Falsely Raised Gradients After Transcatheter Aortic Valve Replacement Obtained with a Nonimaging Probe Due to Brachiocephalic Stenosis

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Severe aortic stenosis post-transcatheter aortic valve replacement (TAVR) with brachiocephalic and right subclavian artery stenosis (n=1). Intervention: Nonimaging continuous-wave Doppler (NI-CWD) probe from the right supraclavicular fossa vs. Transesophageal echocardiography (TEE) and apical transthoracic Doppler. Primary outcome: Aortic valve peak and mean pressure gradients.

Q: What does this research mean for the field?

Nonimaging continuous-wave Doppler interrogation from the right supraclavicular window can yield falsely elevated transvalvular aortic gradients after TAVR due to confounding brachiocephalic artery stenosis. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

K. Lander; S. Weerasooriya

doi:10.1016/j.case.2020.01.006

February 18, 2020CASEOpen Access

Falsely Raised Gradients After Transcatheter Aortic Valve Replacement Obtained with a Nonimaging Probe Due to Brachiocephalic Stenosis

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Key result

Supraclavicular nonimaging Doppler can falsely elevate aortic gradients due to brachiocephalic stenosis.

n=1

Figures

Graphical abstract published by CASE — Graphical abstract · Published by CASE · CC BY-NC-ND

Key Points

To describe a case where nonimaging continuous-wave Doppler falsely indicated prosthetic aortic valve dysfunction due to an unrecognized brachiocephalic artery stenosis.
Clinical and multi-modality diagnostic evaluation of an 83-year-old man presenting for routine follow-up 3 months after successful TAVR.
Evaluation performed using transthoracic echocardiography with an NI-CWD probe, transesophageal echocardiography, vascular ultrasound, and retrospective review of pre-TAVR chest CT scans.
NI-CWD interrogation from the right supraclavicular fossa yielded peak and mean pressure gradients of 91 and 56 mm Hg, whereas apical CWD showed peak and mean gradients of 15 and 10 mm Hg.
Transesophageal echocardiography confirmed normal aortic valve hemodynamics with maximal velocity of 1.9 m/sec and peak and mean gradients of 15 and 9 mm Hg from the transgastric window.
Chest CT review revealed severe calcification and tight stenosis at the origin of the brachiocephalic artery, which was aligned with the right supraclavicular acoustic window and produced the spurious gradients.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

1 male patient (age 83) evaluated 3 months after transcatheter aortic valve replacement (TAVR) for severe aortic stenosis.

E

Exposure

Transthoracic echocardiography utilizing a specialized nonimaging continuous-wave Doppler (NI-CWD) probe from the right supraclavicular window at 3 months post-TAVR

C

Comparator

Transesophageal echocardiography (transgastric window), apical transthoracic continuous-wave Doppler, pre-TAVR chest CT imaging, and vascular ultrasound

O

Outcome

Measured transvalvular peak and mean pressure gradients and flow velocities across the bioprosthetic aortic valvesurrogate

Clinicians using a nonimaging continuous-wave Doppler probe from the right supraclavicular window after TAVR should be aware that peripheral vascular stenoses in the brachiocephalic or subclavian arteries can produce falsely elevated pressure gradients mimicking prosthetic valve dysfunction or thrombosis.

Limitations

Technical limitations on accessing the origin of the great vessels via ultrasound prevented demonstrating flow velocities at the exact site of the brachiocephalic origin stenosis.
Technical limitations on accessing the origin of the great vessels via vascular ultrasound prevented demonstration of flow velocities at the exact site of the brachiocephalic origin stenosis seen on CT.

Implication

Unexpectedly high post-TAVR gradients from right supraclavicular NI-CWD may reflect brachiocephalic stenosis rather than valve dysfunction; leaves open the frequency of this artifact.

Abstract

•Elevated gradients after TAVR were seen using a nonimaging CWD probe.•Normal valve function was seen on transesophageal echocardiography.•A retrospective review of CT imaging showed stenosis of the brachiocephalic artery.•Capturing an elevated gradient from another lesion is a pitfall of nonimaging probes.

Discussion

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Cite This Study

Lander et al. (2020) conducted a case report in Severe aortic stenosis post-transcatheter aortic valve replacement (TAVR) with brachiocephalic and right subclavian artery stenosis (n=1). Nonimaging continuous-wave Doppler (NI-CWD) probe from the right supraclavicular fossa vs. Transesophageal echocardiography (TEE) and apical transthoracic Doppler was evaluated on Aortic valve peak and mean pressure gradients. Nonimaging continuous-wave Doppler from the right supraclavicular window recorded falsely elevated peak/mean gradients (91/58 mm Hg vs 15/9 mm Hg on TEE) due to brachiocephalic stenosis.

synapsesocial.com/papers/6a7324dc0c0db29dfc2c1860 https://doi.org/10.1016/j.case.2020.01.006

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Falsely Raised Gradients After Transcatheter Aortic Valve Replacement Obtained with a Nonimaging Probe Due to Brachiocephalic Stenosis

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Falsely Raised Gradients After Transcatheter Aortic Valve Replacement Obtained with a Nonimaging Probe Due to Brachiocephalic Stenosis

Figures

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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