Chirojit Mukherjee

2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement.

Robert A. Harrington, MD, FACC, Chair Deepak L. Bhatt, MD, MPH, FACC, Vice Chair Victor A. Ferrari, MD, FACC John D. Fisher, MD, FACC Mario J. Garcia, MD, FACC Timothy J. Gardner, MD, FACC Federico Gentile, MD, FACC Michael F. Gilson, MD, FACC Adrian F. Hernandez, MD, FACC Alice K. Jacobs

Aortic valve calcium scoring is a predictor of significant paravalvular aortic insufficiency in transapical-aortic valve implantation‡

OBJECTIVE Transapical-aortic valve implantation (TA-AVI) has evolved as routine for selected high-risk patients. However, paravalvular leaks >1+ remain an unsolved issue using current generations of transcatheter valve devices. The purpose of this study was to investigate the impact of native aortic valve calcification on paravalvular leaks and outcomes using the Edwards SAPIEN™ prosthesis. METHODS One hundred and twenty consecutive patients (out of 307 TA-AVIs) with preoperative computed tomography aged 82.6 ± 6.2 years, 75.0% female were included. Implanted prosthetic valve sizes were 23 mm (n = 31) and 26 mm (n = 89), respectively. Mean logistic European System for Cardiac Operative Risk Evaluation-Score was 30.1 ± 15.5% and mean Society of Thoracic Surgeons-Score was 12.8 ± 7.9%. Electrocardiographic (ECG)-gated cardiac computed tomography allowed to quantify the amount of calcification of aortic valve leaflets using a scoring analogous to the Agatston calcium scoring of coronary arteries [Aortic Valve Calcium Scoring (AVCS)]. Paravalvular leaks were assessed intraoperatively by echocardiography and root angiography. RESULTS All valves were implanted successfully. The mean AVCS in patients without paravalvular leaks (n = 66) was 2704 ± 1510; with mild paravalvular leaks (n = 31) was 3804 ± 2739 (P = 0.05); and with moderate paravalvular leaks (n = 4) was 7387 ± 1044 (P = 0.002). There was a significant association between the AVCS and paravalvular leaks [odds ratio (OR; per AVCS of 1000), 11.38; 95% confidence interval (CI) 2.33-55.53; P = 0.001)] and a trend towards a higher incidence of new pacemaker implantation (OR 1.27; 95% CI 0.85-1.89; P = 0.26). No association was found to 30-day mortality, major cardiac events and stroke rate (OR 1.05; 95% CI 0.84-1.32; P = 0.68; OR 0.92; 95% CI 0.68-1.25; P = 0.57 and OR 0.90; 95% CI 0.41-1.96; P = 0.79, respectively). Overall 30-day mortality was 14.2%. CONCLUSION Severe native valve calcifications are predictive for postoperative relevant paravalvular leak. AVCS prior to TA-AVI might serve as an additional tool to reconsider the TAVI indication to reduce the risk of paravalvular leaks especially in so-called operable patients.

Transapical Off-Pump Valve-in-Valve Implantation in Patients With Degenerated Aortic Xenografts

BACKGROUND The reoperative risk for degenerated aortic valve xenografts may be increased in elderly patients with comorbidities. We evaluated the off-pump beating heart concept of transapical aortic valve implantation using the valve-in-valve (VinV) concept. METHODS Since March 2007, 11 patients with degenerated xenografts received transapical aortic valve implantation using the Edwards Sapien transcatheter heart valve (Edwards Lifesciences, Irvine, CA). After informed consent, all procedures were performed as an off-label use. Mean patient age was 78 +/- 6 years (range, 72 to 89), mean logistic European System for Cardiac Operative Risk Evaluation was 32% +/- 16% (range, 16% to 62%) and mean Society for Thoracic Surgeons score was 7% +/- 3% (range, 3% to 10%). RESULTS All patients were treated off pump. The transapical aortic valve implantation was successful in all patients, and apical access was uncomplicated in all of them. Total operating room time was 71 +/- 14 minutes. On postoperative echocardiography, there was no paravalvular incompetence in any and mild (first degree) central incompetence in 2 of 11 patients. Sufficient flaring of the inflow and outflow parts of the Sapien prosthesis was observed in all patients, suggesting a stable position and an almost absent risk of late embolization. Maximal transvalvular pressure gradients were 21 +/- 8 mm Hg, and mean echocardiographic pressure gradients were 11 +/- 4 mm Hg. Follow-up extends to 330 +/- 293 days (range, 15 to 1,007), and all patients are well and alive. CONCLUSIONS Valve-in-valve implantation is a truly minimally invasive procedure for redo treatment of failed aortic valve xenografts in high-risk elderly patients. The Edwards Sapien valve is well suited for VinV implantation, and this technique may become a routine procedure to treat degenerated xenografts in the future.

Anesthesia Management for Transapical Transcatheter Aortic Valve Implantation: A Case Series

OBJECTIVE The purpose of this study was to review the management of anesthesia for transapical transcatheter aortic valve implantation. DESIGN Retrospective review of collected data. SETTING University-affiliated heart center. PARTICIPANTS One hundred consecutive patients with severe aortic stenosis. INTERVENTIONS General anesthesia followed by an established fast-track protocol. MATERIALS AND METHODS A total of 100 patients with significant AS received transapical transcatheter aortic valve implantation. The patients were treated following a fast-track protocol. The mean arterial pressure was maintained above 65 mmHg by volume and/or inotropes during the procedure. The mean arterial pressure was increased above 75 mmHg to avoid hemodynamic deterioration before starting rapid ventricular pacing for the balloon valvuloplasty and the valve implantation. Transesophageal echocardiography was used to assess valve size and for hemodynamic monitoring. Eighty-one patients were treated completely off pump. There was a significant decline in mean arterial pressure from pre- to postvalvuloplasty (74.7 +/- 9.1 mmHg v 63.6 +/- 11.3 mmHg, p < 0.001) and from pre- to postimplantation (76.5 +/- 12.6 mmHg v 67.2 +/- 12.7, p < 0.001). The first 10 patients in the study intentionally were placed on cardiopulmonary bypass, and 9 patients required cardiopulmonary bypass because of hemodynamic deterioration. CONCLUSION A well-designed anesthetic plan as well as an understanding of the surgical procedure and the hemodynamic effects of rapid ventricular pacing are required to ensure successful outcomes in this new surgical option for high-risk patients.

Awake Transapical Aortic Valve Implantation Using Thoracic Epidural Anesthesia

Transapical aortic valve implantation is a minimally invasive, beating-heart procedure that normally requires a general anesthetic. We herein report an 85-year-old patient with impaired pulmonary function who underwent successful transapical aortic valve implantation while awake, using a thoracic epidural anesthetic.

Value of augmented reality-enhanced transesophageal echocardiography (TEE) for determining optimal annuloplasty ring size during mitral valve repair.

BACKGROUND Mitral valve (MV) annuloplasty is an integral part of MV repair, but sizing under direct vision is occasionally challenging. Furthermore, traditional sizing is not possible for percutaneous MV repair techniques. This study compared augmented reality-enhanced three-dimensional (3D) transesophageal echocardiography (TEE) for determining MV annuloplasty size with conventional surgical sizing. METHODS In patients undergoing elective MV repair, a 3D MV reconstruction was performed using TEE. Modified 4D valve assessment software was used to create 3D computer-aided design models of standard annuloplasty rings (28 to 36 mm), which were stored in a digital database. These virtual 3D annuloplasty ring templates were superimposed on the preoperative 3D TEE reconstructions of the MV, and results were compared with conventional sizing under direct vision. A post hoc validation of the 3D models was performed using the implanted rings as a control. The echocardiographer was blinded to the implanted ring size. RESULTS The study included 50 patients. The correlation between the selected 3D annuloplasty ring template and the implanted annuloplasty ring size was 0.83. Thirty ring templates (60%) were the same size as the implanted annuloplasty ring, 19 templates (38%) differed by +/-2 mm in size, and 1 template differed by +4 mm. Postoperatively, the validation protocol revealed a correlation of 0.94 between the size of the ring templates and the implanted annuloplasty prostheses. CONCLUSIONS Augmented reality-enhanced TEE for determining optimal annuloplasty ring size during MV repair correlates well with conventional surgical sizing and may facilitate future percutaneous MV repair techniques.

Transesophageal Echocardiography for Verification of the Position of the Electrocardiographically-Placed Central Venous Catheter

OBJECTIVE Compare changes in P-wave amplitude of the intra-atrial electrocardiogram (ECG) and its corresponding transesophageal echocardiography (TEE)-controlled position to verify the exact localization of a central venous catheter (CVC) tip. DESIGN A prospective study. SETTING University, single-institutional setting. PARTICIPANTS Two hundred patients undergoing elective cardiac surgery. INTERVENTIONS CVC placement via the right internal jugular vein with ECG control using the guidewire technique and TEE control in 4 different phases: phase 1: CVC placement with normalized P wave and measurement of distance from the crista terminalis to the CVC tip; phase 2: TEE-controlled placement of the CVC tip; parallel to the superior vena cava (SVC) and measurements of P-wave amplitude; phase 3: influence of head positioning on CVC migration; and phase 4: evaluation of positioning of the CVC postoperatively using a chest x-ray. MEASUREMENTS AND MAIN RESULTS The CVC tip could only be visualized in 67 patients on TEE with a normalized P wave. In 198 patients with the CVC parallel to the SVC wall controlled by TEE (phase 2), an elevated P wave was observed. Different head movements led to no significant migration of the CVC (phase 3). On a postoperative chest-x-ray, the CVC position was correct in 87.6% (phase 4). CONCLUSION The study suggests that the position of the CVC tip is located parallel to the SVC and 1.5 cm above the crista terminalis if the P wave starts to decrease during withdrawal of the catheter. The authors recommend that ECG control as per their study should be routinely used for placement of central venous catheters via the right internal jugular vein.

Prediction of the annuloplasty ring size in patients undergoing mitral valve repair using real-time three-dimensional transoesophageal echocardiography

Aims We sought to investigate the additional value of real-time three-dimensional transoesophageal echocardiography (RT 3D TOE)-guided sizing for predicting annuloplasty ring size during mitral valve repair. Methods and results In 53 patients undergoing elective mitral valve repair, an RT 3D TOE was performed pre- and post-operatively. The digitally stored loops were imported into a software for mitral valve assessment. The annuloplasty ring size was predicted by superimposing computer-aided design (CAD) models of annuloplasty rings onto Live 3D zoom loops, measurement of the intercommissural distance, or the height of the anterior mitral leaflet. The surgeon implanted the annuloplasty ring according to the usual surgical technique and was blinded to the echocardiographic measurement results. Pre-operative correlation between the selected ring size with mitral valve assessment and the actual implanted annuloplasty ring size was 0.91. The correlation for measurement of the intercommissural distance was 0.55 and for measurement of the height of the anterior mitral leaflet 0.75. The post-operative correlation with the actual implanted ring size was 0.96 for mitral valve assessment, 0.92 for intercommissural distance, and 0.79 for the anterior mitral leaflet height. Conclusion Superimposition of annuloplasty ring CAD models on the Live 3D zoom loops of the mitral valve using mitral valve assessment is superior to two-dimensional measurements of the intercommissural distance or the height of the anterior mitral leaflet in predicting correct annuloplasty ring size.

Four-dimensional modelling of the mitral valve by real-time 3D transoesophageal echocardiography: proof of concept

OBJECTIVES The complexity of the mitral valve (MV) anatomy and function is not yet fully understood. Assessing the dynamic movement and interaction of MV components to define MV physiology during the complete cardiac cycle remains a challenge. We herein describe a novel semi-automated 4D MV model. METHODS The model applies quantitative analysis of the MV over a complete cardiac cycle based on real-time 3D transoesophageal echocardiography (RT3DE) data. RT3DE data of MVs were acquired for 18 patients. The MV annulus and leaflets were semi-automatically reconstructed. Dimensions of the mitral annulus (anteroposterior and anterolateral-posteromedial diameter, annular circumference, annular area) and leaflets (MV orifice area, intercommissural distance) were acquired. Variability and reproducibility (intraclass correlation coefficient, ICC) for interobserver and intraobserver comparison were quantified at 4 time points during the cardiac cycle (mid-systole, end-systole, mid-diastole and end-diastole). RESULTS Mitral annular dimensions provided highly reliable and reproducible measurements throughout the cardiac cycle for interobserver (variability range, 0.5-1.5%; ICC range, 0.895-0.987) and intraobserver (variability range, 0.5-1.6%; ICC range, 0.827-0.980) comparison, respectively. MV leaflet parameters showed a high reliability in the diastolic phase (variability range, 0.6-9.1%; ICC range, 0.750-0.986), whereas MV leaflet dimensions showed a high variability and lower correlation in the systolic phase (variability range, 0.6-22.4%; ICC range, 0.446-0.915) compared with the diastolic phase. CONCLUSIONS This 4D model provides detailed morphological reconstruction as well as sophisticated quantification of the complex MV structure and dynamics throughout the cardiac cycle with a precision not yet described.

2012 ACCF/AATS/SCAI/STS Expert Consensus Document on Transcatheter Aortic Valve Replacement: Developed in collaboration with the American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery

American College of C Surgeons Representa tative; xThe Society f tative; kSociety of {Society for Cardiov Society of America R Surgery Representati tative; zzAmerican He Advocate, Patient R Representative. Author Recusals: Writi from voting on sectio entities may apply; se This document was app (ACCF) Board of Tru Council, Society for C of Directors, Society 2012 and endorsed b (AHA) Science Adv Echocardiography (A (EACTS), Heart Fail Cardiovascular Anest phy (SCCT), and the January 2012. For the the ACCF Board of T ument, is available at: Officers-and-Trustees industry to the docum vote on approval. David R. Holmes, Jr, MD, FACC, Chair,* Michael J. Mack, MD, FACC, Vice Chair,y Sanjay Kaul, MBBS, FACC, Vice Chair,* Arvind Agnihotri, MD,z Karen P. Alexander, MD, FACC,* Steven R. Bailey,MD, FACC, FSCAI,x John H. Calhoon,MD,z Blase A. Carabello, MD, FACC,* Milind Y. Desai, MBBS, FACC,k,{ Fred H. Edwards, MD, FACC,y Gary S. Francis, MD, FACC, Timothy J. Gardner, MD, FACC,y A. Pieter Kappetein, MD, PhD,** Jane A. Linderbaum, MS, CNP, AACC,* Chirojit Mukherjee, MD,yyDebabrataMukherjee, MD, FACC,* CatherineM. Otto, MD, FACC,* Carlos E. Ruiz, MD, PhD, FACC, FSCAI,x Ralph L. Sacco, MD, MS, FAHA,zz Donnette Smith,xx and James D. Thomas, MD, FACCkk