Επιδιόπθωζη μιηποειδικήρ ζςζκεςήρ ζε ππόπηωζη ή πήξη γλωσίνων Βαζίλειορ Σασπεκίδηρ Επιμεληηήρ Β Καπδιολογίαρ Γ.Ν. Παπαγεωπγίος
MV anatomy Otto C. NEJM 2001
Leaflets anatomy
2% of population Etiology
Terminology Lancellotti P. Eur J Echocardiogr 2010
Spectrum of degenerative mitral disease
Spectrum of degenerative mitral disease Barlow s disease Fibroelastic deficiency
3D imaging Barlow s disease Fibroelastic deficiency
Valve dysfunction
Valve dysfunction
Carpentier s pathophysiologic triad Disease that causes MR Resulting lesions Resulting valvular dysfunction
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
Severity of MR Lancellotti P. Eur J Echocardiogr 2010
Calculation of ERO with PISA
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
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 = 50 60 cm/s
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
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
Systematic 2D TOE examination 60 90 60 90 0-20 135 0-20 135
3D TOE
3D TOE
3D vs 2D TOE Salcedo E et al. JASE 2009
Flail P1
Flail PM commissure
3D reconstruction
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
LV dysfunction Florescu M et al. Echocardiography 2011
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
Don t forget the tricuspid valve
TV annulus diameter 3.5 cm 4.7 cm
Guidelines ESC AHA/ACC
TV repair Interact CardioVasc Thorac Surg 2009
Valve repair procedures Carpentier s method Respect rather than resect - neochordae
Postpump?Residual regurgitation + mechanism MV SAM LVOT obstruction LV and RV size and function Iatrogenic complications
?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
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
Echo predictors of SAM Maslow AD et al. JACC 1999
SAM
LV dysfunction Early dysfunction cardioplegia and/or umasking due to reduced preload after correction of MR (global) If regional suspect air emboli (usually RCA)
Mitral stenosis Very unusual in degenerative MR Mean G > 5 mmhg PHT not reliable
Dehisced annuloplasty ring
Mitral clip
Mitral clip
EVEREST II 74% degenerative MR Feldman T et al. NEJM 2011
EVEREST II editorial
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
Back up slides Βαζίλειορ Σασπεκίδηρ Επιμεληηήρ Β Καπδιολογίαρ Γ.Ν. Παπαγεωπγίος
Systematic 2D TOE examination LAX LAX Bicom Bicom Lambert AS et al. Anesth Analg 1999
Systematic 2D TOE examination 0 20
60 Systematic 2D TOE examination
90 Systematic 2D TOE examination
Systematic 2D TOE examination 90
120 Systematic 2D TOE examination
Systematic 2D TOE examination
0-20 Case A2 P2
60 Case P3 A2 P1
Case 90 135 P3 A3-A2-A1 P2 A2
Case P2 A2