Identifying patients with degenerative mitral regurgitation for mitral valve repair and replacement: a transesophageal echocardiographic study.

OBJECTIVE: We sought to preoperatively identify the suitability of patients with degenerative mitral valve (MV) regurgitation for MV repair (MVR) and MV replacement. BACKGROUND: MVR is the preferred method of treatment over MV replacement, if surgically feasible. MVR preserves left ventricular function and decreases risk of hemolysis, thromboembolism, and-in the absence of anticoagulation-hemorrhage. However, the ability to identify patients suitable for MVR preoperatively is somewhat limited. METHODS: In all, 76 patients underwent MV operation for severe symptomatic mitral regurgitation. The decision to operate was at the discretion of the referring physician in consultation with respective cardiothoracic surgeons at two separate, nonrelated institutions. All patients underwent preoperative and/or intraoperative transesophageal echocardiographic studies. RESULTS: In all, 35 patients (46%) underwent MVR and 41 (54%) underwent MV replacement. There was no difference in the percentage of MVRs between the two institutions: 17 cases (41%) at Hahnemann University Hospital, Philadelphia, Pa, versus 18 cases (53%) at Northwestern University Memorial Hospital, Chicago, Ill (P = not significant). Age was found to be a significant univariate predictor with older age favoring MV replacement. On average, patients who underwent MVR were 11 years younger then those who underwent MV replacement. Heart failure was also found to be a significant univariate predictor: as New York Heart Association functional class worsened, MV replacement was more likely. Echocardiographic variables favoring MVR included chordal length (>29 mm, P <.001), length of posterior mitral leaflet (>17 mm, P <.008), and length of anterior leaflet (>25 mm, P <.01). The only echocardiographic parameter favoring replacement was the presence of anterior mitral annular calcification. Using multivariate analysis, older age (>63 years) was again a significant predictor favoring MV replacement (P <.002; odds ratio [OR] 20). Longer chordal length (>29 mm) was the strongest predictor favoring MVR (P <.001; OR 11.2). Longer length of the posterior leaflet (>17 mm; OR 5.07) and mitral annulus size > 35 mm (OR 7.75) were also significant multivariate predictors favoring MVR. The presence of anterior mitral annular calcification favored MV replacement using multivariate analysis (OR 25). CONCLUSIONS: Patients suitable for MVR can be identified preoperatively using a combination of clinical and echocardiographic parameters.     

Aortic regurgitation: ventricular response after aortic valve replacement

This study was designed to evaluate the usefulness of the ratio of the preoperative regurgitant stroke volume to left ventricular end-diastolic volume (RSV/LVEDV) for assessing the left ventricular function preoperatively. In 26 patients with aortic regurgitation (AR), the percent decrease in LVEDV was compared with the preoperative RSV/LVEDV, ejection fraction (EF), LVEDV, left ventricular end-systolic volume (LVESV) or left ventricular end-diastolic pressure (LVEDP). There was a significant correlation between the percent decrease in LVEDV and RSV/LVEDV. Patients with RSV/LVEDV of more than 0.26 had a significantly smaller postoperative left ventricular end-diastolic volume index (LVEDVI) and left ventricular end-systolic volume index (LVESVI), and a greater postoperative EF than patients with smaller RSV/LVEDV. All but one patient with RSI/LVEDVI larger than 0.0016 LVEDVI had normal postoperative LVEDVI. Based on these findings, it is concluded that the RSV/LVEDV is an useful indicator for preoperative evaluation of left ventricular functions in patients with AR. Surgical intervention for patients with AR should be recommended before the RSI/LVEDVI drops to less than 0.0016 LVEDVI, to expect good postoperative ventricular responses.     

Evaluation of mitral regurgitation by an integrated 2D echocardiographic approach in patients undergoing transcatheter aortic valve replacement

The purpose of this study was to evaluate mitral regurgitation (MR) severity in patients undergoing transcatheter aortic valve replacement (TAVR) by standardized assessment of two-dimensional (2D) transthoracic echocardiography (TTE) and 1-year echocardiographic and clinical outcomes. Pre- and post-procedural TTE’s of patients undergoing TAVR between 2008 and 2014 were analyzed. MR was graded according to current guidelines with a systematic and integrated approach. Longitudinal echocardiographic and clinical results were analyzed. Regression analysis was performed for change in MR grade at follow-up, using pre-determined variables and confounders. Pre- and post-procedural TTE were available in 213 subjects. Significant MR was seen in 22% at baseline and 15% at follow-up; MR grade?≥?3 in <?10%. Severity did not change in 61%, and decreased in 20% of the patients. Overall, the prevalence of MR grades pre- and post TAVR was not significantly different, nor influenced by MR etiology or TAVR prosthesis type. However, higher MR grades and pacemaker absence at baseline, were independently correlated to more improvement of MR after TAVR. Regarding clinical outcomes, NYHA class improved in two-thirds of the patients, irrespective of the baseline MR grade. Overall survival was not significantly different amongst MR grades post-TAVR. MR grading using an systematic 2D echocardiographic approach in patients undergoing TAVR is feasible in clinical practice. Our data revealed a relatively frequent prevalence of significant MR (although grade?≥?3 was scarce), overall no change in the MR grade at 1 year follow-up, improvement of functional NYHA class, and no significant differences in long-term survival amongst the post-TAVR MR grades.     

Atypical pseudoaneurysm after mitral valve replacement: Doppler echocardiographic diagnosis.

Ventricular pseudoaneurysm is a rare complication of mitral valve replacement or myocardial infarction. Typically, a ventricular pseudoaneurysm appears as an echocardiographic lucency posterior and lateral to the left ventricle and is best seen from the parasternal long axis and apical four-chamber views. We present an atypical case of left ventricular pseudoaneurysm that tracts posterior and lateral to the right ventricle that was best visualized from the subcostal and low parasternal windows with medial angulation. Doppler imaging confirmed the diagnosis by demonstrating to-and-fro flow between the left ventricle and the cavity located behind the right ventricle. This case emphasizes the importance of the use of multiple echocardiographic windows.     

Severe tricuspid regurgitation after mitral valve repair: diagnosis by intraoperative transesophageal echocardiography

Transesophageal echocardiography facilitates the evaluation of valvular repair in the operating room. The functional valvular morphology and degree of valvular regurgitation can be assessed before and after repair. This technique can also identify unsuspected findings--in this case, severe tricuspid regurgitation complicating cardiopulmonary bypass. We report a previously undescribed cause of traumatic tricuspid regurgitation.     

Quantitative assessment of paravalvular regurgitation following transcatheter aortic valve replacement

Background

Paravalvular aortic regurgitation (PAR) following transcatheter aortic valve implantation (TAVI) is well acknowledged. Despite improvements, echocardiographic measurement of PAR largely remains qualitative. Cardiovascular magnetic resonance (CMR) directly quantifies AR with accuracy and reproducibility. We compared CMR and transthoracic echocardiography (TTE) analysis of pre-operative and post-operative aortic regurgitation in patients undergoing both TAVI and surgical aortic valve replacement (AVR).

Methods

Eighty-seven patients with severe aortic stenosis undergoing TAVI (56 patients) or AVR were recruited. CMR (1.5 T) and transthoracic echocardiography (TTE) were carried out pre-operatively and a median of 6 days post-operatively. The CMR protocol included regurgitant aortic flows using through-plane phase-contrast velocity. None/trivial, mild, moderate and severe AR by CMR was defined as ≤8%, 9-20%, 21–39%, >40% regurgitant fractions respectively.

Results

Pre- and post-operative left ventricular ejection fraction (LVEF) was similar. Post-procedure aortic regurgitant fraction using CMR was higher in the TAVI group (TAVI 16 ± 13% vs. AVR 4 ± 4%, p < 0.01). Comparing CMR to TTE, 27 of 56 (48%) TAVI patients had PAR which was at least one grade more severe on CMR than TTE (Z = −4.56, p <0.001). Sensitivity analysis confirmed the difference in PAR grade between TTE and CMR in the TAVI group (Z = −4.49, p < 0.001).

Conclusion

When compared to CMR based quantitative analysis, TTE underestimated the degree of paravalvular aortic regurgitation. This underestimation may in part explain the findings of increased mortality associated with mild or greater AR by TTE in the PARTNER trial. Paravalvular aortic regurgitation post TAVI assessed as mild by TTE may in fact be more severe.     

风湿性心脏病二尖瓣置换术后三尖瓣返流的再手术治疗

目的分析风湿性心脏病二尖瓣置换术后再发三尖瓣返流（TR）患者的临床特点、外科手术方法和疗效,总结围手术期处理经验。方法2000年1月至2011年12月,17例风湿性心脏病二尖瓣置换术后再发三尖瓣返流的患者在我院接受单纯再次三尖瓣手术,行三尖瓣成形术10例,包括单纯DeVega成形术1例、瓣叶成形＋人工瓣环成形9例;行三尖瓣置换术7例,其中置换生物瓣4例,双叶机械瓣3例,回顾性分析其临床表现、诊治经过和预后情况。结果术后早期死亡1例（5．88％,1／17）,死于术后左心功能衰竭。术后发生低心排血量综合征3例,肾功能不全2例,呼吸功能不全2例,均成功救治。随访14例,随访时间3～9年,心功能I级2例,Ⅱ级8例,Ⅲ级4例。失访2例。结论对风湿性心脏病二尖瓣置换术后三尖瓣返流患者再手术治疗效果较好,合理掌握手术指征、手术时机和良好的围手术期处理是提高手术成功率的关键。     

二尖瓣机械瓣置换术后远期瓣环力学功能的临床研究

目的：探讨二尖瓣置换术（MVR）后瓣环力学功能的远期变化特点以及对左室重构的作用机制。方法：77例接受二尖瓣机械瓣置换术后1年以上的患者（MVR组），根据心律分为心房颤动组（房颤组）和窦性心律组（窦律组），并选取30例正常人作为对照组。应用二维和M型超声心动图对二尖瓣瓣环的运动幅度、房室腔大小以及心功能进行测量。结果：①与对照组相比，MVR组二尖瓣瓣环M型运动曲线出现异常；②MVR组二尖瓣瓣环运动幅度较对照组明显减低（P〈0.01），窦律组与房颤组之间差异无统计学意义（P〉0.05）；MVR组T波结束距瓣环峰位移时间和R波顶点距瓣环最低点时间与对照组比较有延迟（P〈0．01或P〈0．05）；③MVR组左房收缩末径较对照组扩大（P〈0．01），以房颤组更为明显；房颤组左室内径较对照组扩大（P〈0．01或P〈0.05），而射血分数（EF）和短轴缩短率（FS）则降低（P〈0．05）；窦律组左室内径、EF和FS与对照组差异无统计学意义（P〉0．05）。④二尖瓣瓣环的运动幅度与EF和FS呈正相关。结论：二尖瓣置换术后力学功能异常的瓣环在左室重构过程中起到重要的作用。     

Quantification of mitral regurgitation during percutaneous mitral valve repair: added value of simultaneous hemodynamic and 3D echocardiographic assessment

The objective of this study was to investigate the usefulness of intraprocedural hemodynamic monitoring for MR evaluation during pMRV. Assessment of mitral regurgitation (MR) during percutaneous mitral valve repair (pMVR) procedure is challenging. 3D color Doppler allows exact quantification of MR, but is technically demanding. Sixty patients with moderate to severe MR (14 with structural and 46 functional MR) were included in the study. Intraprocedural pressure curves were continuously obtained in the left atrium (LA) and left ventricle (LV). Transesophageal echocardiography was performed using 3D color Doppler derived mean vena contracta area (VCA_mean) and mitral regurgitation volume (RegVol) to quantify MR severity before and after each clip implantation. In the entire patient group, strongest correlations were observed firstly between VCA and the raise of the ascending limb of the left atrial V pressure wave (V_ascend; r?=?0.58, p?<?0.001) and secondly between the difference of peak V wave pressure and mean LA pressure divided by systolic LV pressure [(V_peak???LA_mean)???LV_systole; r?=?0.53, p?<?0.001]. In patients with structural MR, the highest area under the ROC curve for prediction of mild MR (VCA_mean < 0.2 cm² and RegVol?<?30 ml) after clip implantation was found for V_ascend (AUC 0.89, p?<?0.001) whereas in functional MR calculation of (V_peak???LA_mean)???LV_systole showed the highest predictive value (AUC 0.69, p?=?0.003). Invasive pressure monitoring can give a direct feedback with regard to the success of clip placement during pMVR.     

Intraoperative echocardiographic studies of the mitral valve: Assessment of commissurotomy and repair

Mitral echocardiograms obtained by direct application of the ultrasonic probe to the epicardial surface were compared with echocardiograms obtained by the conventional chest surface technique in 32 patients. The groups comprised 16 patients with stenosis, nine with incompetence, and seven patients with normal mitral valves. In every patient, prior to the exploration of the mitral valve, echocardiograms were obtained from the surface of the chest and from the epicardial surface of the heart. In 13 patients, direct epicardial and chest surface echocardiograms were repeated after mitral valvotomy or repair. The initial mitral valve lesion in these patients was stenosis in seven and incompetence in six. The diastolic closure rates (E-F speed) obtained by direct epicardial surface echocardiography revealed a significant statistical correlation (P < 0.001) which was comparable to that recorded from the chest surface. This technique offers a further means of detecting residual mitral stenosis, before closure of the chest, after conimissurotomy or repair.     

实时三维经食管超声心动图在二尖瓣置换术后人工瓣膜功能异常诊断中的应用价值

目的探讨实时三维经食管超声心动图(RT-3D-TEE)在二尖瓣置换术后人工瓣膜功能异常诊断中的应用价值。方法回顾性分析92例经胸超声心动图(TTE)初步诊断为疑似二尖瓣人工瓣膜功能异常患者的临床资料,患者均再次接受RT-3D-TEE检查。比较RT-3D-TEE和TTE检查的结果,分析RT-3D-TEE在二尖瓣人工瓣膜置换术后瓣膜功能异常诊断中的作用。结果92例疑似二尖瓣人工瓣膜功能异常的患者中,82例TTE检查怀疑存在瓣周漏;经RT-3D-TEE检查后,存在1处瓣周漏患者38例,2处瓣周漏患者26例,3处瓣周漏3例,共67例患者99处瓣周漏,瓣周漏发生率87.0%(67/77);15例为正常人工瓣膜生理性反流,TTE假阳性率为18.3%(15/82)。另外10例患者中,5例TTE检查怀疑瓣膜狭窄,经RT-3D-TEE确诊并明确病因,其中3例为血管翳,另2例为血栓;2例TTE检查怀疑感染性心内膜炎,未见赘生物,RT-3D-TEE检测到赘生物;3例TTE检查为生物瓣反流,但不能明确病因,RT-3D-TEE诊断为生物瓣退行性改变。结论RT-3D-TEE技术能够快速、明确二尖瓣人工瓣膜术后瓣膜功能异常原因,定位功能异常发生部位,降低假阳性率,提高诊断的准确性,为治疗的时机选择及手段提供重要依据,值得临床应用。     

A rare complication of mitral valve replacement: Iatrogenic aortic valve perforation

Iatrogenic aortic valve injury after mitral valve surgery is a well-known but rare complication. Herein, we report a 62-year-old male patient who underwent mitral valve replacement surgery 12 years ago and developed moderate to severe aortic regurgitation immediately after surgery.     

Spontaneous left atrial echocardiographic contrast in mitral stenosis: early disappearance after valve replacement.

We describe a patient with mitral stenosis and severely enlarged left atrium. Transthoracic echocardiography showed a false image of intraatrial thrombus, whereas transesophageal echocardiography showed massive spontaneous left atrial contrast. Intraoperative transesophageal echocardiography was performed. During cardioplegic arrest the contrast was enhanced, but it gradually and completely cleared 15 minutes after cardiopulmonary by-pass arrest. Transesophageal echocardiography is a useful technique for the study of intraatrial masses and may bring a new dimension to tissue characterization studies.     

Thrombosis of a bileaflet prosthetic mitral valve: a real-time three-dimensional transesophageal echocardiography perspective

Rheumatic mitral valve disease being common in India, valve replacement and hence thrombosis of prosthetic heart valves (PHV) are not uncommon. The diagnosis is commonly established by increased gradients across PHV during transthoracic echo and restricted leaflet movement during transesophageal echo or fluoroscopy. We demonstrated both the leaflets of a thrombosed PHV,of which one was stuck in closed position by real-time three-dimensional transesophageal echocardiography.