Intracardiac Doppler Echocardiography for Monitoring of Pulmonary Artery Pressures in High-Risk Patients Undergoing Transcatheter Aortic Valve Replacement.
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.
Division of Cardiology, Department of Internal Medicine III, Innsbruck University Medical School, Innsbruck, Austria.
Silvana
S
Müller
Department of Anesthesiology, Innsbruck University Medical School, Innsbruck, Austria.
Corinna
C
Velik-Salchner
Department of Medical Statistics, Informatics and Health Economics, Innsbruck University Medical School, Innsbruck, Austria.
Michael
M
Edlinger
Department of Cardiac Surgery, Innsbruck University Medical School, Innsbruck, Austria.
Nikolaos
N
Bonaros
Department of Cardiac Surgery, Innsbruck University Medical School, Innsbruck, Austria.
Anneliese
A
Heinz
Department of Radiology II, Innsbruck University Medical School, Innsbruck, Austria.
Gudrun
G
Feuchtner
Department of Cardiology, Department of Cardiovascular Medicine, Heart & Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates. Electronic address: bartelt@clevelandclinicabudhabi.ae.
Thomas
T
Bartel
D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D015150:Echocardiography, Doppler / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D016343:Monitoring, Intraoperative / Q000379:methods*; D011651:Pulmonary Artery / Q000000981:diagnostic imaging / Q000503:physiopathology*; D011669:Pulmonary Wedge Pressure / Q000502:physiology*; D012307:Risk Factors; D065467:Transcatheter Aortic Valve Replacement / Q000379:methods*; D018084:Ultrasonography, Interventional / Q000379:methods*
Aortic stenosis; Hemodynamic monitoring; Intracardiac echocardiography; Pulmonary hypertension; Transcatheter aortic valve replacement