**5. Assessment following implantation**

After the aortotomy is closed, several pitfalls need to be checked (Fig. 11,12). If an unexpected event is detected, a prompt decision for additional intervention should be made.

#### **5.1. Perivalvular or transvalvular leakage**

During weaning from bypass, the surgeon should check for perivalvular leakage. A calcified aortic valve can result in inadequate contact between the annulus and the suture ring of the prosthetic valve. It is readily examined by TEE in the midesophageal long-axis view (Fig. 11A). A minor leak that originates inside of the ring and deviates inwards is transvalvular leak and is not significant (Fig. 11B). When significant leakage is detected in the left ventricular outflow tract that originates outside of the suture ring, perivalvular leakage is probable (Fig. 11C). The assessment of leakage is difficult in cases with concomitant mitral valve replacement. The ring of the prosthetic valve implanted in the mitral position casts an acoustic shadow on the left ventricular outflow tract (Fig. 11D). In such an instance, leakage is assessed in the deep transgastric long-axis view via the left ventricular apex (Fig. 11E).

coronary perfusion cannula and there is considerable leakage, perfusion of the myocardium is a concern. A myocardial thermometer was conventionally used, but may not be useful in warm heart surgery. Real-time assessment of myocardial perfusion is desired, especially in cases with deteriorated cardiac function. Here, a novel method for noninvasively assessing myocardial perfusion is demonstrated (Fig. 10). The transgastric basal or midventricular shortaxis view is visualized. In pulsed-wave Doppler mode, the sample volume is placed on the myocardium. When this portion of myocardium is perfused, a flow signal is detected. Under selective perfusion of the left coronary artery, blood flow is detected in the anterior wall but not in the inferior wall. As coronary perfusion is discontinued, the flow signal instantaneously disappears. The perfused region is identified by mapping the myocardium. This can be helpful

**Figure 10.** TEE assessment of myocardial blood flow during cardioplegia. Under selective perfusion to LCA, blood flow is detectable in the anterior wall (A) but not in the inferior wall (B). As selective RCA perfusion is terminated, blood

After the aortotomy is closed, several pitfalls need to be checked (Fig. 11,12). If an unexpected

During weaning from bypass, the surgeon should check for perivalvular leakage. A calcified aortic valve can result in inadequate contact between the annulus and the suture ring of the

event is detected, a prompt decision for additional intervention should be made.

flow detected in the inferior wall (c) instantaneously disappears (D)

**5. Assessment following implantation**

**5.1. Perivalvular or transvalvular leakage**

for examining the extent of retrograde delivery of cardioplegic solution.

510 Calcific Aortic Valve Disease

**Figure 11.** TEE assessment of prostethic valve following aortic valve replacement. A: Midesophageal long-axis view without abnormal leak from the prosthetic valve. B: Minor transvalvular leak. C: Significant perivalvular leak around the valve. D: Leakage is suspected but visualization is disturbed by the valve in mitral position. E: Deep transgastric view shows mild transvalvular leak F: Blood flow in the entire area of ascending aorta just distal to the prosthetic valve indicates good opening of discs. G,H: Massive transvalvular leak from the bioprosthesis due to everted leaflet.

Valve dysfunction should be checked during weaning from bypass. Dysfunction of a mechan‐ ical valve includes an immobilized disc at the open or closed positions. Since the disc itself is hardly depicted by TEE, dysfunction is examined in the color Doppler mode. In the short-axis view of the ascending aorta at the level just above the valve, opening of both discs can be confirmed by the flow signal, which fills the entire area of the aorta (Fig. 11F). Incompetence of the valve is caused by an immobilized disc of a mechanical valve at the open position probably due to debris or calcium between the disc and ring or by jammed leaflets of a bioprosthetic valve. It can be recognized by massive aortic regurgitation, demonstrated by a regurgitant jet in the left ventricular outflow tract originating from inside of the ring in midesophageal or deep transgastric view (Fig. 11G,H). In this case, exploration revealed that there was unintended eversion of a leaflet on the noncoronary side without jamming or leaflet damage. The leaflet was returned to the normal position and the aortotomy was closed [22].

#### **5.2. Coronary ostium and ventricular contraction**

Obstruction of coronary ostium is checked during weaning from bypass to minimize myocar‐ dial damage under warm ischemia. This event is important especially for the valve implanted in the supra-annular position. In the early timing following aortic declamping, patency and blood flow in both coronary arteries is checked. Both ostia can be visualized in the short-axis view just above the valve (Fig. 12A). In the midesophageal aortic valve long-axis view, the right coronary ostium is seen above the sewing ring (Fig. 12B). The presence of flow and distance from the ring of the prosthetic valve is checked.

Blood flow in the left coronary artery is examined proximal to its bifurcation into the LAD and LCX as shown in Fig. 8. Fig. 12D shows TEE views in a case of a low origin of the LMT. Before cardiopulmonary bypass, the midesophageal long-axis view showed a short distance between the aortic annulus and left main truncus. Following valve replacement at the intra-annular position, knots were found to be in front of the left coronary ostium and accelerated flow was seen. In the midesophageal long-axis view, the left coronary ostium was just above the ring. Surprisingly, the left main truncus was just behind the annulus. A deep suture could have injured the left main truncus. Fig. 12E and F demonstrate a case with a normal origin of the main left coronary artery. Before cardiopulmonary bypass, the coronary orifice was approxi‐ mately 1 cm above the aortic annulus (Fig. 12E1,2). The 3D en face view clearly demonstrated an adequate distance (Fig. 12 E3). After replacement, TEE showed that there was no obstacle in front of the left main truncus in the short-axis view (Fig. 12F1). In the long-axis view, there was adequate distance between the ring and left main truncus (Fig. 12F2). 3D TEE also clearly showed safe implant of the prosthetic valve (Fig. 12F3). As ventricular contraction recovers, regional wall motion abnormalities can be assessed in the midesophageal, 2-chamber and 4 chamber views, or the transgastric basal or mid-short-axis views.

**Figure 12.** TEE assessment of coronary arteries in aortic valve replacement. A; Short-axis view at the level of the sinus of Val‐ salva that shows patent ostia of the RCA and LMT. B: RCA flow in midesophageal AV long-axis view. Distance from the ring to RCA ostium is checked. C: LMT flow in short-axis view of sinus of Valsalva. Knots are seen without obstruction. D: Low take-off of LMT (D1). Following valve replacement, the knots are in front of LMT ostium. A mild acceleration of blood flow is seen (D2). In midesophageal long-axis view, the LMT orifice is just above the ring (D3). LMT was found to course very close to the suture (D4). E: Normal take-off of LMT. LMT originates from the LCS at approximately 1 cm above the aortic annulus (E1 to E2). 3D en face view clearly demonstrates the distance of LMT from the annulus (E3). F: TEE views following valve re‐ placement. There is no obstruction in front of the LMT (F1). There is adequate distance from the ring to the LMT orifice, de‐

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Mitral regurgitation may appear following aortic valve replacement. One reason is perforation of the mitral annulus caused by excessive decalcification of the aortic annulus. Another

picted in midesophageal long-axis view (F2) and 3D en face view (F3)

**5.3. New mitral regurgitation**

If coronary obstruction is suspected as in Fig. 9, early coronary revascularization is to be considered for minimizing myocardial damage. Ischemia can develop not only by obstruction of coronary ostium but by poor myocardial protection or embolism of dislodged calcium or even intracardiac air. Sustained circulatory support may be advantageous or retrograde cardioplegia may potentially help to displace any calcium or air embolus toward the coronary ostium.

**Figure 12.** TEE assessment of coronary arteries in aortic valve replacement. A; Short-axis view at the level of the sinus of Val‐ salva that shows patent ostia of the RCA and LMT. B: RCA flow in midesophageal AV long-axis view. Distance from the ring to RCA ostium is checked. C: LMT flow in short-axis view of sinus of Valsalva. Knots are seen without obstruction. D: Low take-off of LMT (D1). Following valve replacement, the knots are in front of LMT ostium. A mild acceleration of blood flow is seen (D2). In midesophageal long-axis view, the LMT orifice is just above the ring (D3). LMT was found to course very close to the suture (D4). E: Normal take-off of LMT. LMT originates from the LCS at approximately 1 cm above the aortic annulus (E1 to E2). 3D en face view clearly demonstrates the distance of LMT from the annulus (E3). F: TEE views following valve re‐ placement. There is no obstruction in front of the LMT (F1). There is adequate distance from the ring to the LMT orifice, de‐ picted in midesophageal long-axis view (F2) and 3D en face view (F3)

#### **5.3. New mitral regurgitation**

Valve dysfunction should be checked during weaning from bypass. Dysfunction of a mechan‐ ical valve includes an immobilized disc at the open or closed positions. Since the disc itself is hardly depicted by TEE, dysfunction is examined in the color Doppler mode. In the short-axis view of the ascending aorta at the level just above the valve, opening of both discs can be confirmed by the flow signal, which fills the entire area of the aorta (Fig. 11F). Incompetence of the valve is caused by an immobilized disc of a mechanical valve at the open position probably due to debris or calcium between the disc and ring or by jammed leaflets of a bioprosthetic valve. It can be recognized by massive aortic regurgitation, demonstrated by a regurgitant jet in the left ventricular outflow tract originating from inside of the ring in midesophageal or deep transgastric view (Fig. 11G,H). In this case, exploration revealed that there was unintended eversion of a leaflet on the noncoronary side without jamming or leaflet damage. The leaflet was returned to the normal position and the aortotomy was closed [22].

Obstruction of coronary ostium is checked during weaning from bypass to minimize myocar‐ dial damage under warm ischemia. This event is important especially for the valve implanted in the supra-annular position. In the early timing following aortic declamping, patency and blood flow in both coronary arteries is checked. Both ostia can be visualized in the short-axis view just above the valve (Fig. 12A). In the midesophageal aortic valve long-axis view, the right coronary ostium is seen above the sewing ring (Fig. 12B). The presence of flow and

Blood flow in the left coronary artery is examined proximal to its bifurcation into the LAD and LCX as shown in Fig. 8. Fig. 12D shows TEE views in a case of a low origin of the LMT. Before cardiopulmonary bypass, the midesophageal long-axis view showed a short distance between the aortic annulus and left main truncus. Following valve replacement at the intra-annular position, knots were found to be in front of the left coronary ostium and accelerated flow was seen. In the midesophageal long-axis view, the left coronary ostium was just above the ring. Surprisingly, the left main truncus was just behind the annulus. A deep suture could have injured the left main truncus. Fig. 12E and F demonstrate a case with a normal origin of the main left coronary artery. Before cardiopulmonary bypass, the coronary orifice was approxi‐ mately 1 cm above the aortic annulus (Fig. 12E1,2). The 3D en face view clearly demonstrated an adequate distance (Fig. 12 E3). After replacement, TEE showed that there was no obstacle in front of the left main truncus in the short-axis view (Fig. 12F1). In the long-axis view, there was adequate distance between the ring and left main truncus (Fig. 12F2). 3D TEE also clearly showed safe implant of the prosthetic valve (Fig. 12F3). As ventricular contraction recovers, regional wall motion abnormalities can be assessed in the midesophageal, 2-chamber and 4-

If coronary obstruction is suspected as in Fig. 9, early coronary revascularization is to be considered for minimizing myocardial damage. Ischemia can develop not only by obstruction of coronary ostium but by poor myocardial protection or embolism of dislodged calcium or even intracardiac air. Sustained circulatory support may be advantageous or retrograde cardioplegia may potentially help to displace any calcium or air embolus toward the coronary

**5.2. Coronary ostium and ventricular contraction**

512 Calcific Aortic Valve Disease

distance from the ring of the prosthetic valve is checked.

chamber views, or the transgastric basal or mid-short-axis views.

ostium.

Mitral regurgitation may appear following aortic valve replacement. One reason is perforation of the mitral annulus caused by excessive decalcification of the aortic annulus. Another mechanism is systolic anterior motion of the mitral leaflet, which is caused by reduced left ventricular dimensions and/or a sigmoid septum due to left ventricular hypertrophy. When several measures are not effective, emergent mitral valve replacement should be considered.

R-PA right pulmonary artery

RV right ventricle

**Author details**

Kazumasa Orihashi

**References**

(2010). , 20, 625-8.

ac Surg (2005). , 79, 589-95.

662-70.

33, 54-6.

Department of Cardiovascular Surgery, Kochi Medical School, Kochi, Japan

placement in dialysis patients. Ann Thorac Surg (2010). , 89, 65-70.

valve: is there a correlation? J Thromb Thrombolysis (2012). , 34, 425-7.

valve: case report and literature review. J Cardiol (2009). , 54, 158-61.

calcified stenosis. J Heart Valve Dis (2006). , 15, 165-8.

[1] Tanaka, K, Tajima, K, Takami, Y, et al. Early and late outcomes of aortic valve re‐

Aortic Valve Replacement for Calcified Aortic Valves

http://dx.doi.org/10.5772/53418

515

[2] Kaden, J. J, Eckert, J. P, Poerner, T, et al. Prevalence of atherosclerosis of the coronary and extracranial cerebral arteries in patients undergoing aortic valve replacement for

[3] Staico, R, Armaganijan, L, & Lopes, R. D. Coronary embolism and calcified aortic

[4] Mannino, G, Romano, M, Calanchini, M, Mannino, C, & Cascone, N. C. Branch reti‐ nal artery embolization due to calcific aortic valve stenosis. Eur J Ophthalmol

[5] Mahajan, N, Khetarpal, V, & Afonso, L. Stroke secondary to calcific bicuspid aortic

[6] Rivard, A. L, Bartel, T, Bianco, R. W, et al. Evaluation of aortic root and valve calcifi‐ cations by multi-detector computed tomography. J Heart Valve Dis (2009). , 18,

[7] Aviram, G, Sharony, R, Kramer, A, et al. Modification of surgical planning based on cardiac multidetector computed tomography in reoperative heart surgery. Ann Thor‐

[8] Islamoglu, F, Apaydin, A. Z, Degirmenciler, K, et al. Detachment of the mitral valve anterior leaflet as a complication of aortic valve replacement. Tex Heart Inst J (2006). ,

STJ sinotubular junction

SVC superior vena cava

#### **5.4. Aortic dissection**

Following aortic declamping, the aorta distal to the clamp site should be checked for new dissection. It may potentially develop due to detachment of the calcified aortic wall, and inner or outer layer. Dissection can also originate from the arterial cannulation site, root cannula site or aortotomy site.

In conclusion, it is essential to watch for pitfalls in aortic valve replacement for calcified aortic valve, because it is commonly associated with various pathologies that can affect the surgical outcomes. Meticulous monitoring and intraoperative diagnostic imaging are helpful for achieving the best possible results in cases with increased risk factors.
