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Intraoperative Transesophageal Echocardiography for Surgical Repair of Mitral Regurgitation

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Intraoperative Transesophageal Echocardiography for Surgical Repair of Mitral Regurgitation STATE-OF-THE-ART REVIEW ARTICLE Intraoperative Transesophageal Echocardiography for Surgical Repair of Mitral Regurgitation David Andrew Sidebotham, MB ChB, FANZCA, Sara Jane Allen, MB ChB, FANZCA, FCICM, Ivor L. Gerber, MB ChB, MD, FRACP, FACC, and Trevor Fayers, MB ChB, FRACS, FCS(SA), Auckland, New Zealand; Brisbane, Australia Surgical repair of the mitral valve is being increasingly performed to treat severe mitral regurgitation. Transe- sophageal echocardiography is an essential tool for assessing valvular function and guiding surgical decision making during the perioperative period. A careful and systematic transesophageal echocardiographic exam- ination is necessary to ensure that appropriate information is obtained and that the correct diagnoses are ob- tained before and after repair. The purpose of this article is to provide a practical guide for perioperative echocardiographers caring for patients undergoing surgical repair of mitral regurgitation. A guide to perform- ing a systematic transesophageal echocardiographic examination of the mitral valve is provided, along with an approach to prerepair and postrepair assessment. Additionally, the anatomy and function of normal and re- gurgitant mitral valves are reviewed. (J Am Soc Echocardiogr 2014;27:345-66.) Keywords: Transesophageal echocardiography, Mitral valve repair, TEE, Intraoperative, Cardiac surgery In suitable patients, surgical repair is an excellent treatment option for 2.01; 95% confidence interval, 1.19–3.40) and in mixed patient pop- severe mitral regurgitation (MR). The procedure is associated with ulations (odds ratio, 2.39; 95% confidence interval, 1.76–3.26). low mortality and is highly durable. Among 58,370 unselected pa- However, these data are nonrandomized and subject to selection tients from the Society of Thoracic Surgeons Adult Cardiac Surgery bias. Older and sicker patients, and those with less favorable valves, database undergoing isolated mitral valve (MV) surgery in the are more likely to undergo MV replacement. Notwithstanding the United States between January 2000 and December 2007, operative lack of randomized data, for patients with suitable valves, surgical mortality was 1.4% for valve repair compared with 3.8% for valve repair is now the preferred option for treating severe MR. replacement.1 During the study period, the rate of valve repair Transesophageal echocardiography (TEE) affords high-quality, increased from 51% to 69%. Among a cohort of 14,604 older pa- real-time assessment of MV structure and function and is uniquely tients (aged >65 years) undergoing mitral repair, operative mortality suited to intraoperative use. Consequently, TEE is an essential tool was 2.59%, the 10-year reoperation rate was 6.2%, and 10-year sur- during MV repair surgery.4,5 Before repair, TEE is used to vival was 57.4%, equivalent to the matched US population.2 determine the mechanism, extent, and severity of MR. After repair, Although there have been few randomized trials comparing MV TEE is used to evaluate the severity of any residual regurgitation repair with replacement, a meta-analysis in 2007 of nonrandomized and to diagnose other complications, such as systolic anterior series demonstrated reduced early mortality and lower rates of motion (SAM) and mitral stenosis. However, to obtain appropriate thromboembolism for repair compared with replacement.3 In addi- information to guide surgical decision making, perioperative tion to reduced early mortality for patients with degenerative MV dis- echocardiographers must understand the etiology and mechanisms ease (odds ratio, 1.93; 95% confidence interval, 1.08–3.44), mortality of MR, have an appreciation of surgical techniques, and, most was also reduced in patients with functional MR (FMR) (odds ratio, important, be able to perform a comprehensive assessment of MV structure and function in the operating room environment. The primary objective of this review article is to provide an up-to-date, From the Department of Anesthesia, The Cardiovascular Intensive Care Unit (D.A.S., practical guide to perioperative transesophageal echocardiographic S.J.A.) and Green Lane Cardiovascular Service (I.L.G.), Auckland City Hospital, assessment of patients undergoing MV repair surgery. Auckland, New Zealand; and Department of Cardiac Surgical Services, Holy Spirit Northside Hospital and The Prince Charles Hospital, Brisbane, Australia (T.F.). NORMAL ANATOMY AND FUNCTION OF THE MITRAL VALVE Attention ASE Members: ASE has gone green! Visit www.aseuniversity.org to earn free CME through an The MV is best conceptualized as a valve complex, comprising an online activity related to this article. Certificates are available for immediate annulus, leaflets, chordae, papillary muscles, and left ventricular mus- access upon successful completion of the activity. Non-members will need cle. Normal functioning of the MVrequires the coordinated activity of to join ASE to access this great member benefit! all components of the valve complex. Correspondence: David Andrew Sidebotham, MB ChB, FANZCA, Auckland City Hospital, Cardiothoraic and Vascular Intensive Care Unit, Auckland, New Zealand Annulus (E-mail: [email protected]). The mitral annulus is a fibrofatty ring that approximates a hyperbolic pa- 0894-7317/$36.00 raboloid, a geometric shape similar to a riding saddle.6 The annulus has Copyright 2014 by the American Society of Echocardiography. two axes, a shorter and ‘‘higher’’ (more basal) anteroposterior (AP) axis http://dx.doi.org/10.1016/j.echo.2014.01.005 and a longer and ‘‘lower’’ (more apical) commissural axis (Figure 1). The 345 346 Sidebotham et al Journal of the American Society of Echocardiography April 2014 anterior pole of the AP axis corre- Papillary Muscles, Chordae, and Left Ventricle Abbreviations sponds to the ‘‘riding horn’’ of the Two papillary muscles, the anterolateral and the posteromedial, sup- AP = Anteroposterior saddle and the commissural axis port the mitral leaflets. The papillary muscles run parallel with the long CPB = Cardiopulmonary to the ‘‘seat’’ of the saddle. axis of the left ventricle, aligned with the commissures. Systolic bypass Anteriorly, the mitral annulus is contraction of the papillary muscles offsets the base-to-apical short- thickened and fixed to the aortic ening of the left ventricle, which would otherwise cause leaflet pro- EROA = Effective regurgitant annulus, a region termed the in- orifice area lapse. The larger anterolateral muscle typically arises from the mid tervalvular fibrosa. The saddle anterolateral wall of the left ventricle and supports the ipsilateral FED = Fibroelastic deficiency shape of the mitral annulus acts half of both leaflets: A1/P1 and the anterolateral part of A2/P2. to reduce tension on the leaflets, FMR = Functional mitral The smaller posteromedial muscle typically arises from the mid infe- particularly the middle scallop of rior wall of the left ventricle and supports the ipsilateral part of both regurgitation 7,8 the posterior leaflet. Annular leaflets: A3/P3 and the posteromedial part of A2/P2. Branches of LVEF = Left ventricular height is normalized to annular the left anterior descending and circumflex coronary arteries supply ejection fraction size by the ratio of height to the anterolateral muscle, whereas the posteromedial muscle is sup- LVOT = Left ventricular commissural length at end- plied entirely by branches of the right coronary artery and is therefore outflow tract systole and is normally about more vulnerable to rupture after myocardial infarction. 15%.8 Leaflet tension increases MR = Mitral regurgitation The papillary muscles attach to the leaflets via chordae tendineae. dramatically when this ratio falls Primary chords attach to the free edges of the leaflets, and secondary MV = Mitral valve below 10% (i.e., when the chords attach to the undersurface of the leaflets. Primary chords sup- annulus becomes planar NL = Nyquist limit port the free edges of the leaflets during systole. Rupture of primary [decreased height] or dilated chords causes acute MR. Secondary chords help maintain left ventric- PISA = Proximal isovelocity [increased commissural length]). ular geometry, particularly the two thicker strut chords, which attach surface area Ventricular contraction results to the undersurface of the anterior leaflet.6 PVR = Pulmonary vascular in important conformational resistance changes in the mitral annulus 9-11 (Figure 1). In early systole, ETIOLOGY OF MITRAL REGURGITATION SAM = Systolic anterior left ventricular contraction motion causes a sphincter-like decrease In developed countries, degenerative disease and FMR are the two TEE = Transesophageal in posterior annular area. The most common indications for surgical treatment of MR, accounting echocardiography annulus shortens along the AP for approximately 70% and 20% of cases, respectively.13 axis, and overall annular area is 3D = Three-dimensional Rheumatic heart disease is relatively uncommon in developed nations reduced by approximately 25%. but remains the most frequent cause of valvular heart disease in devel- TR = Tricuspid regurgitation Ventricular contraction also oping countries. Other important causes of MR include endocarditis, 2D = Two-dimensional causes systolic folding of the clefts, and papillary muscle rupture. anterior annulus, leading to a VCA = Vena contracta area deepening of the saddle. The AP Degenerative MR VCW = Vena contracta width diameter returns to normal in midsystole, but increased annular Degenerative MV disease encompasses a range of pathology, height is maintained
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