longitudinal probe yielded a left ventricular long-axis view. The endoscope was then rotated medially and the probe tip anteflexed, yielding a long-axis equivalent view of the aortic valve.3 Continuouswave Doppler was used rather than pulse-wave because the flow velocity was great enough that unacceptable aliasing occurred during pulse-wave examination of these structures. Valvuloplasty was seen as a reasonable alternative to
PERCUTANEOUS
AORTIC VALVULOPLASTY
a3
Fig 4. Doppler spectrum of blood flow across aottlc valve, immediately after placement of TEE probe. Initial flow velocity of 3.8 m/s corresponds to a peak pressure gradient of 58 mm IHg. View obtained as described in discussion.
valve replacement for this patient. The patient’s preoperative condition signaled the need for prompt intervention. An attempt to operatively replace the aortic valve was made but aborted after this approach was deemed likely to result
Fig 5. Doppler spectrum of blood flow across aortlc valve after percutaneous valvuloplasty. Flow velocity of 3.0 m/s corresponds to a peak pressure gradient of 36 mm/Hg. View obtained as described in discussion.
in significant morbidity. Given this situation, percutaneous valvuloplasty was performed in the operating room. TEE was a valuable tool in this case both to aid the execution of valvuloplasty and to confirm its efficacy.
REFERENCES
1. Litvack F, Jakubowski AT, Buchbinder NA, et al: Lack of sustained improvement in an elderly population after percutaneous aortic valvuloplasty. Am J Cardiol62:270-275, 1988 2. Hendry PJ, Lowe JE: Aortic valvuloplasty: A surgical perspective, in Bashore TM, Davidson CJ (eds): Percutaneous Balloon
Valvuloplasty and Related Techniques. Philadelphia, PA, Williams & Wilkins, 1991 3. Seward JB, Khandheria BK, Edwards WD, et al: Biplanar transesophageal echocardiography: Anatomic correlations, image orientation, and clinical applications. Mayo Clin Proc 65:11931213,199O
Aortic Balloon Valvuloplasty Under Echocardiographic Guidance R.Joseph
Transesophageal
Isner, MD, and James A. DiNardo, MD
P
ERCUTANEOUS BALLOON valvuloplasty is a procedure normally carried out in cardiac catheterization laboratories under fluoroscopic guidance. Improvement of aortic stenosis with balloon valvuloplasty is typically shortlived and the procedure is often reserved for patients who are poor surgical candidates. lx2This report documents the use of transesophageal echocardiography to both aid the execution of valvuloplasty and to confirm its efficacy in a patient for whom aortic valve replacement was deemed prohibitively dangerous after induction of anesthesia. CASE REPORT
The patient was a 56-year-old man with aortic stenosis who presented for aortic valve replacement. He had previously undergone coronary artery bypass grafting and had received extensive external beam radiation to his left chest as treatment for lymphoma. His preoperative peak aortic valve gradient as measured by transthoracic echocardiography was 55 mmHg. The patient had a history of syncope, angina, and congestive heart failure. Following induction of anesthesia, a biplane transesophageal echocardiography probe was inserted without difficulty. Initial findings included a peak pressure gradient across the aorticvalve of 58 mmHg without evidence of aortic insufficiency. Median sternotomy was performed and significant hemorrhage noted resulting from transection of the innominate vein. The patient was placed on partial femoral bypass and the transsected vein repaired, but further dissection resulted in disruption of the right ventricular wall and massive hemorrhage. After this bleeding was controlled, the surgeons decided further dissection would be potentially fatal. Because of the severity of the patient’s aortic stenosis, however, it was believed that intervention was necessary. Percutaneous aortic valvuloplasty was undertaken in the operating room by a cardiologist using a left femoral artery approach. Initially, a guidewire was passed across the aortic valve with transesophageal echocardio-
graphic (TEE) guidance. The wire and its position were readily identified by two-dimensional (2D) echocardiography using a long-axis view of the left ventricular outflow tract and aortic root (Fig 1). An Amplatz balloon valvuloplasty catheter was then passed over the guidewire. The distal tip of the catheter itself was less easily localized by TEE, but the use of agitated saline given as sonographic contrast through the distal catheter port helped confirm that the tip of the catheter had crossed the aorticvalve (Fig 2). Once the catheter was in place, serial balloon inflations were performed. The dilated balloon was easily seen with TEE (Fig 3). Once the dilations were completed, efficacy of the valvuloplasty was confirmed by comparing postvalvuloplasty aortic annulus diameter (2.8 cm) with preoperative values (2.4 cm) using a 2D long-axis view of the left ventricular outflow tract and aortic root. Postdilatation Doppler measurement of flow velocity across the aortic valve was compared with values obtained immediately following induction of anesthesia using a transgastric longitudinal view of the aortic valve. Baseline (immediate postinduction) peak flow velocity was 3.8 m/s, corresponding to a pressure gradient of 58 mmHg across the aortic valve (Fig 4). Postoperative peak flow velocity was 3.0 m/s, corresponding to a 36 mmHg pressure gradient (Fig 5). DISCUSSION
The TEE probe used in this case was a biplane instrument with both transverse and longitudinal probes. This is
From the Department of Anesthesiology, University of Arizona Health Sciences Center, Tucson, AZ. Reprints are not available. Copyright 0 1994 by W.B. Saunders Company 1053-0770/94/0801-0018$03.00/0 Key words:percutaneous aortic valvuloplasty, transesophageal echocardiography
Fig 1. Longitudinal view of left ventricular outflow tract (right), aecending aorta (left). and aortic valve. Guidewire is seen crossing the aortic valve.
Journalof Cardiothoracic and VascularAnesthesia, Vol8, No 1 (February), 1994: pp 81-83
81
ISNER AND DiNARDO
Fig 2. Agitated saline injected as sonographiceontrast through the distal balloon catheter port confirms that the catheter has crossed the aortic valve.
important because without a longitudinal probe 2D and Doppler examinations of the aortic valve and aortic root are more difficult and less informative. Two-dimensional views of the aortic root used to aid retrograde guidewire and catheter placement and to confirm a change in aortic valve annulus size were obtained in the following manner.’ The transducer elements were positioned posterior to the left atrium, approximately 25 cm from the incisors. The tip of the endoscope was flexed leftward (laterally) and the endoscope was rotated slightly to the right (medially) until optimal views of the left ventricular outflow tract, aortic valve, and aortic root were obtained. Though this technique offers excellent 20 views of these structures, it is subopti-
Fig 3. Longitudinal view of inflated balloon catheter.
ma1 for Doppler assessment of aortic valve disease. For this portion of the examination, the transducer was advanced into the transgastric position (approximately 35 to 40 cm from the incisors) by observing the transverse probe and adjusting the endoscope depth until a transgastric shortaxis view was obtained. Switching to the longitudinal probe yielded a left ventricular long-axis view. The endoscope was then rotated medially and the probe tip anteflexed, yielding a long-axis equivalent view of the aortic valve.3 Continuouswave Doppler was used rather than pulse-wave because the flow velocity was great enough that unacceptable aliasing occurred during pulse-wave examination of these structures. Valvuloplasty was seen as a reasonable alternative to
PERCUTANEOUS
AORTIC VALVULOPLASTY
a3
Fig 4. Doppler spectrum of blood flow across aottlc valve, immediately after placement of TEE probe. Initial flow velocity of 3.8 m/s corresponds to a peak pressure gradient of 58 mm IHg. View obtained as described in discussion.
valve replacement for this patient. The patient’s preoperative condition signaled the need for prompt intervention. An attempt to operatively replace the aortic valve was made but aborted after this approach was deemed likely to result
Fig 5. Doppler spectrum of blood flow across aortlc valve after percutaneous valvuloplasty. Flow velocity of 3.0 m/s corresponds to a peak pressure gradient of 36 mm/Hg. View obtained as described in discussion.
in significant morbidity. Given this situation, percutaneous valvuloplasty was performed in the operating room. TEE was a valuable tool in this case both to aid the execution of valvuloplasty and to confirm its efficacy.
REFERENCES
1. Litvack F, Jakubowski AT, Buchbinder NA, et al: Lack of sustained improvement in an elderly population after percutaneous aortic valvuloplasty. Am J Cardiol62:270-275, 1988 2. Hendry PJ, Lowe JE: Aortic valvuloplasty: A surgical perspective, in Bashore TM, Davidson CJ (eds): Percutaneous Balloon
Valvuloplasty and Related Techniques. Philadelphia, PA, Williams & Wilkins, 1991 3. Seward JB, Khandheria BK, Edwards WD, et al: Biplanar transesophageal echocardiography: Anatomic correlations, image orientation, and clinical applications. Mayo Clin Proc 65:11931213,199O