Intraoperative TEE assessment during mitral valve repair for degenerative and ischemic mitral valve regurgitation

Intraoperative assessment of the mitral valve (MV) in patients undergoing repair for MV regurgitation is a valuable support for the cardiac surgical team; results can be favored by adequate assessment tailored to the main condition affecting the MV. This article will review current available data for assessment of the MV in degenerative and ischemic mitral regurgitation.     

Intraoperative transesophageal echocardiography for the evaluation of mitral, aortic and tricuspid valve repair A tool to optimize surgical outcome

The present study reviews the clinical applicability and usefulness of intraoperative transesophageal echocardiography (TEE) during valve repair. Intraoperative TEE was performed in 48 consecutive patients, who were divided into three groups: 1. mitral valve repair (MVR), 2. aortic valve repair (AVR), 3. tricuspid valve repair (TVR). Residual valve regurgitation was assessed by color Doppler echocardiography on a scale from 0 to 4. The ratios of the jet area (JA) to the left- and right-atrial areas (JA/LAA and JA/RAA) were analyzed before and after cardiopulmonary bypass (CPB). In group 1, 14 patients were scheduled for MVR, of which 4 patients underwent valve replacement and 10 MVR. Post-repair TEE studies showed a significant decrease of mitral regurgitation. In 2 of the 10 patients, TEE demonstrated severe residual regurgitation requiring valve replacement during the same thoracotomy. In group 2, 11 patients underwent aortic commissurotomy. Post-repair TEE showed an increase in the systolic opening diameter and opening area of the aortic valve. One patient underwent valve substitution because of severe aortic regurgitation. In group 3, 23 patients were scheduled for TVR. In 3 of them TEE showed no significant regurgitation thus rendering tricuspid valve surgery unnecessary. Twenty patients underwent TVR of whom two showed unacceptable post-repair regurgitation requiring further surgery. Eighteen patients showed a significant reduction of valve regurgitation after TVR, and a further reduction was achieved by adjusting the tricuspid annuloplasty under TEE guidance.     

Mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation

BACKGROUND: Mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation is rare. METHODS: From 1990 to 1999, 478 patients had mitral valve repair for myxomatous and 40 patients had mitral valve repair for ischemic mitral regurgitation. The Carpentier annuloplasty ring (Edwards Lifesciences, Irvine, CA) was used in 72 patients, the Duran ring (Medtronic, Minneapolis, MN) in 152, a posterior band in 221 and no ring or band in 73 patients. RESULTS: Four patients developed mitral stenosis late after mitral valve repair: 2 for myxomatous disease and 2 for ischemic mitral regurgitation. All 4 patients had Duran annuloplasty rings (sizes 25 to 31). The diagnosis of mitral stenosis was made by Doppler echocardiography. The mitral valve area in these 4 patients decreased from 2.7 cm2 (range, 2.3 to 3.2 cm2) early postoperatively to 0.85 cm2 (0.4 to 1.2 cm2) after a mean follow-up of 66 months (range, 38 to 110 months). Three patients had mitral valve replacement and the etiology of the mitral stenosis was the same in all patients (ie, pannus overgrowth on the annuloplasty ring with extension onto both leaflets rendering them stiff and immobile). The fourth patient had a mitral valve area of 1.2 cm2, which was mildly symptomatic with normal pulmonary artery pressure, and this patient has not had reoperation. CONCLUSIONS: Mitral stenosis may develop after mitral valve repair for myxomatous disease or ischemic mitral regurgitation when a Duran ring is used for annuloplasty. The stenosis is caused by pannus on the annuloplasty ring with extension onto the leaflets.     

Predictors of residual tricuspid regurgitation after mitral valve surgery

BACKGROUND: Whether preoperative tricuspid regurgitation (TR) will regress or progress late after surgery is unknown. The aim of this study was to evaluate predictors of significant TR late after mitral valve surgery. METHODS: A retrospective analysis was performed on a total of 174 patients who underwent mitral valve surgery without tricuspid valve surgery. Preoperatively, 46 patients (26%) had 2+ TR, and 128 patients (74%) had 1+ or less TR. Postoperative 3+ TR was considered significant TR. Variables were used to evaluate predictors of TR development by univariate or multivariate analysis. RESULTS: The mean follow-up was 8.2 years (range 1.0 to 14.5 years) after surgery. There was progressive TR (3+ or more) in 28 patients (16%) during the follow-up period. In univariate analysis, atrial fibrillation, rheumatic etiology, huge left atrium, left ventricular dysfunction, and preoperative 2+ TR were significant risk factors for TR development. Multivariate analysis identified preoperative 2+ TR, atrial fibrillation, and huge left atrium as statistically significant predictors for late TR after surgery. CONCLUSIONS: Aggressive repair of accompanying TR should be undertaken at the time of initial surgery in patients with huge left atrium or atrial fibrillation, even if preoperative TR is 2+.     

Patient survival characteristics after routine mitral valve repair for ischemic mitral regurgitation

BACKGROUND: Ischemic mitral regurgitation has been associated with diminished survival compared with nonischemic mitral regurgitation. Conversion from mitral valve replacement to valve repair has improved prognosis, but it is unclear whether ischemic mitral regurgitation remains an independent predictor of outcome after mitral valve repair. METHODS: Five hundred thirty-five patients undergoing mitral valve repair (primarily rigid ring annuloplasty) with or without coronary bypass from 1993 through 2002 were reviewed retrospectively (ischemic mitral regurgitation, n = 141; nonischemic mitral regurgitation, n = 394). A Cox proportional hazards model evaluated survival as a function of 9 simultaneous covariates: ischemic versus nonischemic mitral regurgitation, age, sex, number of medical comorbidities, ejection fraction, New York Heart Association class, coronary disease, reoperation, and year of operation. RESULTS: According to univariable analysis, patients with ischemic mitral regurgitation had greater age, higher comorbidity, lower ejection fraction, higher New York Heart Association, and higher reoperation rate (all P < .001) compared with those having nonischemic mitral regurgitation. Univariable 30-day mortality was as follows: 4.3% for patients with ischemic mitral regurgitation versus 1.3% for patients with nonischemic mitral regurgitation (P = .01). Unadjusted 5-year mortality was as follows: 44% +/- 5% for patients with ischemic mitral regurgitation versus 16% +/- 3% for patients with nonischemic mitral regurgitation (P < .001). In the multivariable model, however, only the number of preoperative comorbidities and advanced age were independent predictors of survival (P < .0001), whereas ischemic mitral regurgitation, sex, ejection fraction, New York Heart Association class, coronary disease, reoperation, and year of operation did not achieve significance (all P > .19). After being adjusted for differences in all preoperative risk factors, survival was not statistically different between ischemic mitral regurgitation and nonischemic mitral regurgitation (P = .33). CONCLUSIONS: With routine application of rigid ring annuloplasty, long-term patient survival is more influenced by baseline patient characteristics and comorbidity than by ischemic cause of mitral regurgitation per se. Future risk assessment and decision making should be based on patient condition and should not be biased by ischemic cause of mitral regurgitation.     

Late results of mitral valve repair for mitral regurgitation

OBJECTIVE: This study was undertaken to evaluate the long-term results of mitral valve repair for mitral regurgitation. METHODS: Between 1991 and 2000, 301 patients with mitral regurgitation underwent mitral valve repair. There were 167 men and 134 women whose mean age was 56 +/- 14 years. The patients were comprised of 7 patients in Carpentier's type I, 277 patients in type II, and 17 patients in type III. Chordal replacement with expanded polytetrafluoroethylene sutures had been prospectively applied to repair the anterior mitral leaflet prolapse. Ring annuloplasty was performed in 230 patients (76%). The follow-up was complete and mean follow-up was 67 +/- 33 months, for a cumulative follow-up of 1,624 patient-years. RESULTS: There were 5 hospital deaths and 11 late deaths (2 cardiac and 9 noncardiac). All survivors except those with stroke were in the New York Heart Association (NYHA) functional class I or II. At 10 years, the actuarial survival was 90 +/- 3%, the freedom from embolism was 86 +/- 4%, the freedom from reoperation was 96 +/- 2%, and the freedom from valve-related events was 77 +/- 4%. At 10 years, the freedom from reoperation in the patients with anterior leaflet prolapse was 90 +/- 5%. CONCLUSIONS: Mitral valve repair is feasible in most patients with mitral regurgitation and is associated with low mortality and low rates of valve related events. Chordal replacement with expanded polytetrafluoroethylene sutures is effective, safe, and durable at long-term follow-up for patients with anterior leaflet prolapse.     

Late results of mitral valve repair for mitral regurgitation

Objective: This study was undertaken to evaluate the long-term results of mitral valve repair for mitral regurgitation.Methods: Between 1991 and 2000, 301 patients with mitral regurgitation underwent mitral valve repair. There were 167 men and 134 women whose mean age was 56±14 years. The patients were comprised of 7 patients in Carpentier's type I, 277 patients in type II, and 17 patients in type III. Chordal replacement with expanded polytetrafluoroethylene sutures had been prospectively applied to repair the anterior mitral leaflet prolapse. Ring annuloplasty was performed in 230 patients (76%). The follow-up was complete and mean follow-up was 67±33 months, for a cumulative follow-up of 1,624 patient-years.Results: There were 5 hospital deaths and 11 late deaths (2 cardiac and 9 noncardiac). All survivors except those with stroke were in the New York Heart Association (NYHA) functional class I or II. At 10 years, the actuarial survival was 90±3%, the freedom from embolism was 86±4%, the freedom from reoperation was 96±2%, and the freedom from valve-related events was 77±4%. At 10 years, the freedom from reoperation in the patients with anterior leaflet prolapse was 90±5%.Conclusions: Mitral valve repair is feasible in most patients with mitral regurgitation and is associated with low mortality and low rates of valve related events. Chordal replacement with expanded polytetrafluoroethylene sutures is effective, safe, and durable at long-term follow-up for patients with anterior leaflet prolapse. Read at the Fifty-fifth Annual Meeting of The Japanese Association for Thoracic Surgery, Symposium, Fukuoka, October 9–11, 2002.     

Improved evaluation of the location and mechanism of mitral valve regurgitation with a systematic transesophageal echocardiography examination.

Mitral regurgitation (MR) is a major determinant of outcome in cardiac surgery. The location and mechanism of mitral lesions determine the approach to various repairs and their feasibility. Because of incomplete evaluations or change in patient condition, detailed intraoperative transesophageal echocardiography (TEE) examination of the mitral valve may be required. We hypothesized that a systematic TEE mitral valve examination would allow precise identification of the anatomic location and mechanism of MR in patients undergoing mitral surgery. We designed a systematic mitral valve examination consisting of six views: five-chamber, four-chamber, two-chamber anterior, two-chamber mid, two-chamber posterior and short-axis. We used this examination prospectively in 13 patients undergoing mitral valve surgery for severe MR and compared the results with the surgical findings. We then retrospectively interpreted 11 similar patients who had undergone intraoperative TEE studies before this examination. TEE correctly diagnosed the mechanism and precise location of pathology in 12 of 13 patients in the prospective group, but in only 6 of 10 patients in the retrospective group. TEE also correctly identified 75 of 78 mitral segments (96%) as being normal or abnormal. In the retrospective group, only 42 of 60 segments (70%) were correctly identified (P < 0.001). We conclude that this systematic TEE mitral valve examination improves identification of mitral segments and precise localization of pathologies and may also improve the diagnosis of the mechanism of MR. IMPLICATIONS: In this article, we describe how a systematic examination of the mitral valve by using transesophageal echocardiography allows identification of the different segments of the mitral valve, precise localization of pathology, and helps to diagnose the mechanism of mitral regurgitation. This is important in determining an approach to mitral valve repair and its feasibility.     

Evolution of tricuspid regurgitation after mitral valve repair for functional mitral regurgitation in dilated cardiomyopathy.

OBJECTIVE: To assess the evolution of tricuspid regurgitation (TR) in dilated cardiomyopathy (DCM) patients submitted to mitral repair for functional mitral regurgitation (MR). METHODS: Ninety-one DCM patients (mean age 61+/-11.3) submitted to MV repair (+/-tricuspid repair) for functional MR were included. Preoperative EF was 30.9+/-6.5%, left ventricular (LV) end-diastolic volume 113+/-31.5 ml/m(2), LV end-systolic volume 81.8+/-26.7 ml/m(2), functional MR > or =3+/4+. TR was classified as < or =1+/4+ in 57 patients (62.6%), 2+/4+ in 21 (23%) and > or =3+/4+ in 13 (14.2%). Most of the patients were in NYHA class III or IV. A tricuspid annuloplasty was associated to mitral repair whenever preoperative TR was > or =3+. Therefore 13 patients (14.2%) underwent concomitant tricuspid annuloplasty whereas the remaining 78 (with preoperative TR < or =2+) did not. RESULTS: At follow-up (mean 1.8+/-1.2 years), 12% of the patients (11/91) had still 3-4+ TR due to failure of the tricuspid repair or progression of untreated < or =2+ TR. Freedom from TR > or =3+ was 78+/-8.8% at 3.5 years. Among the 78 patients not submitted to tricuspid repair, 14 (18%) showed a progression of TR severity equal or greater than two grades. The multivariate analysis identified grade of TR at discharge (OR 5.4, p=0.01) and preoperative RV dysfunction (OR 19.6, p=0.02) as the only independent predictors of TR > or =3+/4+ at follow-up. CONCLUSIONS: A significant number of patients submitted to mitral repair for functional MR present > or =3+ TR at follow-up as consequence of progression of untreated TR or failure of tricuspid repair. A more aggressive and effective treatment of functional TR in this setting should be pursued.     

Determinants and assessment of regurgitation after mitral valve repair

OBJECTIVES: The ability to detect residual regurgitation is important in the management of patients after mitral valve repair. We performed a study of 264 patients to determine the risk factors and to compare the accuracy of clinical assessment with that of echocardiography. METHODS: Operative details and valve pathologic data were obtained from individual patient case notes. Clinical assessment consisted of history, examination, and electrocardiography. The presence of regurgitation was ranked in 7 grades, from none to severe. Transthoracic echocardiography was performed blinded to and independently of clinical assessment on the same visit and was graded similarly. Univariate analyses of demographic, etiologic, and operative variables were performed. Significant factors were entered into a multivariate logistic regression model. Sensitivities and specificities were calculated for each diagnostic modality, and the kappa statistic was used to express agreement. RESULTS: Mean (+/- SE) freedoms from regurgitation at 1 and 5 years were 91.5% +/- 1.7% and 47.5% +/- 3.2%. Factors independently associated with postoperative regurgitation were poor ventricular function (P =.04), increased age (P =.01), and chordal procedures (P =.006). When assessing the presence of regurgitation, auscultation conferred a specificity of 78%, a sensitivity of 77%, and a kappa of 0.43 relative to echocardiography. Electrocardiographic criteria for left ventricular hypertrophy were superior, with a complete specificity of 100% but a low sensitivity of 15%. Agreement within 7 grades of severity was moderate, with a weighted kappa value of 0.42. CONCLUSIONS: The hazard function for regurgitation after mitral repair increases steadily after the third year, with ventricular function, age and chordal procedures as independent risks. Clinical assessment and electrocardiography are excellent in identifying regurgitation, but their agreement is less when grading severity.     

Intraoperative assessment of the mitral valve: transesophageal Doppler echocardiography vs. left ventricular filling of the flaccid heart.

Several methods can be used for the intraoperative assessment of residual mitral regurgitation (MR) following reconstruction of the mitral valve. The aim of this study was to compare the reliability of two of these methods: left ventricular filling of the arrested heart with saline (LVF) and intraoperative transesophageal Doppler echocardiography (TEE). Reliability was assessed by comparing LVF and TEE to postoperative left ventricular angiography (LVA) in 27 patients. LVF, TEE and LVA grading of MR was 0-4. Correlations, as measured by the Kappa statistic, were as follows: LVF-LVA: K = 0.33 (95% confidence interval (CI): 0.06-0.59), TEE-LVA: K = 0.48 (95% CI: 0.20-0.77), LVF-TEE: K = 0.43 (95% CI: 0.20-0.67). Considering LVF and TEE as predictors of LVA gradings above 2, sensitivities were 0.4 and 0.6, respectively. Specificities were 1.0 for each method. In conclusion, we found TEE in the beating heart not to be significantly more reliable in the prediction of residual MR than LVF in the flaccid heart.     

Long-term results of mitral valve repair for non-rheumatic mitral regurgitation

The durability of mitral valve repaired with reconstructive techniques is variable. If the durability continues to be good, mitral valve repair may be the procedure of choice in many patients with mitral regurgitation. Between December 1970 and June 1993, 54 patients had mitral valve repair for non-rheumatic mitral regurgitation. There were 38 men and 16 women with a mean age of 46.8 (range 19–68) years. The pathology which required surgical treatment was torn chordae in 38 patients, elongation of the chordae in five, valve prolapse without elongation or rupture of the chordae in six, infective endocarditis in three, and annular dilatation in two. Forty-four patients had triangular or quadrangular resection of the mitral leaflet, and seven had annuloplasty alone. Choral reconstruction was performed on three patients. There were no operative deaths. Five patients (9%) died late after operation. The actuarial survival rate and the valve-related death-free rate at 10 years were 83.9% and 90.0%, respectively. Seven patients (13%) required reoperation. Freedom from reoperation at 10 years was 84.5%. Improper evaluation of residual regurgitation during operation and suture dehiscence were the principal causes of reoperation. It was concluded that mitral valve repair for non-rheumatic mitral regurgitation showed low operative mortality and stable long-term results. It is suggested that intraoperative transoesophageal colour Doppler echocardiography provides accurate assessment of mitral valve competence and may be helpful in reducing the need for reoperation.     

The impact of intraoperative residual mild regurgitation after repair of degenerative mitral regurgitation

ObjectivesDuring degenerative mitral repair, surgeons must decide if further repair is warranted for residual mild mitral regurgitation. We examined the incidence of mild mitral regurgitation, late echocardiographic and clinical outcomes, and influence of surgical experience in decision making.MethodsFrom April 2004 to June 2018, 1155 of 1195 patients with pure degenerative disease underwent repair (97% repair rate). Propensity score matching was performed between patients with trace/no mitral regurgitation and patients with mild residual mitral regurgitation. Late echocardiographic outcome and freedom from reoperation were compared using competing-risks models. A comparison of outcomes of the referent surgeon (89.8% of repairs) with all other surgeons was performed.ResultsMild mitral regurgitation was present in 73 patients (6%). Propensity score–matched analyses compared 69 patients with mild mitral regurgitation with 198 patients without mitral regurgitation. Late moderate or greater mitral regurgitation was higher in those with mild mitral regurgitation than in those with no mitral regurgitation (17% vs 7%, P = .033), as was late moderate-severe or greater mitral regurgitation (6% vs 1%, P = .016). Ten-year freedom from reoperation was low in both groups (99.5% no vs 96.9% mild; P = .10). The referent surgeon had fewer patients with mild residual mitral regurgitation (6% vs 11%, P = .027) and less progression of mitral regurgitation compared with other surgeons (late moderate or greater mitral regurgitation 6% vs 15%, P = .002).ConclusionsResidual mild mitral regurgitation was uncommon, and late progression to moderate or greater mitral regurgitation was rare and never led to late mitral reoperation. Experienced surgeons may be better able to determine repairs likely to remain stable, and most mild residual mitral regurgitation does not require re-repair.