Journal Article

Comparison of Simultaneous Transthoracic Versus Transesophageal Echocardiography for Assessment of Aortic Stenosis

Sagie, Alexander, Vaturi, Mordehay, Schwartzenberg, Shmuel, Kazum, Shirit, Monakier, Daniel, Ofek, Hadas, Yedidya, Idit, Shapira, Yaron, Kornowski, Ran

2022

Overview

•LVOT velocity is significantly underestimated by TEE compared with TEE•Transgastric TEE probe aligns better than transapical TTE with aortic valve flow.•TEE compared with TTE in aortic stenosis yields lower DVI despite larger LVOT area.•Doppler probe insonation angle with TTE versus TEE accounts for these differences.•TEE overestimates AS severity versus awake or simultaneous sedation state paired TTE. Transthoracic echocardiography (TTE) is the gold standard for aortic stenosis (AS) assessment. Transesophageal echocardiography (TEE) provides better resolution, but its effect on AS assessment is unclear. To answer this question, we studied 56 patients with ≥moderate AS. Initial TTE (TTE1) was followed by conscious sedation with simultaneous TEE and TTE2. Based on conservative versus actionable implication, AS types were dichotomized into group A, comprising moderate and normal-flow low-gradient, and group B, comprising high gradient, low ejection fraction low-flow low-gradient, and paradoxical low-flow low-gradient AS. Paired analysis of echocardiographic variables and AS types measured by TEE versus TTE2 and by TEE versus TTE1 was performed. TEE versus simultaneous TTE2 comparison demonstrated higher mean gradients (31.7 ± 10.5 vs 27.4 ± 10.5 mm Hg) and velocities (359 ± 60.6 vs 332 ± 63.1 cm/s) with TEE, but lower left ventricular outflow velocity-time-integral (VTI1) (18.6 ± 5.1 vs 20.2 ± 6.1 cm), all p <0.001. This resulted in a lower aortic valve area (0.8 ± 0.21 vs 0.87 ± 0.28 cm2), p <0.001, and a net relative risk of 1.86 of group A to B upgrade. TEE versus (awake state) TTE1 comparison revealed a larger decrease in VTI1 because of a higher initial awake state VTI1 (22 ± 5.6 cm), resulting in similar Doppler-velocity-index and aortic valve area decrease with TEE, despite a slight increase in mean gradients of 0.8 mm Hg (confidence interval −1.44 to 3.04) and velocities of 10 cm/s (confidence interval −1.5 to 23.4). This translated into a net relative risk of 1.92 of group A to B upgrade versus TTE1. In conclusion, TEE under conscious sedation overestimates AS severity compared with both awake state TTE and simultaneous sedation state TTE, accounted for by different Doppler insonation angles obtained in transapical versus transgastric position.

• Publisher: Elsevier Inc,Elsevier Limited
• Subject: Aged / Aged, 80 and over / Anesthesia / Aorta / Aortic stenosis / Aortic valve / Aortic Valve Stenosis - diagnostic imaging / Aortic Valve Stenosis - physiopathology / Blood Flow Velocity / Blood pressure / Cardiology / Cardiovascular disease / Confidence intervals / Conscious Sedation / Echocardiography / Echocardiography - methods / Echocardiography, Doppler - methods / Echocardiography, Transesophageal - methods / Female / Heart / Heart valves / Humans / Male / Severity of Illness Index / Stroke Volume - physiology / Velocity / Ventricle