Intraoperative transesophageal echocardiography for evaluation of mitral valve repair.

BACKGROUND AND AIM OF THE STUDY: Although mitral valve repair is a well-established procedure, incorrect assessment of the repaired valve may occasionally lead to the need for reoperation. This study was performed to evaluate the accuracy of color Doppler in assessing the competence of the repaired mitral valve. METHODS: Transesophageal echocardiography (TEE) and left ventriculography were each performed in 72 patients to compare the two techniques and a semi-quantitative index derived. Using this relationship, post bypass intraoperative TEE was then performed in 34 patients who underwent mitral valve repair, in order to assess the competence of the repaired valve. RESULTS: Significant differences were apparent in maximal regurgitant mosaic area between angiographic grade 0, and grades 1+ (p = 0.0006), 1+ and 2+ (p < 0.0001) and 2+ and 3+ (p = 0.0010). A maximal regurgitant area < 2 cm2 predicted angiographic grade as 0 (sensitivity 100%, specificity 95%), an area of 2-4 cm2 as 1+ (sensitivity 82%, specificity 100%), an area of 4-7 cm2 as 2+ (sensitivity 78%, specificity 90%), and an area > 7 cm2 as grade 3+ or 4+ (sensitivity 79%, specificity 93%). All 34 patients completed valve repair with the maximal regurgitant mosaic area < 2.5 cm2. Postoperative left ventriculography showed grade +1 in only five patients; four of these completed mitral valve repair with a maximal mosaic area > 2.0 cm2 as assessed by post bypass intraoperative TEE. During follow up, transthoracic echocardiography (TTE) detected recurrent mitral regurgitation which required mitral valve replacement in one patient, and rapid progression of mitral regurgitation in three patients. CONCLUSIONS: It is important that mitral valve repair should be completed with a maximal mosaic area < 2.0 cm2 as assessed by intraoperative TEE, in order to reduce the need for reoperation.     

术中经食管超声心动图监测行二尖瓣成形术

目的　评价术中经食管超声心动图在二尖瓣成形术中的作用。方法　 1993年 3月至 2 0 0 3年 3月 ,6 2例二尖瓣关闭不全病人在经食管超声心动图监测下行二尖瓣成形术 ,男 2 4例 ,女 38例 ,平均年龄 (31 3± 7 5 )岁。病因为退行性变 4 2例 ,先天性 2 0例。重度二尖瓣关闭不全 5 9例 ,中度 3例。根据二尖瓣病变的特征进行相应的成形手术。结果　全组无一例手术死亡 ,8例改行二尖瓣替换术。术后超声心动图检查二尖瓣无返流 3例 ,轻度返流 4 9例 ,中度返流 2例。结论　经食管超声心动图在术中能即时判断二尖瓣成形术的效果 ,并找出失败原因 ,从而指导进一步成形术。     

Delayed systolic anterior motion after mitral valve repair

A rare case of systolic anterior motion (SAM) after mitral valve repair is described. A temporary postoperative left ventricular (LV) dysfunction protected against this complication during the early postoperative period. Only on day 9 postoperatively did the left ventricle recover and SAM develop, with significant obstruction of the LV outflow tract. Subsequently, mitral valve replacement was required. This case demonstrates the importance of the LV geometrical relationships that predispose to this complication.     

Transient mitral regurgitation due to mitral valve prolapse accompanied by systolic anterior motion of the mitral valve

A grade 4/6 systolic murmur, systolic anterior motion of the mitral valve (SAM), and severe mitral regurgitation (MR) documented by two-dimensional Doppler echocardiography developed suddenly on the structurally normal heart of a patient with idiopathic portal hypertension. The patient did not have signs of congestive heart failure and the aforementioned phenomenon disappeared completely when the patient was in hepatic failure. This could be explained by a change in circulating blood volume either by gastrointestinal hemorrhage or hepatic failure.     

Mechanism and severity of mitral regurgitation by transesophageal echocardiography in patients referred for percutaneous valve repair

Percutaneous mitral valve repair with the MitraClip has been shown to decrease mitral regurgitation (MR) severity, left ventricular volumes, and functional class in patients with severe (3+ or 4+) MR. Determination of which patients are optimal candidates for MitraClip therapy versus surgery has not been rigorously evaluated. Transesophageal echocardiography was prospectively performed in 113 consecutive patients referred for potential MitraClip therapy under the REALISM continued access registry. MR severity was assessed quantitatively in all patients. Mitral valve anatomy and feasibility of MitraClip placement were assessed by transesophageal echocardiography and clinical parameters. MR was degenerative (mitral valve prolapse) in 60 patients (53%), functional (anatomically normal) in 44 (39%), and thickened with restricted motion (Carpentier IIIB classification) in 9 (8%). MR was mild in 19 patients (17%), moderate in 27 (24%), and severe (3 to 4+) in 67 (59%) by Transesophageal echocardiography. MitraClip placement was performed in only 17 of 113 patients (15%); all were successful. Surgical mitral valve repair was performed in 25 patients (22%), mitral valve replacement in 12 (11%). Most patients (59 of 113, 52%) were treated medically, usually because MR was not severe enough to warrant intervention. In conclusion, most patients referred for MitraClip therapy do not have severe enough MR to warrant intervention. Of those with clinical need for intervention, surgery is more often recommended for anatomic or clinical reasons. Three-dimensional transesophageal echocardiography with quantitative assessment of MR severity is helpful in evaluating these patients.     

Intraoperative echocardiography in mitral and tricuspid valve repair

Echocardiography with Doppler color flow mapping is a very useful intraoperative technique in patients undergoing mitral or tricuspid valve repair. In the patient who is a repair candidate, this technique can be used intraoperatively to answer important clinical questions: the severity of the regurgitation; the morphological basis of the regurgitant lesion; and the feasibility of repair. Other important issues such as the impact of physiological interventions on regurgitation severity, the presence of associated lesions, and the state of ventricular function can also be addressed. In the patient who has undergone a valve repair, this technique can be used intraoperatively prior to chest closure to assess the adequacy of the repair procedure and to detect associated complications such as outflow tract obstruction.     

Multiplane transesophageal echocardiography: a roadmap for mitral valve repair

Multiplane transesophageal echocardiography (TEE) is useful in providing a detailed anatomic map for successful mitral valve repair. This report describes an approach, developed over the past two to three years, which helps to delineate valve anatomy in specific detail. Mid-esophageal views are selected to view different segments of the valve leaflets. When correlated with surgical anatomy, this approach is found to be both practical and useful.     

Prevention of systolic anterior motion after mitral valve repair with an anterior leaflet valvuloplasty

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair (MVR) is the preferred method of treatment of the complex floppy mitral valve. Immediate repair failure, due to systolic anterior motion (SAM), is related to excessive anterior mitral valve leaflet (AMVL) tissue and/or anterior displacement of the leaflet coaptation point by the posterior mitral valve leaflet (PMVL) with resultant left ventricular outflow tract (LVOT) obstruction. Herein are reported the authors' experience of the AMVL valvuloplasty, a simple alternative to the sliding technique, to prevent post-MVR SAM. METHODS: Between January 1996 and June 2003, elliptical excisions of the base of the AMVL and annuloplasty rings (nine Physio, 38 Seguin) were performed in 47 patients (mean age 66 years; range: 29-86 years). The surgical procedure included posterior mitral valve leaflet (PMVL) resection in 37 patients (80%), AMVL resection in 28 (61%), and transposition flaps in nine (19%). Four patients (8%) had a tricuspid valve repair, six (13%) had an aortic valve replacement, and nine (19%) had coronary bypass grafting. Intraoperative transesophageal echocardiography before and after MVR was performed to assess mitral valve anatomy, the presence and severity of mitral regurgitation (MR), and SAM. RESULTS: There was no postoperative SAM. The severity of MR was reduced to trace or mild in all 47 patients. The mean AMVL length was 3.0 cm before and 2.2 cm after MVR, a tissue reduction of 27%. In those patients with a PMVL resection, the mean length was decreased from 1.95 cm to 1.5 cm, a tissue reduction of 23%. The mean annulus diameter decreased from 3.9 cm to 3.0 cm. The mean AMVL:PMVL ratio decreased from 1.6 to 1.4. The proportional size reduction of the AMVL compared to the PMVL was 17%. The mean coaptation point to annulus distance (CPAD) decreased from 1.1 cm to 0.9 cm. There was no 30-day in-hospital mortality. CONCLUSION: The AMVL valvuloplasty eliminated postoperative SAM. There was both reduction of the AMVL surface area, limiting the excursion of the AMVL into the LVOT, and reduction of CPAD. This technique does not compromise the geometry of the mitral valve apparatus.     

Patterns of systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: assessment by two-dimensional echocardiography

A variety of patterns of systolic anterior motion (SAM) of the mitral valve were identified by realtime, 2-dimensional echocardiography in 62 patients with hypertrophic cardiomyopathy. In 36 patients (58%), both the anterior and posterior mitral leaflets appeared to participate importantly in SAM, although the anterior leaflet actually contacted or most closely approached the ventricular septum during systole because of its anterior anatomic position. In 19 patients (31%), SAM was produced selectively by the posterior mitral leaflet. In only 6 patients (10%) was the anterior leaflet alone responsible for SAM. In just 1 patient did the chordae tendineae appear to be primarily responsible for the SAM. In 51 patients (82%), only the distal portion of the anterior or posterior mitral leaflet (and possibly the attached proximal chordae tendineae) approached or contacted the septum in systole; in 10 patients both the body and tip regions of the anterior leaflet produced mitral-septal apposition. Hence, in obstructive hypertrophic cardiomyopathy, (1) the morphologic structures responsible for moderate to severe SAM are not identical in all patients, and a variety of patterns of SAM occur; (2) the posterior mitral leaflet plays an important role in SAM in almost 90% of patients, either by producing SAM alone (31%) or by moving anteriorly in concert with the anterior leaflet (58%); (3) SAM produced selectively by the anterior mitral leaflet is relatively uncommon; and (4) SAM is usually produced primarily by the distal portions of the mitral leaflets (with or without the attached chordae tendineae).     

Detection of mechanisms of immediate failure by transesophageal echocardiography in quadrangular resection mitral valve repair technique for severe mitral regurgitation

Residual mitral regurgitation (MR) after repair is a risk factor for late reoperation. The use of intraoperative transesophageal echocardiography (IOTEE) decreases the incidence of immediate repair failure. This study identifies the mechanisms of immediate failure by IOTEE in the quadrangular resection technique, a well-standardized mitral valve repair procedure to guide further repair procedures. Two hundred five consecutive patients underwent quadrangular resection due to prolapse or flail posterior leaflet. Twenty-four patients (11%) had immediate failure. Immediate reinstitution of cardiopulmonary bypass ("second pump run") was needed in 21 patients (10%) for further repair. The identified mechanisms of failure were residual cleft provoking interscallop malcoaptation into the posterior leaflet in 8 patients, residual prolapse of the anterior or posterior leaflets in 1 and 4 patients, respectively, residual annular dilation in 3, left ventricular outflow obstruction in 2, suture dehiscence in 2, and other mechanisms in another 2 patients. In 20 patients (95%), IOTEE guided further repair with resolution of the residual MR, whereas 1 patient underwent valve replacement due to pharmacologically untreatable left ventricular outflow obstruction. In conclusion, even if this type of valve repair technique is well standardized, the incidence of immediate failure is not negligible. IOTEE identified the mechanisms of the immediate failure and guided further repair procedures, thus reducing the incidence of valve replacement (0.5%) without increasing perioperative mortality and morbility.     

Validation of a decision-making strategy for systolic anterior motion following mitral valve repair

Low cardiac output syndrome and hypotension are dreadful consequences of systolic anterior motion (SAM) after a mitral valve (MV) repair. The management of SAM in the operating room remains controversial. We validate a recently suggested two-step management method and classification of this complication. This was a teaching hospital-based observational study. We validated a novel two-step conservative management method, consisting in intravascular volume expansion and discontinuation of inotropic drugs (step 1), and increasing the afterload by ascending aorta manual compression while administering esmolol e.v. (step 2). We also validate a novel classification of SAM: easy-to-revert (responding to step 1), difficult-to-revert (responding to step 2), or persistent. Fifty patients had an easy-to-revert while 26 had a difficult-to-revert SAM; 4 patients had a persistent condition (promptly diagnosed through our decisional algorithm) and underwent an immediate second pump run to repeat the mitral repair surgery. We confirmed that SAM after a repair of a degenerative MV is common and validated a simple two-step conservative management method that allows to clearly identify those few patients who require immediate surgical revision.     

SAM-systolic anterior motion of the anterior mitral valve leaflet post-surgical mitral valve repair

Systolic anterior motion (SAM) is a postoperative complication experienced by patients undergoing mitral valve repair. The incidence of SAM after mitral valve repair ranges from 5 to 10%. Early recognition of the signs and symptoms of SAM is imperative to the management of these patients. This article presents the pathophysiology of mitral valve dysfunction to give the practitioner a clear understanding of the dynamics of SAM. This article's main focus is the detection and management of SAM and the most current treatment modalities. A case study is used to illustrate the complex management necessary for the patient with SAM.     

Role of real-time three-dimensional transesophageal echocardiography in mitral valve repair

Background and objective Pre-operative assessment of mitral valve (MV) anatomy is essential to surgical design in patients undergoing MV repair.Although 2-dimensional (2D) echocardiography provides precise information regarding MV anatomy,RT-3D TEE could increase the understanding of MV apparatus and individual scallop identification.We aimed to investigate the value of RT- 3DTEE in MV repair.Methods RT-3DTEE was performed in six patients with mitral valve prolapse (MVP) by using Philips 1E33 with X7-2t probe.Preoperative RT-3DTEE studies were compared with surgical findings in patients undergoing surgical mitral valve repair,and quantitative evaluation was performed by QLab 6.0 software before and after surgical mitral valve repair.Results RT- 3DTEE could display dynamic morphology of MV,the location of prolapse,and spatial relation to the surrounding tissue.It could provide surgical views of the valves and the valvular apparatus.These results were consistent with surgical findings.The quantitative evaluation before and after surgical MV repair indicated that anterolateral to posteromedial diameter of annulus,anterior to posterior diameter of annulus,perimeter of annulus,and area of annulus in projection plane were significantly smaller after operation compared with those before operation (P<0.05).The length of posterior leaflet,the area of anterior and posterior leaflet,the maximal prolapse height,the volume of leaflet prolapse and the length of coaptation in projection plane were significantly reduced after operation (P<0. 05).Conclusion RT-3DTEE is a unique new modality for rapid and accurate evaluation ofmitral valve prolapse and mitral valve repair.     

The Duromedics mitral valve mechanical prosthesis: evaluation by means of transesophageal echocardiography

We investigated via transesophageal echocardiography 29 patients with Duromedics mitral prosthesis to define the characteristics of normal and abnormal functioning valves as well as the advantages of this study compared to transthoracic echocardiography. The clinical and transthoracic examination identified three groups. The first group consisted of 8 patients with abnormal hemodynamic parameters (maximal velocity 245.5 +/- 38.4 cm/sec, maximal gradient 24.6 +/- 7.9 mmHg, medium gradient 9.8 +/- 0.8 mmHg, pressure half time 121.6 +/- 58.8 msec, valvular area 2.1 +/- 0.8 cm2). In 4 cases we detected a paravalvular regurgitant jet. The second group was formed of 12 symptomatic patients, with normal hemodynamic parameters (maximal velocity 169.1 +/- 20.1, maximal gradient 11.6 +/- 2.5, medium gradient 4.8 +/- 1.8, pressure half time 118 +/- 18 msec, valvular area 1.9 +/- 2.8 cm2). In 4 cases we detected a paravalvular regurgitant jet. The third group was formed by 9 asymptomatic patients with normal hemodynamic parameters: maximal velocity 160.6 +/- 26.6, maximal gradient 10.5 +/- 3.3, medium gradient 4 +/- 1, pressure half time 118 +/- 40, valvular area 2 +/- 0.5. We did not observe a regurgitant jet in any of these patients. Transesophageal echocardiography detected a paravalvular jet in all patients of the first group, with an area of 6.9 +/- 5.8 cm2; in the second group it demonstrated one or two valvular jets, with a maximal area of 5.1 +/- 3.2 cm2. Furthermore, it defined as valvular, the site of a jet previously described as paravalvular with the transthoracic examination.(ABSTRACT TRUNCATED AT 250 WORDS)     

Echocardiographic correlates of left ventricular outflow obstruction and systolic anterior motion following mitral valve repair

BACKGROUND AND AIM OF THE STUDY: Systolic anterior motion (SAM) of the mitral valve resulting in left ventricular outflow obstruction is a well-recognized complication of repair of the degenerative myxomatous mitral valve. A precise mechanism is unknown. A current approach consists of sliding annuloplasty of the posterior leaflet. It was postulated that excess tissue of the anterior mitral leaflet (AML) was as equally (or more) important as the excess posterior mitral leaflet (PML) tissue in the development of SAM subsequent to valve repair. METHODS: Thirty-two patients without post-repair SAM (No-SAM group) were compared with eight patients with SAM (SAM group). The AML and PML heights and the mitral annulus diameter were measured by TEE using mid-esophageal four-chamber and long-axis planes. RESULTS: Pre-repair TEE showed the AML height to be greater in the SAM group (p = 0.04), and that of the posterior leaflet tended to be greater (p = 0.08), whilst the annular dimensions were similar in both groups. In the post-repair status, the AML height was markedly greater (p = 0.005) and the annulus markedly smaller (p = 0.001) in the SAM group. Post-repair assessment showed the relative difference between AML height and annular dimension (AML - Ann) as well as the difference between combined leaflet heights and annular dimension (AML + PML - Ann) to be strikingly greater in the SAM group as compared with the No-SAM group (p = 0.001). CONCLUSION: A disparity between dimension of the annulus following mitral valve repair and combined heights of the two leaflets explains post-repair SAM. The AML height is a more important factor in the development of SAM. Thus, surgical techniques to reduce AML heights should be considered in patients with disproportionately large anterior leaflets in order to prevent SAM. Selection of size of the annuloplasty ring should take into consideration the height of the AML.     

Diagnosis of mitral valve myxoma by transesophageal echocardiography

Mitral valve myxomas are rare. We report a patient with a mitralmyxoma arising from the posterior mitral leaflet in whom transthoracicechocardiography revealed equivocal findings. However, transoesophagealechocardiography provided accurate relevant anatomical informationincluding the size, morphological characteristics, and tumourattachment point.     

Visualization of mitral valve aneurysm by transesophageal echocardiography

This article describes the transesophageal echocardiographic findings in a patient with pathologically proven mitral valve aneurysm. This aneurysm probably occurred as a complication of aortic valve endocarditis. Transesophageal echocardiography showed a saccular structure attached to the left atrial side of the anterior mitral leaflet with systolic expansion and diastolic collapse, and its orifice was visualized with excellent resolution. Transesophageal echocardiography is a useful diagnostic tool for evaluation of mitral valve aneurysm.     

Pseudo-false-positive exercise treadmill testing caused by systolic anterior motion of the anterior mitral valve leaflet.

Subendocardial ischemia as indicated by electrocardiography during exercise, in association with severe systolic anterior motion of the anterior mitral valve leaflet without left ventricular hypertrophy, has not been well described. We report the case of a 42-year-old man who presented with symptoms of exertional angina and 2-mm ST depression on treadmill electrocardiography but had a normal perfusion scan and coronary angiogram. Initially the negative angiographic results caused us to regard the treadmill results as false-positive. Subsequently, low-dose dobutamine echocardiography showed severe systolic anterior motion of the anterior mitral valve leaflet with a >144-mmHg left ventricular outflow tract gradient; we then recognized the original treadmill results to be pseudo-false-positive. Electrocardiographic changes in association with the above-described motion of the anterior mitral valve leaflet and increased left ventricular outflow tract gradient were verified by use of treadmill and supine bicycle stress echocardiography.