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CLINICAL STUDY: VALVE DISEASE

Reoperation for prosthetic aortic valve obstruction in the era of echocardiography: trends in diagnostic testing and comparison with surgical findings

Steven E. Girard, MD, PhD^*, Fletcher A. Miller, Jr., MD, FACC^*, Thomas A. Orszulak, MD, Charles J. Mullany, MD, Samantha Montgomery, MS, William D. Edwards, MD, Henry D. Tazelaar, MD, Joseph F. Malouf, MD, FACC^* and A. Jamil Tajik, MD, FACC^*

^* Division of Cardiovascular Disease, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Division of Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Division of Cardiovascular Surgery, Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA
Division of Anatomic Pathology, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Manuscript received April 12, 2000; revised manuscript received August 23, 2000, accepted October 2, 2000.

Reprint requests and correspondence: Dr. Fletcher A. Miller, Jr., Mayo Clinic, 200 First Street, SW, Rochester, Minnesota 55905
miller.fletcher{at}mayo.edu

OBJECTIVES

We sought to: 1) identify trends in the diagnostic testing of patients with prosthetic aortic valve (AVR) obstruction who undergo reoperation and 2) compare diagnostic test results with pathologic findings at surgery.

BACKGROUND

It is unclear whether Doppler transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have reduced hemodynamic catheterization rates.

METHODS

We reviewed 92 consecutive cases of AVR reoperation at a single center from 1989 to 1998, comparing 49 cases of mechanical AVR obstruction (group A) to 43 cases of bioprosthetic obstruction (group B). Preoperative Doppler TTE was performed in all cases.

RESULTS

In group A cases, there was a marginally significant trend towards lower catheterization rates for the Gorlin AVR area, from 36% in 1989 to 1990 to 10% in 1997 to 1998 (p = 0.07), but diagnostic TEE utilization (47% of cases) did not vary. The cause of mechanical AVR obstruction was pannus in 26 cases (53%), mismatch (P-PM) in 19 (39%) and thrombosis in 4 (8%). The mechanism (pannus/thrombus vs. mismatch) was identified in 10% by TTE and 49% by TEE (p < 0.001). In group B cases, hemodynamic catheterization rates (21%) and diagnostic TEE utilization (21%) did not vary with time. Obstruction was caused by structural degeneration in 37 cases (86%), thrombosis in 3 (7%), mismatch in 2 (5%) and pannus in 1 (2%). The mechanism was correctly identified in 63% by TTE and in 81% by TEE (p = 0.18).

CONCLUSIONS

Doppler TTE is the primary means to diagnose AVR obstruction; hemodynamic catheterization is not routinely needed. In unselected patients with mechanical AVR obstruction, TEE differentiation of pannus or thrombus from mismatch is challenging.

Abbreviations and Acronyms   AVR = aortic valve replacement   DVI = dimensionless velocity index   EOA = effective orifice area   MVR = mitral valve replacement   TEE = transesophageal echocardiography   TTE = transthoracic echocardiography

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