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• W4319872566 abstract "TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) has long been considered an important tool in understanding mitral valvular pathology. In the most recent American College of Cardiology–American Heart Association guidelines for managing patients with structural heart disease, the assessment of morphology and feasibility of both transcatheter and surgical mitral repair using TEE imaging is a class 1 recommendation, and transcatheter edge-to-edge repair (TEER) has a class 2a recommendation for high-risk patients with appropriate valve morphology.1Otto CM Nishimura RA Bonow RO et al.2020 ACC/AHA Guideline for the management of patients with valvular heart disease: Executive summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation. 2021; 143: e35-e71PubMed Google Scholar Additionally, for patients with rheumatic mitral stenosis (MS), TEE imaging to assess valve morphology and left atrial appendage clot prior to percutaneous mitral balloon commissurotomy is a class 1 recommendation.1Otto CM Nishimura RA Bonow RO et al.2020 ACC/AHA Guideline for the management of patients with valvular heart disease: Executive summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation. 2021; 143: e35-e71PubMed Google Scholar Given the increasing number of transcatheter structural heart interventions that use TEE imaging for procedural planning, the American Society of Echocardiography recently published recommendations for a preprocedural TEE framework to identify the mechanism and severity of structural or valvular dysfunction and anatomic features that may support or preclude intervention.2Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Subsequently, the aim of this editorial is to review and comment on these recommendations from the American Society of Echocardiography on performing TEE screening for transcatheter interventions, with a focus on preprocedural imaging for mitral interventions. Patients with severe mitral regurgitation (MR) largely benefit from a comprehensive baseline TEE, which is a superior modality to transthoracic echocardiography (TTE) for the visualization of the mitral valve.1Otto CM Nishimura RA Bonow RO et al.2020 ACC/AHA Guideline for the management of patients with valvular heart disease: Executive summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation. 2021; 143: e35-e71PubMed Google Scholar The goals of TEE are as follows: (1) to determine the suitability of a transcatheter intervention versus surgery and (2) to determine the feasibility of the type of mitral device in consideration. Accordingly, a preprocedural TEE is performed on nearly all patients undergoing mitral valve structural heart interventions such as TEER. Although the proposed recommendations are intended for level II–trained echocardiographers performing preprocedural TEE, they are also relevant to cardiac anesthesiologists because they routinely perform preprocedural TEEs, and their certification in advanced perioperative TEE is similar to the TTE requirements for level II echocardiographers.3Wiegers SE Ryan T Arrighi JA et al.2019 ACC/AHA/ASE advanced training statement on echocardiography (revision of the 2003 ACC/AHA clinical competence statement on echocardiography): A Report of the ACC Competency Management Committee.Catheter Cardiovasc Interv. 2019; 94: 481-505Crossref PubMed Scopus (5) Google Scholar As integral members of the structural heart team, cardiac anesthesiologists need to understand critical preprocedural imaging findings, how these findings may differ from intraprocedural TEE, and the next steps to take when standard preprocedural imaging is not available. Although most patients undergoing percutaneous mitral intervention will have a preprocedural TEE, it is not required. A subset of patients may only have a preprocedure TTE.1Otto CM Nishimura RA Bonow RO et al.2020 ACC/AHA Guideline for the management of patients with valvular heart disease: Executive summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation. 2021; 143: e35-e71PubMed Google Scholar In this setting, the anesthesiologist may be performing the patient's first TEE assessment, and a new finding may alter intraprocedural decision-making. The preprocedural TEE recommendations provide a framework to perform this important evaluation and aid with procedural planning. While this document provides guidance to assess the degree and mechanism of mitral disease, it does not account for situations in which disease severity may vary with anesthesia, despite emphasizing that MR is affected by loading conditions that should be considered during valvular assessment.2Hahn RT Saric M Faletra FF et al.Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography.J Am Soc Echocardiogr. 2022; 35: 1-76Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar The severity of MR can differ greatly in a patient who is under sedation compared to general anesthesia, given the changes in preload, afterload, contractility, and heart rate. A recent meta-analysis and systematic review of 6 studies, including 273 patients, compared MR severity on intraoperative TEE versus preoperative TEE or TTE with sedation. Mitral regurgitation severity was underdiagnosed in 75 out of 191 (39%) patients under general anesthesia, and overdiagnosed in 17 out of 191 (9%) patients, resulting in a misdiagnosis in 92 out of 191 (48%) patients. Furthermore, even under hemodynamic alterations to restore “awake” loading conditions, MR severity remained discordant with preprocedural imaging findings in 37 out of 91 (41%) patients. Interestingly, hemodynamic matching more often led to an overestimation of MR, and was found to occur in 26 out of 91 (29%) patients compared to underestimation in only 11 out of 91 (12%) patients.4Sanfilippo F Johnson C Bellavia D et al.Mitral regurgitation grading in the operating room: A systematic review and meta-analysis comparing preoperative and intraoperative assessments during cardiac surgery.J Cardiothorac Vasc Anesth. 2017; 31: 1681-1691Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar Another recent retrospective cohort study of 50 patients with severe primary (n = 11) and secondary (n = 39) MR undergoing TEER found that intraprocedural MR during TEE with general anesthesia was less severe than when measured on preprocedural TEE under sedation independent of hemodynamic variations. However, when patients were reanalyzed subsequently according to MR classification, MR severity was only significantly underestimated in patients with secondary MR but not primary MR. Those with secondary MR had decreases in the color-flow jet area (10 ± 7 cm² v 7 ± 3 cm², p < 0.001), vena contracta (5.5 ± 1.6 mm v 4.7 ± 1.5 mm, p = 0.002), effective regurgitant orifice area (30 ± 11 mm² v 24 ± 10 mm², p < 0.001), and regurgitant volume (47 ± 17 mL/beat v 34 ± 13 mL/beat, p < 0.001). Additionally, 3-dimensional measurements of MR, such as 3-dimensional vena contracta area, were less likely to underestimate severity than 2-dimensional assessments, as they only resulted in MR underestimation in 20% of patients compared to 44% of patients.5Alachkar MN Kirschfink A Grebe J et al.General anesthesia leads to underestimation of regurgitation severity in patients with secondary mitral regurgitation undergoing transcatheter mitral valve repair.J Cardiothorac Vasc Anesth. 2022; 36: 974-982Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar These findings were consistent with other studies that also have noted that quantitative assessments (ie, effective regurgitant orifice area and regurgitant volume) may be more accurate in grading MR severity under anesthesia, as they are less dependent on loading conditions.4Sanfilippo F Johnson C Bellavia D et al.Mitral regurgitation grading in the operating room: A systematic review and meta-analysis comparing preoperative and intraoperative assessments during cardiac surgery.J Cardiothorac Vasc Anesth. 2017; 31: 1681-1691Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 5Alachkar MN Kirschfink A Grebe J et al.General anesthesia leads to underestimation of regurgitation severity in patients with secondary mitral regurgitation undergoing transcatheter mitral valve repair.J Cardiothorac Vasc Anesth. 2022; 36: 974-982Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 6Banks DA Con: Mitral regurgitation can be reliably assessed under general anesthesia.J Cardiothorac Vasc Anesth. 2009; 23: 558-560Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Similarly, an accurate assessment of MS under general anesthesia with altered loading conditions may be challenging. A small study of 22 patients undergoing percutaneous mitral balloon commissurotomy for rheumatic MS compared preprocedural TEE under sedation to TEE after induction of general anesthesia. After induction, there was significant variability in mean mitral gradients that were unrelated to heart rate or blood pressure changes. Fourteen out of 22 (63%) patients had a drop in their mean mitral valve gradient, whereas 7 out of 22 (31%) had a rise. This resulted in a misdiagnosis of MS severity in 8 out of 22 (36%) of patients measured by the Gorlin formula; MS was underestimated in 6 (27%) patients and overestimated in 2 (9%) patients.7Kuperstein R Raibman-Spector S Canetti M et al.Influence of anesthesia on hemodynamic assessment of mitral stenosis severity.Cardiol J. 2022; 29: 245-251Crossref PubMed Scopus (1) Google Scholar There are several reasons why preprocedural TEE findings correlate poorly with intraprocedural findings. Preload conditions may change, as many patients often undergo additional hemodynamic optimization with diuresis in preparation for structural heart interventions. Decreased filling pressures may decrease cardiac chamber and annular size, especially with secondary, functional MR (due to Carpentier type 1 or type IIIa).8Furukawa A Abe Y Ito K et al.Mechanisms of changes in functional mitral regurgitation by preload alterations.J Cardiol. 2018; 71: 570-576Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Furthermore, afterload and left ventricular contractility decrease upon the induction of anesthesia, as many agents decrease systemic vascular resistance and sympathetic stimulation. Although provocative testing may promote hemodynamic matching under anesthesia, these tests usually only use vasopressors to account for changes in afterload. Provocative testing with inotropes may provide a more accurate assessment, with the caveat that significant tachycardia also may lead to underestimation of MR.6Banks DA Con: Mitral regurgitation can be reliably assessed under general anesthesia.J Cardiothorac Vasc Anesth. 2009; 23: 558-560Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar,9Essandoh M Intraoperative grading of mitral regurgitation during general anesthesia: Is hemodynamic matching useful?.J Cardiothorac Vasc Anesth. 2018; 32: e39-e40Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar The addition of positive-pressure ventilation under general anesthesia also significantly alters cardiac physiology by decreasing right ventricular preload, increasing right ventricular afterload, and decreasing left ventricular preload, afterload, and stroke volume, resulting in decreased cardiac output.10Corp A Thomas C Adlam M. The cardiovascular effects of positive pressure ventilation.BJA Educ. 2021; 21: 202-209Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Furthermore, the addition of positive end-expiratory pressure alters mitral valve geometry as well. A study of 50 patients undergoing TEER for primary (n = 23), secondary (n = 15), or mixed etiology (n = 12) MR found that increasing positive end-expiratory pressure from 3 mmHg-to-10 mmHg-to-20 mmHg during leaflet grasping decreased preload (left ventricular end-systolic diameter 43.8 ± 10.7 mm v 39.9 ± 11.0 mm, p < 0.001) and the size of the mitral valve annulus (anterior-posterior diameter 32.4 ± 4.3 mm v 30.5 ± 4.4 mm, p < 0.001; mediolateral diameter 35.4 ± 4.2 mm v 34.1 ± 3.9 mm, p = 0.002), and increased mitral valve leaflet coaptation length (3.0 ± 0.8 mm v 5.4 ± 1.1 mm, p < 0.001), allowing for easier clip placement and decreased procedural time (152 ± 49 min v 116 ± 26 min, p = 0.05). Although leaflet coaptation length increased in all patients, the increased length was most pronounced in functional or mixed etiology MR than in degenerative MR (p = 0.02).11Patzelt J Zhang Y Seizer P et al.Effects of mechanical ventilation on heart geometry and mitral valve leaflet coaptation during percutaneous edge-to-edge mitral valve repair.JACC Cardiovasc Interv. 2016; 9: 151-159Crossref PubMed Scopus (27) Google Scholar These studies showed that the balance among intraprocedural TEE valvular assessment, hemodynamics, and fluid status remains incredibly complex. For procedural success, these nuances need to be understood to best predict postprocedural findings—especially when intraprocedural imaging differs significantly from preprocedural findings. The anesthesiologist plays a crucial role in understanding and optimizing patient physiology for echocardiographic assessment and procedural success. It also should be mentioned that manipulation of many of these parameters may also affect shunt fraction calculations when evaluating septal defects, iatrogenic or congenital, for closure. Although not discussed in the recommendations, preprocedural imaging should also include an assessment of biventricular function, major vasculature, and pericardial structures. Patients undergoing high-risk procedures, such as valve-in-mitral annular calcification transcatheter mitral valve replacement, have an increased risk of left ventricular perforation and neo-left ventricular outflow tract obstruction, which may result in acute hemodynamic instability and cardiogenic shock. The identification and characterization of a preintervention pericardial effusion may help the structural heart team determine the speed and extent of fluid accumulation and the need for periprocedural drainage or close monitoring. These patients may require intraprocedural mechanical support. Evaluation of their ventricular function and vasculature can help with multidisciplinary preprocedural planning if a ventricular support device is warranted.12Khatib D Neuburger PJ Pan S et al.Transcatheter Mitral valve interventions for mitral regurgitation: A review of mitral annuloplasty, valve replacement, and chordal repair devices.J Cardiothorac Vasc Anesth. 2022; 36: 3887-3903Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,13Nicoara A Skubas N Ad N et al.Guidelines for the use of transesophageal echocardiography to assist with surgical decision-making in the operating room: A surgery-based approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons.J Am Soc Echocardiogr. 2020; 33: 692-734Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Mechanical support may also be indicated to aid with procedural candidacy and success. A small case series of 4 patients with decompensated heart failure, severe MR, and noncoapting mitral leaflets underwent evaluation for TEER. They were initially not eligible for TEER, given the size of their leaflet gaps, so they received intra-aortic balloon pumps. The subsequent decreases in preload and afterload resulted in a decreased mitral annular area and improved leaflet coaptation, which allowed successful TEER implantation.14Eliaz R Turyan A Beeri R et al.Utilization of intra-aortic balloon pump to allow MitraClip procedure in patients with non-coapting mitral valve leaflets: A case series.Eur Heart J Case Rep. 2019; 3: ytz045Crossref PubMed Scopus (11) Google Scholar Lastly, a thorough preprocedural assessment should identify which imaging planes provide the best views for procedural guidance. Occasionally, supine positioning may result in inadequate views of the mitral valve, which can be improved with left lateral positioning. This information is useful to determine the best patient positioning for the procedure and if combination modalities, such as the addition of intracardiac echocardiography or TTE, should be used.15Gheorghe LL Mobasseri S Agricola E et al.Imaging for native mitral valve surgical and transcatheter interventions.JACC Cardiovasc Imaging. 2021; 14: 112-127Crossref PubMed Scopus (17) Google Scholar As we continue to perform an increasing number of percutaneous structural heart procedures under TEE guidance, it will be useful to understand if preprocedural TEE can identify patients who may not require intraprocedural TEE. Given the recent concern for an increased risk of complications (3%-4%) with intraprocedural TEE for structural heart interventions compared to intraoperative and preprocedural TEE (<1%), it will be interesting to see if we can perform more of these procedures with other modalities such as intracardiac echocardiography (ICE).16Hasnie AA Parcha V Hawi R et al.Complications associated with transesophageal echocardiography in transcatheter structural cardiac interventions.J Am Soc Echocardiogr. 2022; ([e-pub ahead of print]) (Accessed February 2, 2023)https://doi.org/10.1016/j.echo.2022.12.023Abstract Full Text Full Text PDF Scopus (1) Google Scholar Many patent foramen ovale closures and some left atrial appendage device occluders are already performed with intracardiac echocardiography alone. Procedures using ICE instead of TEE can often be performed with spontaneous ventilation and sedation, which may circumvent some of the hemodynamic changes discussed above and perhaps allow for more accurate intraprocedural assessment. As the technology for structural heart interventions continues to rapidly evolve, guidance and standardization of preprocedural imaging key steps in procedural planning and success that should be understood by all members of the heart valve team. Preprocedural TEE often determines patient candidacy and success for structural heart interventions. Therefore, the cardiac anesthesiologist plays a crucial role in understanding the effects of general anesthesia and positive-pressure ventilation on loading conditions, and how they subsequently may alter mitral pathology on intraprocedural TEE to aid with procedural success. Dr Methangkool receives consulting fees from Edwards LifeSciences and author royalties from UpToDate." @default.
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• W4319872566 title "Preprocedural Transesophageal Echocardiography Recommendations for Mitral Structural Heart Interventions: Implications for the Cardiac Anesthesiologist" @default.
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