Outline. EuroScore II. Society of Thoracic Surgeons Score. EuroScore II
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1 SURGICAL RISK IN VALVULAR HEART DISEASE: WHAT 2D AND 3D ECHO CAN TELL YOU AND WHAT THEY CAN'T Ernesto E Salcedo, MD Professor of Medicine University of Colorado School of Medicine Director of Echocardiography University of Colorado Hospital Outline Valvular Surgery - surgical risk Strengths and limitations of Echocardiography in surgery and interventions for: Stenotic lesions TAVR Low gradient aortic stenosis Regurgitant lesions Aortic insufficiency secondary to aortic root disease Ischemic mitral regurgitation Society of Thoracic Surgeons Score EuroScore II o Procedure o Demographics o Risk Factors o Interventions o Medications o Hemodynamics o Operative EuroScore II Guidelines on the management of valvular heart disease (version 2012) European Heart Journal (2012) 33,
2 Valvular Stenosis Severity AORTIC STENOSIS Echo Doppler Assessment of AS Severity Severe Aortic Stenosis Transcatheter Aortic-Valve Implantation for Aortic Stenosis in Patients Who Cannot Undergo Surgery Leon MB N Engl J Med 2010;363:
3 Underestimation of LVOT Diameter by 2D Echocardiography in a Patient with Aortic Stenosis 3D TEE and CT for Aortic Annular Dimensions Tandon A J Am Coll Cardiol Img. 2013;6(2): Courtesy Dr Robert Quaife University of Colorado Denver Vascular Access for TAVR Choosing the Proper C Arm Position for TAVR Deployment Courtesy Dr Robert Quaife University of Colorado Denver Courtesy Dr Robert Quaife University of Colorado Denver
4 Relationship Between Mean Gradient (Y Axis) and Transvalvular Flow (X Axis) According to the Gorlin Formula for 3 Different AVA Values (0.7, 1.0, and 1.5 cm2) Dobutamine Stress Echo in a Patient With Low Gradient Severe Aortic Stenosis Baseline Dobutamine10 μg/kg/min Peak velocity 3.2 m/s, mean gradient 25 mm Hg, calculated AVA 0.45 cm2 Peak velocity increased to 4.1 m/s, mean gradient to 39 mm Hg, and AVA remained at 0.5 cm2 Speckle tracking Results of global longitudinal strain, which was 5.5%, indicating severely abnormal myocardial function Pseudo Aortic Stenosis Dobutamine Stress Echo 0 ug 5ug 10ug 20ug Peak velocity remained fairly constant, but AVA increased from 1.0 cm2 to 1.4 cm2, demonstrating both contractile reserve and absence of severe AS AORTIC REGURGITATION SECONDARY TO AORTIC ROOT DISEASE Dilation of the Sino tubular junction causing aortic insufficiency Aortic Valve short and Long Axis Views David T Prog Cardiovasc Dis 2010;52:
5 Aortic valve sparing operations for aortic root aneurysm aneurysm 2D and M mode Echo aneurysm 2D Color aneurysm 2D Color and Spectral Doppler aneurysm 3D Multiplane Reconstruction aneurysm 3D Volume Rendition
6 Cardiac MRI Aortic Graft ISCHEMIC MITRAL REGURGITATION Normal Mitral Valve Dal-Bianco J Cardiol Clin 31 (2013) Mitral Fibroelastoma Ischemic MR The main mechanism of ischemic mitral regurgitation (MR) relates to distortion of the spatial relationships between the mitral valve and papillary muscles secondary to ventricular remodeling This process can then become self-perpetuating as MR leads to ventricular dilatation, which in turn leads to further papillary muscle displacement, annular dilatation, and then more MR Echocardiography provides mechanistic insights into the complex pathophysiology that involves the myocardium, the mitral subvalvular apparatus, and mitral annulus. Hung J Cardiol Clin 31 (2013)
7 Ischemic Mitral Regurgitation
8 Ischemic Mitral Regurgitation 3D Mitral Valve Tenting Ischemic Mitral Regurgitation Comprehensive Annular and Subvalvular Repair of Chronic Ischemic Mitral Regurgitation Improves Long-Term Results With the Least Ventricular Remodeling Anterior leaflet bend by papillary muscle displacement and leaflet tethering producing mitral regurgitation Restoration of coaptation after cut of basal chordal, relieving tethering on the anterior leaflet Szymanski, C Archives of Cardiovascular Disease (2013) 106, Normal Leaflet Coaptation Clockwise Basal Rotation Abnormal Leaflet Coaptation Impaired Basal Rotation Zito C J Am Soc Echocardiogr 2013
9 Anterior and Inferior MI Impaired Basal Rotation- Severe MR Conclusions Echocardiography plays a central role in the diagnosis and management of patients with advanced and complex valvular heart disease. Echocardiography is uniquely qualified to provide structural and functional information regarding valve dysfunction and its effects in ventricular remodeling. TAVR, Low grade aortic stenosis, aortic regurgitation secondary to aortic root disease and ischemic mitral regurgitation exemplify clinical scenarios where echocardiography provide unique information to enhance the diagnosis and treatment of patients with valvular heart disease ernesto.e.salcedo@ucdenver.edu
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