The functional aortic annulus in the 3D era: focus on transcatheter aortic valve replacement for the perioperative echocardiographer

Bicuspid Aortic Valve Disease: Classifications, Treatments, and Emerging Transcatheter Paradigms

Bicuspid aortic valve (BAV) is a common congenital valvular malformation, which may lead to early aortic valve disease and bicuspid-associated aortopathy. A novel BAV classification system was recently proposed to coincide with transcatheter aortic valve replacement being increasingly considered in younger patients with symptomatic BAV, with good clinical results, yet without randomized trial evidence. Procedural technique, along with clinical outcomes, have considerably improved in BAV patients compared with tricuspid aortic stenosis patients undergoing transcatheter aortic valve replacement. The present review summarizes the novel BAV classification systems and examines contemporary surgical and transcatheter approaches.

Three-dimensional transesophageal echocardiography is an attractive alternative to cardiac multi-detector computed tomography for aortic annular sizing: Systematic review and meta-analysis

BACKGROUND

Cardiac imaging is the cornerstone of the pretranscatheter aortic valve replacement (TAVR) assessment. Multi-detector computed tomography (MDCT) is considered the conventional imaging modality. However, there is still no definitive gold standard. Targeted cohort of inoperable high-risk patients with underlying comorbidities, particularly renal impairment, makes apparent the need for MDCT alternative. We aimed to demonstrate the correlation extent between MDCT and three-dimensional transesophageal echocardiography (3DTEE) aortic annular area measures and to answer the question: Is 3DTEE a good alternative to MDCT?

METHODS

A systematic literature search and meta-analysis were conducted to evaluate the degree of correlation and agreement between 3DTEE and MDCT aortic annular sizing. A thorough assessment of EMBASE, PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. All studies comparing 3DTEE and MDCT in relation to aortic annular sizing were included.

RESULTS

Thirteen studies were included (N = 1228 patients). A strong linear correlation was found between 3DTEE and MDCT measurements of aortic annulus area (r = 0.84, P < 0.001), mean perimeter (r = 0. 0.85, P < 0.001), and mean diameter (r = 0.80, P < 0.001). Bland-Altman plots revealed smaller mean 3DTEE values in comparison to MDCT for aortic annular area, the mean difference being -2.22 mm² with 95% limits of agreement -12.79 to 8.36.

CONCLUSION

Aortic annulus measurements obtained by 3DTEE demonstrated a high level of correlation with those evaluated by MDCT. This makes 3DTEE a feasible choice for aortic annulus assessment, with advantage of real time assessment, lack of contrast, and no radiation exposure.

Bicuspid Aortic Valve: An Update in Morphology, Genetics, Biomarker, Complications, Imaging Diagnosis and Treatment

The bicuspid aortic valve, a kind of heart disease that comes from parents, has been paid attention around the world. Although most bicuspid aortic valve (BAV) patients will suffer from some complications including aortic stenosis, aortic regurgitation, endocarditis, and heart dysfunction in the late stage of the disease, there is none symptom in the childhood, which restrains us to diagnose and treatment in the onset phase of BAV. Hemodynamic abnormalities induced by the malformations of the valves in BAV patients for a long time will cause BAV-associated aortopathy: including progress aortic dilation, aneurysm, dissection and rupture, cardiac cyst and even sudden death. At present, preventive surgical intervention is the only effective method used in this situation and the diameter of the aorta is the primary reference criterion for surgery. And the treatment effects are always not satisfactory for patients and clinicians. Therefore, we need more methods to evaluate the progression of BAV and the surgery value and the appropriate intervention time by combining basic research with clinical treatment. In this review, advances in morphology, genetic, biomarkers, diagnosis and treatments are summarized, which expects to provide an update about BAV. It is our supreme expectations to provide some evidences for BAV early screening and diagnosis, and in our opinion, personalized surgical strategy is the trend of future BAV treatment.

Role of 3D Echocardiography in Cardiac Surgery: Strengths and Limitations

PURPOSE OF REVIEW

This review aims to highlight the general and specific strengths and limitations of intraoperative 3D echocardiography. This article explains the value of real-time three-dimensional transesophageal echocardiography (RT 3D TEE) during cardiac surgery and cardiac interventions.

RECENT FINDINGS

Recently published recommendations and guidelines include the use of RT 3D TEE. RT 3 D TEE provides additional value particularly for guidance during cardiac interventions (i.e., transcatheter mitral valve repair, left atrial appendix and atrial septal defect closures), assessment of the mitral valve in surgical repair, measurement of left ventricular outflow tract area for transcatheter valvular replacements, and estimating right and left ventricular volumes and function. The exact localization of paravalvular leakage is another strength of RT 3D TEE. The major limitation is the reduced temporal resolution compared to 2D TEE.

SUMMARY

Three-dimensional echocardiography is a powerful tool that improves communication and accurate measurements of cardiac structures.

Anatomy of the aortic root: implications for aortic root reconstruction

Since the introduction of valve-preserving root replacement and aortic annuloplasty, precise understanding of the aortic root anatomy has emerged as a key to successful aortic valve-preservation surgery. Fundamentally, surgeons need to know the precise anatomical definition and structure of the aortic root, including its normal dimensions, know the anatomy of the coronary arteries, and understand the cardiac conduction system. Surgeons must be able to clearly distinguish normal and abnormal structures, and recognize the effects of aortic valve regurgitation or root expansion on dimensions and geometric relationships within the aortic root. Possessing a detailed understanding of the aortic root, surgeons can select appropriately sized grafts and achieve optimum annular fixation. This review covers the essentials of aortic root anatomy and provides tips for correct and safe performance of aortic valve-preservation surgery with a view toward durable late outcomes.

Dynamic Three-Dimensional Geometry of the Aortic Valve Apparatus-A Feasibility Study

OBJECTIVE

To provide (1) an overview of the aortic valve (AV) apparatus anatomy and nomenclature, and (2) data regarding the normal AV apparatus geometry and dynamism during the cardiac cycle obtained from three-dimensional transesophageal echocardiography (3D TEE).

DESIGN

Retrospective feasibility study.

SETTING

A single-center university teaching hospital.

PARTICIPANTS

The study was performed on data of 10 patients with a nonregurgitant, nonstenotic aortic valve undergoing cardiac surgery.

INTERVENTIONS

Intraoperative 3D TEE was performed on all the participants using the Siemens ACUSON SC2000 ultrasound system and Z6Ms transducer (Siemens Medical Systems, Mountainview, CA).

MEASUREMENTS AND MAIN RESULTS

Dynamic offline analyses were performed with Siemens eSie valve analytical software in a semiautomated fashion. Forty-five parameters were exported of which 13 were selected and analyzed. The cardiac cycle was divided into 4 quartiles to account for frame-rate variations. The annulus, sinus of Valsalva (SoV) and sinotubular junction (STJ) areas, diameter, perimeter and height, aortic leaflet height, leaflet coaptation height, and aortic valve-mitral valve angle changed significantly during the cardiac cycle (p < 0.001). STJ expanded more than both the annulus and the SoV (p < 0.001). The maximum aortic valve leaflet height change was greater in the left and right versus noncoronary leaflet (p < 0.001).

CONCLUSIONS

The semiautomated AV apparatus dynamic assessment using eSie valve software is a clinically feasible technique and can be performed readily in the operating room. It has the potential to significantly impact intraoperative decision-making in cases suitable for AV repair. The AV apparatus is a dynamic structure and demonstrates significant changes during the cardiac cycle.

Moderate Aortic Stenosis and Coronary Artery Bypass Grafting: Clinical Update for the Perioperative Echocardiographer

Incidental aortic stenosis in the setting of coronary artery bypass surgery may be a perioperative challenge. The accurate assessment of the degree of aortic stenosis remains an important determinant. Although severe aortic stenosis is an indication for valve replacement, current guidelines advise a balanced approach to the management of moderate aortic stenosis in this setting. Multiple factors should be considered in a team discussion to balance risks versus benefits for the various management options in the given patient. The rapid progress in aortic valve technologies also offer alternatives for definitive management of moderate aortic stenosis in this setting that will likely become even safer in the near future.