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The Sudden Appearance of a Mobile Mass in the Ascending Aorta on Transesophageal Echocardiography After Transcatheter Aortic Valve Replacement

Trunfio, Giuseppe MD*; Konstadt, Steven MD*; Ribakove, Greg MD; Crooke, Greg MD; Frankel, Robert MD; Shani, Jacob MD; Sadiq, Adnan MD; Ovanez, Christopher MD, MPH; Feierman, Dennis E. PhD, MD*

doi: 10.1213/ANE.0000000000000975
Cardiovascular Anesthesiology: Echo Rounds
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From the Departments of *Anesthesiology, Surgery, and Cardiology, Maimonides Medical Center, Brooklyn, New York.

Accepted for publication July 19, 2015.

Funding: None.

The authors declare no conflicts of interest.

The patient and family gave permission to publish this report.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Reprints will not be available from the authors.

Address correspondence to Dennis E. Feierman, PhD, MD, Department of Anesthesiology, Maimonides Medical Center, 4802 10th Ave., Brooklyn, NY 11219. Address e-mail to Dfeierman@maimonidesmed.org.

A 93-year-old man with a history of severe aortic stenosis (AS), hypertension, atrial fibrillation, and chronic obstructive pulmonary disease presented with an acute exacerbation of chronic heart failure and was scheduled for transcatheter aortic valve replacement (TAVR). The Society of Thoracic Surgeons’ risk score and the EuroSCORE for perioperative surgical mortality were 19.74% and 15.99%, respectively. Transthoracic echocardiography (TTE) revealed severe AS with an aortic valve area of 0.7 cm2, a mean gradient of 34 mm Hg, an aortic annulus diameter of 19 mm, left ventricular ejection fraction estimated at 40% to 45%, mild to moderate aortic insufficiency (AI), mild to moderate mitral regurgitation, and moderate pulmonary hypertension with estimated right ventricular systolic pressure of 43 mm Hg. After induction of general anesthesia, a pulmonary artery catheter and an X7-2 transesophageal echocardiogram (TEE) probe (Philips Healthcare, Andover, MA) were inserted. A midesophageal aortic valve long-axis view of the ascending aorta before the valvuloplasty, during rapid ventricular pacing at 180 beats/min, revealed an echodense, apparently calcified structure consistent with a grade 4 calcified atheroma,1 with no mobile component (Fig. 1, Video 1, Supplemental Digital Content 1, http://links.lww.com/AA/B214). Arch and descending aorta echo assessment revealed several grade 3 atheromas. The aortic annulus measured 20 mm.

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

The right femoral artery was surgically exposed and a 22F sheath was inserted. After institution of rapid ventricular pacing (180 beats/min), aortic annulus balloon valvuloplasty was performed (Fig. 2) and no mobile plaque was seen. Subsequently, a 23-mm Edwards Sapien (Edwards Lifesciences, Irvine, CA) aortic valve was deployed. No post-deployment dilation was necessary because there was no evidence of paravalvular leak. A long-axis view of the ascending aorta revealed a mobile plaque (Fig. 3; and Videos 2 and 3, Supplemental Digital Content 1 and 2, http://links.lww.com/AA/B215, http://links.lww.com/AA/B216). There was a full discussion of the risks and benefits to remove the mobile plaque, and it was unanimously agreed to not intervene. Postoperative antithrombotic prophylaxis consisted of aspirin and clopidogrel. After 6 months, the patient was neurologically asymptomatic. He underwent 2 postprocedure TTE examinations that did not visualize any mobile aortic masses.

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DISCUSSION

There are many imaging modalities to preoperatively evaluate these patients.2 In our case, we used TTE, cardiac catheterization, and full body computed tomography angiography (CTA). The calcification of the aortic annular area can be evaluated with CTA. This patient’s CTA showed a moderate to severe calcified aortic valve and moderate atherosclerotic and calcific changes in the ascending aorta without evidence of aneurysm. The perioperative use of TEE for TAVR is considered very useful.3–5 Before the procedure, it can be used to confirm aortic annulus size, measure the aortic annulus-coronary ostia distance, detect aortic atheromas, and exclude absolute contraindications such as subaortic stenosis and relative contraindications such as bicuspid aortic valve or sigmoid interventricular septum. Intraprocedurally, TEE can be used to verify the position of the guidewire across the aortic valve, exclude injury to the mitral valve apparatus or ventricular perforation, examine the aortic annular anatomy, and measure dimensions needed to position and deploy the TAVR prosthesis, as well as corroborate positioning and full deployment of the TAVR prosthesis. After deployment, it can evaluate the degree and location (intra- or paravalvular) of AI, follow improvement or worsening of AI in real time, and detect complications,3 that is, exclude segmental wall motion abnormalities secondary to coronary occlusion, evaluate mitral valve function, and assess for pericardial effusion. Before deployment, the use of 3D TEE with multiplanar reconstruction is superior to 2D in aortic annulus sizing because it assists in defining the shape of the aortic annulus and a closer approximation of its perimeter, area, and diameter. The location and the severity of post-deployment AI jets can be better characterized on 3D TEE; although 3D electrocardiogram-gated full-volume data sets with color flow may be superior, they may not be easy to obtain in an acute clinical situation.

The presence of complex aortic plaque is prevalent in patients with severe AS and is independently associated with increased risk of cerebral infarction.6,7 Our patient had a grade 4 plaque, according to the classification by Katz et al.1

Our patient’s mobile plaque was located adjacent to the distal margin of the TAVR prosthesis. The mobile plaque was not visualized until after the deployment of the valve and not during the insertion of the system or after the balloon valvuloplasty. Balloon aortic valvuloplasty is typically an integral part of TAVR when using the Sapien valve, and it usually precedes the deployment of the valve even in the presence of aortic plaque; therefore, a decision to use, for example, the self-expanding CoreValve (Medtronic, Minneapolis, MN), which does not require valvuloplasty, would have had to be made preoperatively. We believe that the creation of the mobile plaque was due to the apposition of the end of the valve mesh, with respect to the plaque. When the valve was inserted through the aortic valve, the valve mesh pressed into the plaque and caused it to partially fracture.

Cerebral embolization rather than hypotension-related ischemia is the most common mechanism of TAVR-related cerebrovascular accidents.8 They occur predominantly in the early periprocedural period and are associated with multiple device implantation attempts, chronic obstructive pulmonary disease, and low body mass index. They increase the risk of death 10-fold.6 In an elderly patient, such as ours, it seems reasonable to integrate intraoperative TEE examination into neurologic risk stratification, even if TEE requires the administration of a general anesthetic. It is unknown whether a balloon-expanded system such as the Sapien valve predisposes to more aortic manipulation and trauma than a self-expanding system such as the CoreValve. The CoreValve’s deployment device has a smaller diameter, and it does not usually require surgical exposure or balloon aortic valvuloplasty. In addition, it has a longer stent. Its longer stent may be used to cover a proximal plaque without interfering with the coronary ostia.

Ura et al.9 found that surgically induced new intimal lesions in the ascending aorta were associated with a significant incidence of cerebrovascular accidents (3/10), and the intimal lesions that embolized were all mobile. There has only been one case report suggesting a mobile plaque was associated with mortality after TAVR.10 When a mobile plaque is found after deployment of a TAVR prosthesis, the benefits and risks need to be assessed with each patient, that is, whether or not to surgically intervene by covering the plaque with a stent versus postoperative anticoagulation. In this patient, leaving the mobile atheroma was probably the best alternative. Reasons not to use a stent to cover the lesion are the potential occlusion of the aortic arch vessels if the stent is placed too distally or interference with the TAVR prosthesis or coronary ostia if placed too proximally and embolization or fracturing the plaque.

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Clinician’s Key Teaching Points

By Nikolaos J. Skubas, MD, Kent H. Rehfeldt, MD, and Martin J. London, MD

  • Transcatheter aortic valve replacement (TAVR) is facilitated by multiple imaging modalities including preprocedural echocardiography and computed tomography, as well as intraprocedural transesophageal echocardiogram (TEE) and fluoroscopy. Important uses of TEE include measurement of the aortic annulus to guide prosthesis sizing. Although aortic annulus measurement has commonly been performed with a standard 2D, midesophageal (ME), aortic valve (AV), long-axis (LAX) view, the use of 3D TEE with multiplanar reconstruction better characterizes the elliptical shape of this region and allows more accurate measurement of annular diameter, perimeter, and area.
  • Other uses of TEE during TAVR include identification of procedural contraindications such as subaortic stenosis and bicuspid AV. Correct positioning of the guidewire and prosthesis can also be verified, and recognition of iatrogenic injuries such as mitral valve damage or ventricular perforation is possible. After prosthesis deployment, TEE is used to quantify valvular and paravalvular regurgitation, exclude pericardial effusion, and diagnose regional wall motion abnormalities that could signify inadvertent coronary ostial occlusion.
  • In this case, severe, immobile atheromatous plaque in the ascending aorta was identified with TEE in an ME AV LAX view before balloon valvuloplasty and prosthesis deployment. After device deployment, an ME ascending aorta LAX view revealed mobile, intraluminal aortic debris consistent with disrupted plaque that had likely been dislodged by the distal mesh structure of the transcatheter valve.
  • Although the patient in this case recovered without neurologic complications, embolic phenomena are the leading cause of stroke related to TAVR. TEE is able to characterize aortic atheromatous disease and identify iatrogenic intimal lesions in the ascending aorta that increase the risk for stroke. The management of aortic intimal lesions and mobile atheromatous plaque, whether with antithrombotic prophylaxis or stent coverage, should be individualized.
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DISCLOSURES

Name: Giuseppe Trunfio, MD.

Contribution: This author helped analyze the data, write the manuscript, and is an anesthesiologist for patient.

Attestation: Giuseppe Trunfio approved the final manuscript.

Name: Steven Konstadt, MD.

Contribution: This author helped analyze the data, write the manuscript, and is an anesthesiologist for patient.

Attestation: Steven Konstadt approved the final manuscript.

Name: Greg Ribakove, MD.

Contribution: This author helped analyze the data, write the manuscript, and is a cardiac surgeon for the patient.

Attestation: Greg Ribakove approved the final manuscript.

Name: Greg Crooke, MD.

Contribution: This author helped analyze the data, write the manuscript, and is a cardiac surgeon for the patient.

Attestation: Greg Crooke approved the final manuscript.

Name: Robert Frankel, MD.

Contribution: This author helped analyze the data, write the manuscript, and is a cardiologist for the patient.

Attestation: Robert Frankel approved the final manuscript.

Name: Jacob Shani, MD.

Contribution: This author helped analyze the data, write the manuscript, and is the cardiologist for patient.

Attestation: Jacob Shani approved the final manuscript.

Name: Adnan Sadiq, MD.

Contribution: This author helped analyze the data, write the manuscript, and is an echocardiologist.

Attestation: Adnan Sadiq approved the final manuscript.

Name: Christopher Ovanez, MD, MPH.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: Christopher Ovanez approved the final manuscript.

Name: Dennis E. Feierman, PhD, MD.

Contribution: This author helped analyze the data and write the manuscript.

Attestation: Dennis E. Feierman approved the final manuscript.

This manuscript was handled by: Martin London, MD.

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REFERENCES

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2. Holmes DR Jr, Mack MJ, Kaul S, Agnihotri A, Alexander KP, Bailey SR, Calhoon JH, Carabello BA, Desai MY, Edwards FH, Francis GS, Gardner TJ, Kappetein AP, Linderbaum JA, Mukherjee C, Mukherjee D, Otto CM, Ruiz CE, Sacco RL, Smith D, Thomas JDAmerican College of Cardiology Foundation; American Association for Thoracic Surgery; Society for Cardiovascular Angiography and Interventions; Society for Thoracic Surgeons; American Heart Association; American Society of Echocardiography; European Association for Cardio-Thoracic Surgery; Heart Failure Society of America; Mended Hearts; Society of Cardiovascular Anesthesiologists; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance. American College of Cardiology Foundation; American Association for Thoracic Surgery; Society for Cardiovascular Angiography and Interventions; Society for Thoracic Surgeons; American Heart Association; American Society of Echocardiography; European Association for Cardio-Thoracic Surgery; Heart Failure Society of America; Mended Hearts; Society of Cardiovascular Anesthesiologists; Society of Cardiovascular Computed Tomography; Society for Cardiovascular Magnetic Resonance. . 2012 ACCF/AATS/SCAI/STS expert consensus document on transcatheter aortic valve replacement: developed in collaboration with the American Heart Association, American Society of Echocardiography, European Association for Cardio-Thoracic Surgery, Heart Failure Society of America, Mended Hearts, Society of Cardiovascular Anesthesiologists, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. Ann Thorac Surg. 2012;93:1340–95
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