Επιδιόπθωζη μιηποειδικήρ ζςζκεςήρ ζε ππόπηωζη ή πήξη γλωσίνων. Βαζίλειορ Σασπεκίδηρ Επιμεληηήρ Β Καπδιολογίαρ Γ.Ν. Παπαγεωπγίος

Transcription

1 Επιδιόπθωζη μιηποειδικήρ ζςζκεςήρ ζε ππόπηωζη ή πήξη γλωσίνων Βαζίλειορ Σασπεκίδηρ Επιμεληηήρ Β Καπδιολογίαρ Γ.Ν. Παπαγεωπγίος

2 MV anatomy Otto C. NEJM 2001

3 Leaflets anatomy

4 2% of population Etiology

5 Terminology Lancellotti P. Eur J Echocardiogr 2010

6 Spectrum of degenerative mitral disease

7 Spectrum of degenerative mitral disease Barlow s disease Fibroelastic deficiency

8 3D imaging Barlow s disease Fibroelastic deficiency

9 Valve dysfunction

10 Valve dysfunction

11 Carpentier s pathophysiologic triad Disease that causes MR Resulting lesions Resulting valvular dysfunction

12 Role of echo Preop or prepump - Severity of regurgitation - Precise anatomy and dysfunction of valve - LV and RV size and function - Other valve problems (esp TV) Postpump -?Residual regurgitation + mechanism - MV SAM LVOT obstruction - LV and RV size and function - Iatrogenic complications

13 Severity of MR Lancellotti P. Eur J Echocardiogr 2010

14

15 Calculation of ERO with PISA

16 Significance of MR quantification n = 456 pts with asymptomatic organic MR 63 ± 14 y Enriquez-Sarano M et al. NEJM 2005 EF = 70 ±8 (excluded EF < 50%) ESD = 34 ± 6 MV surgery (91% MV repair) reduced risk of death

17 Limitations of intraoperative TOE Optimal loading conditions (reduction of afterload or intravascular volume) May underestimate severity esp in ischaemic MR Increase intravascular volume - use iv phenylephrine Nyquist limit = cm/s

18 Precise anatomy and mechanism of MR Why is it so important? Omran AS et al. JASE 2002 Adams DH et al. Cur Opin Cardiol 2008

19 n = 394 pts with flail MV and MR (64% NYHA I-II) 102 pts NYHA I and EF > 60% 64 ± 11 y EF = 67 ±10 ESD = 35 ± 7 MV surgery in 80% - MV repair (80%) better than MV replacement MV repair better than MV replacement Grigioni F et al. JACC Card Imag 2008

20 Systematic 2D TOE examination

21 3D TOE

22 3D TOE

23 3D vs 2D TOE Salcedo E et al. JASE 2009

24 Flail P1

25 Flail PM commissure

26 3D reconstruction

27 LV dysfunction EF < 60% n = 409 pts operated for severe organic MR 64 ± 13 y EF = 62 ± 11 ESD = 38 ± 9 Enriquez-Sarano M et al. Circulation 1994

28 LV dysfunction Florescu M et al. Echocardiography 2011

29 LV size ESD > 40 mm n = 739 pts with flail MV and MR (69% NYHA I-II) 65 ± 12 y EF = 65 ±10 ESD = 35 ± 7 Tribouilloy C et al. JACC 2009

30 Don t forget the tricuspid valve

31 TV annulus diameter 3.5 cm 4.7 cm

32 Guidelines ESC AHA/ACC

33 TV repair Interact CardioVasc Thorac Surg 2009

34 Valve repair procedures Carpentier s method Respect rather than resect - neochordae

35 Postpump?Residual regurgitation + mechanism MV SAM LVOT obstruction LV and RV size and function Iatrogenic complications

36 ?Mitral regurgitation Leaflet coaptation line = 5 8 mm Assess after LV function and loading conditions are relatively normal (off pump) If more than mild assess mechanism 4 11% second pump run

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38 SAM 2 9 % of patients in older series Usually occurs in patients with large mitral leaflets and a small hyperdynamic ventricle Initial management: stop inotropes and increase intracardiac volume If problem persist second pump run

39 Echo predictors of SAM Maslow AD et al. JACC 1999

40 SAM

41 LV dysfunction Early dysfunction cardioplegia and/or umasking due to reduced preload after correction of MR (global) If regional suspect air emboli (usually RCA)

42 Mitral stenosis Very unusual in degenerative MR Mean G > 5 mmhg PHT not reliable

43 Dehisced annuloplasty ring

44 Mitral clip

45 Mitral clip

46 EVEREST II 74% degenerative MR Feldman T et al. NEJM 2011

47 EVEREST II editorial

48 Summary Echo provides invaluable information in patients with degenerative MR Preop 3D echo = surgeon s eye view better planning of the operation Post op assessment of residual MR and potentially lethal complications if unrecognized

49 Back up slides Βαζίλειορ Σασπεκίδηρ Επιμεληηήρ Β Καπδιολογίαρ Γ.Ν. Παπαγεωπγίος

50 Systematic 2D TOE examination LAX LAX Bicom Bicom Lambert AS et al. Anesth Analg 1999

51 Systematic 2D TOE examination 0 20

52 60 Systematic 2D TOE examination

53 90 Systematic 2D TOE examination

54 Systematic 2D TOE examination 90

55 120 Systematic 2D TOE examination

56 Systematic 2D TOE examination

57 0-20 Case A2 P2

58 60 Case P3 A2 P1

59 Case P3 A3-A2-A1 P2 A2

60 Case P2 A2