Bartels et al. (2014)2424 Pan C, Shu XH, Cao Q, et al. Role of real-time three-dimensional transesophageal echocardiography in mitral valve repair. J Geriatr Cardiol. 2008;5:137–41.
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Hypothesized that quantitative 3D analysis would reveal distinct differences among diseased, repaired, and normal MV. |
Case-control observational clinical study.
Retrospectively analyzed 80 patients who underwent intraoperative TEE: 20 patients with degenerative MR were evaluated before and after mitral valve repair, 20 patients had functional MR and 20 patients had no MV disease.
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Annulus area was enlarged in degenerative and functional MR. Annular displacement distance was decreased in functional MR and repaired valves. Annular displacement velocity was decreased in functional MR. Annular area fraction was decreased in functional MR and repaired valves. |
Normal, functional regurgitant, degenerative, and repaired MV have distinctly different dynamic signatures of anatomy and function as reliably determined by perioperative echo-cardiographic tracking. |
Ben Zekry et al. (2016)3030 Vergnat M, Levack MM, Jassar AS, et al. The influence of saddleshaped annuloplasty on leaflet curvature in patients with ischaemic mitral regurgitation. Eur J Cardiothorac Surg. 2012;42:493–9.
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The investigation was aimed at deriving novel intrinsic parameters of regional and global MA shape and function, namely, curvature and torsion. |
Prospective observational study. Indices were evaluated in a group of 15 patients with normal MVand in a group of 15 patients with organic MR, prior to and after MV repair.
Novel parameters of MA curvature and torsion were derived from 3D TEE.
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Patients with organic MR presented the smallest global curvature and torsion; this decrease in curvature and torsion reflects a loss of tonicity of the MA tissue. These changes were largely corrected with MV repair surgery, to higher values, compared with normal individuals. The regional analysis revealed similar trends. The maximal MA curvature was found to be at the MA ‘anterior horn’, whereas the MA ‘posterior horn’ had the lowest curvature values. |
Novel MA parameters of curvature and torsion can be computed from 3D echocardiography and provide quantitative characteristics of dynamic regional MA geometry. In patients with organic MR, the reduced regional and global curvatures improve following surgical MV repair. These quantitative parameters may help further refine the quantitative description of MA geometry in various mitral valve pathologies and after MV repairs. |
Grewal et al. (2010)2525 Tautz L, Walczak L, Georgii J, et al. Combining position-based dynamics and gradient vector flow for 4D mitral valve segmentation in TEE sequences. Int J Comput Assist Radiol Surg. 2020;15:119–28.
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Investigated and compare mitral annular size, shape, and motion over the cardiac cycle using RT 3D-TEE in patients with myxomatous MV disease before and after repair, in normal control subjects and in patients with ischemic MR. |
Prospective observational study. RT 3D-TEE of the mitral valve was acquired in 32 patients with MVD before and after repair, 15 normal control subjects, and 10 patients with IMR of identical body surface area. |
RT 3D-TEE provides insights into normal, dynamic MA function with early-systolic area contraction and saddle-shape deepening contributing to mitral competency. MVD annulus is also dynamic but considerably different with loss of early-systolic area contraction and saddle-shape deepening despite similar magnitude of ventricular contraction, suggestive of ventricular-annular decoupling. Subsequent area enlargement may contribute to mitral incompetence. After mitral repair, MVD annulus remains dynamic without systolic saddle-shape accentuation. |
RT 3D-TEE provides new insights that allow the refining of mitral pathophysiology concepts and repair strategies |
Ma et al. (2008)2020 Ender J, Sgouropoulou S. Value of transesophageal echocardiography (TEE) guidance in minimally invasive mitral valve surgery. Ann Cardiothorac Surg. 2013;2:796–802.
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Investigated the feasibility, imaging quality and accuracy of live 3D-TEE for assessing MV morphology to determine if live 3D-TEE has important value in MV surgery. |
Prospective observational study. Twenty-four patients with MV disease underwent live 3D-TEE and 2D-TEE before and after MV surgery. Sensitivity, specificity, and total consistency rates of live 3D-TEE for diagnosing ruptured chordae were calculated and compared to surgeon’s findings. We also compared the diagnostic accuracy of MV disease between live-3D-TEE and 2D TEE. |
Live-3D-TEE allowed visualization of the anatomic structures of the heart online and clearly identified the valvular apparatus and their defects. Sensitivity and specificity for the detection of ruptured chordae by live 3D-TEE were 87.5% and 100% respectively, and the total consistency rate was 95.8%. Additional defects not diagnosed by 2D TEE were found in three cases (12.5%) preoperatively by live 3D-TEE. Live 3D-TEE could evaluate the function of prosthetic or native valves immediately after operation. One case was re-repaired (4.2%) using guidance by live 3D-TEE. |
Live 3D-TEE enabled evaluation of MV function and provided adequate valuable information before and after MV surgery. We conclude that live 3D-TEE can play an important role in MV surgery. |
Ma et al. (2018)3434 Manabe S, Kasegawa H, Fukui T, et al. Morphological analysis of systolic anterior motion after mitral valve repair. Interact Cardiovasc Thorac Surg. 2012;15:235–9.
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Investigated the impact of full annuloplasty rings versus C-shape bands on mitral annular geometry in the presence of FED assessed by intraoperative 3D-TEE. |
Retrospective study. 65 patients who underwent MV repair for severe MR caused by FED using full rings (the Ring group, n = 30) and C-shape bands (the Band group, n = 35). 71 controls without valvular heart disease were also included. Thorough 3D-TEE inspections were performed for the entire cohort to measure morphological parameters of MA before and after surgery. Mid-term repair durability and left atrial diameter were followed up. |
The preoperative 3D-TEE parameters, including annular diameters, area, height and aorto-mitral angle, were significantly larger in the FED groups than normal, and were comparable between two groups using different annuloplasty devices. After repair, the anterior-posterior diameter, annulus circumference and area were significantly larger in the Band group than in the Ring group. The aorto-mitral angle became comparable with normal value in the Ring group, but not in the Band group. Follow-up echocar-diographic data showed a significant correlation between postoperative aorto-mitral angle and reduced left atrial diameter at 50.3 months after surgery. |
Compared with C-shape bands, full rings may impose less narrowing on aorto-mitral angle, which correlates well with midterm left atrial reverse remodeling |
Maffessanti et al. (2011)2121 Reshmi JL, Gopan G, Varma PK, et al. Transesophageal Echocardiographic Assessment of the Repaired Mitral Valve: A Proposed Decision Pathway. In: Seminars in Cardiothoracic and Vascular Anesthesia; 2021. September.
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Quantified the effects induced by prolapse on MVanatomy in the presence of FED or Barlow’s disease, assess the effect of surgery on the MVapparatus, and investigate the potential role of 3D-TEE in surgical planning. |
Prospective observational study. 56 patients (29 with FED, 27 with Barlow’s disease) undergoing MV repair and annuloplasty were studied immediately before and after surgery. Also, 18 age-matched patients with normal MVanatomy, undergoing coronary artery bypass, were included as a control group. 3D-TEE data sets were acquired and analyzed to quantify several MV annulus and leaflet parameters using dedicated software. |
MV prolapse and regurgitation were associated with a markedly enlarged annulus and leaflets compared with controls, while annular height and the mitral aortic angle were similar. Patients with Barlow’s disease showed greater values than those with FED. MV repair and annuloplasty led to a significant undersizing of leaflet and annular areas, diameters, and height compared with controls. CL remained in the normal range. Differences between Barlow’s disease and FED were reduced but still present after surgery. |
Intraoperative 3D-TEE allows quantitative evaluation of the MV apparatus in the presence of FED or Barlow’s disease and could be useful for immediate assessment of the surgical procedure. |
Mahmood et al. (2010)3636 Ma W, Ye W, Zhang J, et al. Impact of different annuloplasty rings on geometry of the mitral annulus with fibroelastic deficiency: the significance of aorto-mitral angle. Int J Cardiovasc Imaging. 2018;34:1707–13.
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Investigated if when compared to flat rings, saddle-shaped rings would decrease the NPA after MV repair for both ischemic and myxomatous MV disease. |
Prospective observational study. Geometric analysis on 38 patients undergoing MVrepair for myxomatous and ischemic MR with full flat rings (n = 18) and saddle rings (n = 18) were performed. The acquired 3D volumetric data were analyzed and the degree of change in the NPA was calculated and compared before and after repair for both types of rings. |
Both types of annuloplasty rings resulted in significant changes in the geometric structure of the MVafter repair. However, saddle rings lead to a decrease in the NPA, whereas flat rings increased the NPA. |
Implantation of saddle-shaped rings during MV repair surgery is associated with augmentation of the nonplanar shape of the MA. This favorable change in the mitral annular geometry could possibly confer a structural advantage to MV repairs with the saddle rings. |
Mahmood et al. (2008)2626 Bartels K, Thiele RH, Phillips-Bute B, et al. Dynamic indices of mitral valve function using perioperative three-dimensional transesophageal echocardiography. J Cardiothorac Vasc Anesth. 2014;28:18–24.
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Studied the feasibility of using 3D-TEE in the operating room for MV repair or replacement surgery. To perform geometric analysis of the mitral valve before and after repair. |
Prospective observational study. Intraoperative reconstruction of 3D images of the mitral valve in 102 consecutive patients scheduled for MV surgery. |
Successful image reconstruction was performed in 94 patients ‒ 8 patients had arrhythmias or a dilated MVannulus resulting in significant artifacts. Time from acquisition to reconstruction and analysis was less than 5 minutes. Surgeon identification of MV anatomy was 100% accurate. |
The study confirms the feasibility of performing intraoperative 3D reconstruction of the MV. The incorporation of CFD into these 3D images helps in identification of the commissural or perivalvular location of regurgitant orifice. |
Mahmood et al. (2009)3535 Rosendal C, Hien MD, Bruckner T, et al. Left ventricular outflow tract: intraoperative measurement and changes caused by mitral valve surgery. J Am Soc Echocardiogr. 2012;25:166–72.
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3D intraoperative TEE evaluation of the MVannulus before and immediately after repair |
Prospective observational study. 3D geometric analysis on 75 patients undergoing MV repair during coronary artery bypass graft surgery for MR or myxomatous MV disease. Geometric analysis of the MV was performed before and immediately after valve repair with full rings and annuloplasty bands. |
Complete echocardiographic assessment of the MV was feasible in 69 of 75 patients (92%) within 2 to 3 minutes of acquisition. Placement of full rings resulted in an increase in the NPA or a less saddle shape of the native MA. By contrast, the NPA did not change significantly after placement of partial rings. |
Mitral annular nonplanarity can be assessed in the operating room. Application of full annuloplasty rings resulted in the MA becoming more planar. Partial annuloplasty bands did not significantly change the nonplanarity angle. Neither of the two types of rings restored the native annular planarity |
Maslow et al. (2014)2727 Grewal J, Suri R, Mankad S, et al. Mitral annular dynamics in myxomatous valve disease: new insights with real-time 3-dimensional echocardiography. Circulation. 2010;121:1423–31.
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Examined the geometric changes of the MVafter repair using conventional and 3D echocardiography. |
Prospective observational study. 50 consecutive patients scheduled for elective repair of the MV for regurgitant disease. Intraoperative TEE assessments of MVA were performed using 2D-PLAN, PHT, and 3D-PLAN. In addition, the direction of ventricular inflow was assessed from the 3D imaging. |
Good correlations and agreement were seen between the MVA measured with 3D-Plan and PHTand were better than either one compared to 2D-Plan. MVAs were smaller after repair of functional disease repaired with an annuloplasty ring. After repair, ventricular inflow was directed toward the lateral ventricular wall. Subgroup analysis showed that the change in inflow angle was not different after repair of functional disease as compared to those presenting with degenerative disease. |
3D imaging provides caregivers with a unique ability to assess changes in valve function after MV repair. |
Nishi et al. (2016)3737 Mahmood F, Subramaniam B, Gorman 3rd JH, et al. Three-dimensional echocardiographic assessment of changes in mitral valve geometry after valve repair. Ann Thorac Surg. 2009;88: 1838–44.
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Assessed the effects of different types of prosthetic rings on mitral annular dynamics using RT 3D-TEE. |
Prospective observational study. 44 patients, including patients undergoing mitral annuloplasty using the Cosgrove-Edwards flexible band (Group A, n = 10), the semi-rigid Sorin Memo 3D ring (Group B, n = 17), the semi-rigid Edwards Physio II ring (Group C, n = 7) and ten control subjects. Various annular diameters were measured throughout the cardiac cycle. |
Flexible anterior annulus motion in all of the groups except Group C. A flexible posterior annulus was only observed in Group B and the Control group. The MAA changed during the cardiac cycle by 8.4 ± 3.2, 6.3 ± 2.0, 3.2 ± 1.3, and 11.6 ± 5.0 % in Group A, Group B, Group C, and the Control group, respectively. The dynamic diastolic to systolic change in mitral annular diameters was lost in Group C, while it was maintained in Group A, and to a good degree in Group B. In comparison to the Control group, the MA shape was more ellipsoid in Group B and Group C, and more circular in Group A. |
Although MR was well controlled by all of the types of rings that were utilized in the present study, we demonstrated that the annulus motion and annulus shape differed according to the type of prosthetic ring that was used, which might provide important information for the selection of an appropriate prosthetic ring. |
Owais et al. (2014)3838 Mahmood F, Gorman 3rd JH, Subramaniam B, et al. Changes in mitral valve annular geometry after repair: saddle-shaped versus flat annuloplasty rings. Ann Thorac Surg. 2010;90:1212–20.
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Selectively flexible rings are used for annuloplasty during MV repair to facilitate dynamic annular motion while preventing annular dilation. This study assessed the extent and nature of the flexibility of 2 rings in vivo. |
Prospective observational study. 3D-TEE was used intraoperatively to acquire data regarding dynamic motion of mitral annuli and annuloplasty rings in 33 patients undergoing mitral repair and in 15 control patients. Data were analyzed to assess the dynamic changes in annular geometry after implantation of selectively flexible rings. |
After annuloplasty, there was an immediate and significant decrease in annular displacement and annular displacement velocity. Dynamic change in multiple variables including anteroposterior diameter and annular area was also significantly depressed. In comparison with normal MV, partially flexible rings allowed limited dynamic motion: percentage changes in anteroposterior diameter, AL diameter, PM diameter, and total circumference were significantly lower. Compared with each other, the two rings resulted in similar changes in anterior annulus length, posterior annular length, and annular area. |
Mitral annular dynamics were uniformly depressed after implantation of these rings. Selective flexibility could not be demonstrated in vivo using echocardiographic data. |
Pan et al. (2008)2222 Ma N, Li ZA, Meng X, et al. Live three-dimensional transesophageal echocardiography in mitral valve surgery. Chin Med J. 2008;121:2037–41.
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Investigated the value of RT-3D-TEE in MV repair. |
Prospective observational study. RT-3D-TEE was performed in 6 patients with MV prolapse. Preoperative RT-3D-TEE studies were compared with surgical findings in patients undergoing surgical MV repair, and quantitative evaluation was performed before and after surgical MV repair. |
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 AL to PM 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. 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. |
RT-3DTEE is a unique new modality for rapid and accurate evaluation of MV prolapse and MV repair. |
Tautz et al. (2020)2323 Maffessanti F, Marsan NA, Tamborini G, et al. Quantitative analysis of mitral valve apparatus in mitral valve prolapse before and after annuloplasty: a three-dimensional intraoperative transesophageal study. J Am Soc Echocardiogr. 2011;24:405–13.
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Provided a new 4D segmentation method to enable a quantitative assessment of valve geometry and pathological properties in all heart phases, as well as the changes achieved through surgery. |
Prospective observational study. Tracking-based approach combining GVF and PBD. An open-state surface model of the valve is propagated through time to the closed state, attracted by the GVF field of the leaflet area. The PBD method ensures topological consistency during deformation. For evaluation, one expert in cardiac surgery annotated the closed-state leaflets in 10 TEE sequences of patients with normal and abnormal MVand defined the corresponding open-state models. |
The average point-to-surface distance between the manual annotations and the final tracked model was 1.00 ± 1.08 mm. Qualitatively, four cases were satisfactory, five passable and one unsatisfactory. Each sequence could be segmented in 2–6 min. |
Our approach enables to segment the mitral valve in 4D-TEE image data with normal and pathological valve closing behavior. With this method, in addition to the quantification of the remaining orifice area, shape and dimensions of the coaptation zone can be analyzed and considered for planning and surgical result assessment. |
Veronesi et al. (2012)3131 Vergnat M, Jackson BM, Cheung AT, et al. Saddle-shape annuloplasty increases mitral leaflet coaptation after repair for flail posterior leaflet. Ann Thorac Surg. 2011;92:797–803.
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Characterized MAC in 3D space before and after MVrepair and to identify the untoward effects of annuloplasty rings on MAC compared with normal valvular function. |
Prospective observational study. RT-3D-TEE was performed on 28 consecutive patients with degenerative MV disease and severe MR before and after MV repair and in 25 age-matched control subjects. Custom software was used to semi-automatically identify the mitral and aortic annuli throughout the cardiac cycle and to measure parameters describing valvular dynamics. |
Patients with MR before MV repair were characterized by altered morphology and function of the MV but preserved MAC because of the maintained ability of the MA to change size and position. MV repair together with annuloplasty ring implantation forced the MA to be smaller and less pulsatile, with decreased displacement ability compared with normal mitral annuli. Because of this alteration in MAC, the “unaffected” aortic annulus became less pulsatile and less mobile. |
This study shows unwanted and unexpected changes in aortic annular function secondary to MV repair with an annuloplasty ring due to altered MAC mechanisms. These changes may alter the dynamic mechanism of the aortic root that facilitates blood ejection, so MAC should be considered and evaluated from diagnosis to treatment in MV disease. |
Wang et al. (2011)1313 Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63:2438–88.
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Delineated the utility of intraoperative TEE in robotic MV repair. |
Prospective observational study. Intraoperative TEE was performed in 22 consecutive patients undergoing robotic MVrepair for severe degenerative MR over a period of 2 years. Before CPB, TEE was used to define the lesions of degenerative MR and the localization of the prolapsed leaflets, and to evaluate the severity of MR. During establishment of peripheral CPB, TEE was used to guide placement of the cannula in the IVC, SVC, and AAO. After weaning from CPB, TEE was used to assess immediately the competency of the surgical repair. |
Agreement between TEE and surgical findings was 92.3% for the lesions of degenerative MR, and 98.5% for the localization of the prolapsed leaflets. Under TEE guidance, all the cannulas in the SVC, IVC, and AAO were placed correctly. TEE demonstrated all the patients had successful robotic MV repairs. |
Intraoperative TEE is a valuable adjunct in the assessment of robotic MVrepair. |
Ender et al. (2010)5454 Wei D, Han J, Zhang H, et al. The correlation between the coaptation height of mitral valve and mitral regurgitation after mitral valve repair. J Cardiothorac Surg. 2017;12:120.
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Evaluated an echocardiographic method to visualize the course and flow of the circumflex artery, to detect iatrogenic injury to this structure intrao-peratively, as well as to predict the coronary dominance pattern in MV surgery patients. |
Prospective study. 110 patients undergoing minimal invasive MV repair. Intraoperative TEE was used to visualize the circumflex artery using a combination of B-mode imaging and color Doppler with different Nyquist limits. The course of the circumflex artery and the coronary sinus and their corresponding diameters were documented at the proximal and distal ends of both vessels. Preoperative angiographic data were used to determine the coronary dominance type. |
The course of the circumflex artery could be detected proximally in 109 patients (99%), to the point of intersection with the coronary sinus in 99 patients (90%), and distal to this intersection in 95 patients (86%). Three patients had evidence of iatrogenic aliasing (circumflex stenosis) or “no flow” (circumflex occlusion) on TEE examination after repair and therefore underwent surgical or percutaneous correction. |
The early recognition of iatrogenic injury of the circumflex artery is feasible with intraoperative TEE examination and may lead to treatment before extensive myocardial infarction occurs. |
Grapsa et al. (2015)3939 Nishi H, Toda K, Miyagawa S, et al. Annular dynamics after mitral valve repair with different prosthetic rings: a real-time three-dimensional transesophageal echocardiography study. Surg Today. 2016;46:1083–90.
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Assessed the papillary muscle strain as a contributor to recurrent MR after MV repair for FED. |
Prospective study. 64 patients with isolated posterior MV prolapse and severe MR referred for surgery. 2D, 3D-TEE and speckle tracking were performed in all patients. The longitudinal strain of the AL and PM papillary muscles were individually calculated as well as the global longitudinal strain of both papillary muscles was measured before and after mitral repair and normalized to left ventricle end-diastolic volume. |
Eight patients (12.5%) had at least moderate MR 6 months after mitral repair. The longitudinal strain of the AL and the PM papillary muscles as well as the global strain of both papillary muscles were all reduced after surgical repair. The longitudinal strain of the PM papillary muscle was the strongest predictor of recurrent MR. The global preoperative papillary muscle strain was also a determinant of recurrent MR when the global strain was greater than 29.05. |
Patients with isolated posterior mitral leaflet prolapse are less likely having any residual MR post repair when the global papillary muscle strain of both papillary muscles is close or equal to zero. Strain of the papillary muscles may be an important determinant in predicting residual MR in patients who undergo mitral valve repair. |
Guo et al. (2018)5252 Bax JJ, Braun J, Somer ST, et al. Restrictive annuloplasty and coronary revascularization in ischemic mitral regurgitation results in reverse left ventricular remodeling. Circulation. 2004;110(11 Suppl 1). II103–8.
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Evaluated the utility of 2D and 3D-TEE to assess MV coaptation before and after MVrepair. |
Prospective study. 48 patients undergoing MV repair for MR were studied. Assessed the utility of 2D and 3D-TEE to assess MV coaptation before and after MV repair. Complete conventional 2D and 3D-TEE studies were performed, and the degree of the MV coaptation defect before and after surgery was assessed by measuring the MV CL and CLI with 2D TEE, and the CA and CAI with 3D-TEE. |
Compared with preoperatively, postoperative CL, CLI, CA, and CAI were significantly increased. Correlation analysis revealed that the CLI and CAI had a significant negative correlation with the degree of MR. Furthermore, correlation analysis revealed that the CLI was significantly correlated with the CAI both preoperatively and postoperatively. |
The coaptation variables increased significantly in patients undergoing MV repair. The CLI and CAI significantly correlated with MR severity. The CL and CLI determined with 2D TEE are more feasible than the CA and CAI determined with 3D-TEE. Both 2D and 3D variables may complement each other for aiding MV repair. 2D CLI is an alternative to 3D CAI due to its simplicity. |
Kang et al. (2013)4444 Essandoh M. Intraoperative echocardiographic assessment of mitral valve area after degenerative mitral valve repair: a call for guidelines or recommendations. J Cardiothorac Vasc Anesth. 2016;30:1364–8.
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Hypothesized that MVA with echocardiography, using 3D-PLAN technique (measured at one point at maximal opening of MV) versus PHT (measured during entire diastolic phase) in MV repair surgery would be different. |
Retrospective study. 26 patients who had undergone MV repair were retrospectively reviewed, and two different observers measured the MVAs using PHTand 3D-PLAN technique. The MVAs derived from recorded medical data, using PHTand 3D-PLAN technique were abbreviated to MVA-PHT1 and MVA-3D1, and data from the PHTand 3D-PLAN techniques by observer A and observer B were determined as MVA-PHT2 and MVA-3D2, and MVA-PHT3 and MVA-3D3, respectively. The MVA derived by post-operative TTE using the PHT technique was determined as MVA-TTE. |
Intraclass correlation coefficients were 0.90 for the intra-operative PHT technique and 0.78 for the intra-operative 3D-PLAN technique. MVA-3D1, MVA-3D2 and MVA-3D3 were significantly larger than MVA-TTE, but intraoperative MVAs-PHTwere not. |
MVA measured by 3D-PLAN technique with TEE at the intraoperative post-MV repair period was seemed to be larger than that measured by the PHT technique with TTE at the postoperative period. However, it did not mean that the 3D-PLAN technique was inaccurate but needs cautions at determination of MVA using different techniques. |
Karamnov et al. (2020)4545 Vernick WJ, Ochroch EA, Horak J, et al. Validation study of Doppler-derived transmitral valve gradients compared to near simultaneously obtained directly measured catheter gradients immediately after mitral valve repair surgery. J Card Surg. 2013;28:329–35.
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Compared repaired MVAs obtained with commonly used 2D and 3D echocardiographic methods to a 3DOA, which is a novel echocardiographic measurement and independent of geometric assumptions |
Retrospective study. Intraoperative 2D and 3D TEE images from 20 patients who underwent MV repair for MR obtained immediately after repair were retrospectively reviewed. MVAs obtained by PHT, 2D-PLAN, and 3D-PLAN were compared to those derived by 3DOA. |
MVAs obtained by the 3DOA method were significantly smaller compared to those obtained by PHT, 2DP, and 3DP. In addition, MVA defined as an area ≤1.5 cm22 Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet. 2009;373:1382–94. was identified by 3DOA in 2 patients and by 3DP in 1 patient. |
Post-MV repair, MVAs obtained using the novel 3DOA method were significantly smaller than those obtained by conventional echocardiographic methods and may be consistent with a higher incidence of MVA reduction when compared to 2D techniques. |
Maslow et al. (2011)4040 Owais K, Kim H, Khabbaz KR, et al. In-vivo analysis of selectively flexible mitral annuloplasty rings using three-dimensional echocardiography. Ann Thorac Surg. 2014;97:2005–10.
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3 different methods to measure MVA after MV repair were studied. Data obtained immediately after repair were compared with postoperative data. The objective was to determine the feasibility and correlation between intraoperative and postoperative MVA data. |
Prospective study. 25 patients scheduled for MV repair surgery. Echocardiographic data included MVAs obtained using the PHT, 2D-PLAN, and the CE. These data were obtained immediately after CPB and were compared with data obtained before hospital discharge (transthoracic echocardiogram 1) and 6 to 12-months after surgery (transthoracic echocardiogram 2). Intraoperative care was guided by hemodynamic goals designed to optimize cardiac function. |
The data show good agreement and correlation between MVA obtained with PHTand 2D-PLAN within and between each time period. MVA data obtained with the CE in the postoperative period were lower than and did not correlate or agree as well with other MVA data. |
The MVA recorded immediately after valve repair, using PHT, correlated and agreed with MVA data obtained in the postoperative period. |
Riegel et al. (2011)4343 Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, et al. Guidelines for the use of transesophageal echocardiography to assist with surgical decision-making in the operating room: a surgery-based approach: from the american society of echocardiography in collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr. 2020;33:692–734.
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Hypothesized that intraoperative echocardiography can be utilized to diagnose iatrogenic MS immediately after MV repair. |
Retrospective study. Data of 552 consecutive patients undergoing MVrepair at a single institution were reviewed. Post-CPB peak and mean TMPG, and PHT were obtained from intraoperative TEE examinations in each patient. |
Nine patients received a reoperation for primary MS, prior to hospital discharge. All of these patients already showed intraoperative post-CPB mean and peak TMPGs that were significantly higher compared to values for those who did not However, PHT varied considerably within the entire population, and only weakly predicted the requirement for reoperation Receiver operating characteristic curves showed strong discriminating ability for mean gradients and peak gradients, but poor performance for PHT. A value of 7 mmHg for mean, and 17 mmHg for peak TMPG, best separated patients who required reoperation for MS from those who did not. |
Intraoperative TEE diagnosis of a peak TMPG 17 mmHg or mean TMPG 7 mmHg immediately following CPB are suggestive of clinically relevant MS after MV repair. |
Vernick et al. (2013)4242 Maslow A, Gemignani A, Singh A, et al. Intraoperative assessment of mitral valve area after mitral valve repair: comparison of different methods. J Cardiothorac Vasc Anesth. 2011;25:221–8.
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Evaluated the accuracy of Doppler-derived transmitral valve gradients immediately after MV repair by comparing them with near simultaneously obtained direct catheter gradients. |
Prospective study. 20 patients presenting for MV repair surgery. After completion of the MV repair and subsequent cardiac de-airing, the patient was weaned from CPB. Immediately after separation, near simultaneous transmitral Doppler gradients were obtained with directly measured catheter gradients via the vent catheter. |
While the mean peak gradient difference of 1.1 mmHg was small, the correlation between Doppler and catheter gradient measurements only approached statistical significance due to the large variance associated with the small sample size. In all patients with a peak gradient greater than 10 mmHg (4 of the 20 patients), overestimation of catheter gradients by Doppler occurred, with two showing a 62% to 73% discrepancy. In these two cases, there was also evidence for elevated LVEDP along with high transmitral blood flow velocities. |
Doppler-derived transmitral gradients provide a simple, safe, and reliable measure of the true physiologic transmitral valve gradient. At the same time, it is important to recognize that significant Doppler over-estimation of catheter gradients may occur in patients with elevated Doppler transmitral velocities. |
Mabrouk-Zerguini et al. (2008)5353 Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: best practice revolution. Eur Heart J. 2010;31:1958–66.
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Tested the hypothesis where the Tei-index could be useful in assessing the perioperative cardiac function in patients undergoing MV repair. |
Prospective study. 25 patients were enrolled. TEE was performed perioperatively before and after the correction of MR. We compared the impact of the MV repair on the left ventricular FAC and the Tei-index. FAC was calculated from the transgastric short-axis view and Tei-index was determined from the four chambers and deep transgastric views. |
FAC significantly decreased after MVR from 53% to 42%, while Tei index was unaffected. A significant relationship was found between the preoperative Tei index and the postoperative FAC. Moreover, a significant and clinically relevant relationship was determined between the predicted (using preoperative Tei-index) and the measured postoperative FAC. |
FAC but not the Tei index is influenced by MVR. The preoperative determination of the Tei index allows predicting postoperative FAC and offers the opportunity to identify patients in whom a severe unsuspected systolic dysfunction could render difficult the weaning from CPB. |
Manabe et al. (2012)3232 Ben Zekry S, Jain S, Alexander SK, et al. Novel parameters of global and regional mitral annulus geometry in man: comparison between normals and organic mitral regurgitation, before and after mitral valve repair. Eur Heart J Cardiovasc Imaging. 2016;17:447–57.
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Investigated SAM of the MV mechanism by analysing the change in MV morphology associated with operative procedures. |
Retrospective study. Components of MV were measured before and after operative procedures by TEE in 179 patients who underwent MV repair. Comparisons were made between 15 patients with SAM (SAM group) and 164 patients without SAM (non-SAM group). |
Operative procedures shifted the coaptation point towards the LVOT by 6.9 mm and increased the extra portion of anterior leaflet that extended beyond the coaptation point by 5.4 mm. These changes were enhanced in the SAM group. Intergroup comparison revealed that there were no differences in the pre-operative MV morphologies between the two groups. After operative procedures, however, the SAM group showed smaller annular diameter and smaller coapted anterior/posterior length ratio compared with the non-SAM group. |
The results of this study show that operative procedures might modify the morphology of MV susceptible to developing SAM. Postoperative smaller annular diameter and anterior shift of coaptation point were considered to contribute to the development of SAM. |
Rosendal et al. (2012)3333 Veronesi F, Caiani EG, Sugeng L, et al. Effect of mitral valve repair on mitral-aortic coupling: a real-time three-dimensional transesophageal echocardiography study. J Am Soc Echocardiogr. 2012;25:524–31.
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RT-3D-TEE permits excellent visualization of the LVOTand might improve standard 2D measurements. In this study, LVOTarea and shape were assessed before and after MV surgery. |
Retrospective study. 35 patients undergoing MV repair or replacement were compared with 15 patients undergoing coronary artery bypass grafting. LVOT area was measured by planimetry. Maximum possible methodologic errors by assuming a circular LVOT and an eccentricity index were calculated. LVOT diameter in a midesophageal long-axis view served to calculate the error for the circular LVOT determined in common intraoperative practice. |
Common intraoperative 2D measurements underestimated actual LVOT area by 21%. MV surgery led to a significant reduction of LVOTarea by 7%. Although LVOT height remained unchanged, width decreased, resulting in a more circular shape of the LVOT. This effect was more pronounced the smaller the size of the implanted annuloplasty ring or prosthesis. Coronary artery bypass grafting did not affect the LVOT. LVEF was significantly correlated with LVOT eccentricity. Impaired ventricular function and higher end-systolic volumes were associated with a rounder shape. |
The eccentric LVOTshape leads to a distinct underestimation of its area with 2D measurements. LVOT eccentricity is less distinct in patients with low ejection fractions and higher end-systolic volumes. LVOTwidth is decreased through annuloplasty rings and prostheses, and the smaller the implanted device, the more profound the reduction. |
Vergnat et al. (2011)2929 Maslow A, Mahmood F, Poppas A, et al. Three-dimensional echocardiographic assessment of the repaired mitral valve. J Cardiothorac Vasc Anesth. 2014;28:11–7.
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Hypothesized that saddleshaped annuloplasty would improve leaflet coaptation in cases of MV repair for flail posterior leaflet segments. |
Prospective study. 16 with flail posterior segment and severe MR had MV repair using standard techniques. 8 patients received saddle-shaped annuloplasty and 8 patients received flat annuloplasty. RT-3D-TEE was performed before and after repair. Images were analyzed using custom software to calculate MAA, SLD, CW, TLA, and LCA. |
Post-repair MAA and TLA were similar in both groups. Post-repair LCA was significantly greater in the saddle group than in the flat group. |
When compared with flat annuloplasty, saddle-shaped annuloplasty improves LCA after MV repair for severe MR secondary to flail posterior leaflet segment. Use of saddle-shaped annuloplasty devices may increase repair durability. |
Vergnat et al. (2012)2828 Mahmood F, Karthik S, Subramaniam B, et al. Intraoperative application of geometric three-dimensional mitral valve assessment package: a feasibility study. J Cardiothorac Vasc Anesth. 2008;22:292–8.
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Used RT-3D-TEE to assess the influence of the ring shape on leaflet curvature in patients with IMR. |
Prospective study. RT-3D-TEE was performed in 21 patients with IMR after placement of either a flat or saddle shaped annuloplasty ring. A combination of commercially available and customized software was used to measure multiple leaflet curvature parameters across all regions of the MV. |
Independently of the shape of the annuloplasty ring, all patients were subject to the same degree of annular undersizing. Patients who received saddle-shaped annuloplasty rings had greater leaflet curvature in all six MV leaflet regions compared with patients who received flat annuloplasty rings. These differences were statistically significant in all regions except the P1 region. |
Saddle-shaped annuloplasty rings increase leaflet curvature compared with flat rings in patients with IMR. As a result, saddle-shaped annuloplasty may decrease leaflet stress and potentially increases the durability of the repair in patients with IMR. |
Wei et al. (2017)5151 Greenhouse DG, Dellis SL, Schwartz CF, et al. Regional changes in coaptation geometry after reduction annuloplasty for functional mitral regurgitation. Ann Thorac Surg. 2012;93:1876–80.
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Investigated the association between the CH of MVand MR after MV repair. |
Retrospective study with prospective follow-up. 20 patients that underwent MV valvuloplasty for MR were included. Ring annuloplasty was performed in all cases. MVd, CH, LVEF were measured by TEE before the operation in operation room and 3 months and 12 months after the operation by the TEE. A degree from 0 to 4 was used to measure the degree of MR. |
There were 14 patients with 0, 3 patients with 1, 3 patients with 2 of MR 12 months after the operation. CH increased significantly at 3 months and 12 months after operation. MVd and LVEF were not significantly changed after MV repair. Furthermore, CH after resuscitation have a statistically significant negative correlation with the degree of MR 12 months after operation. |
The MV repair with MV ring induces the morphologic change of the MV structure. The increase of CH after MV repair may be one of the main factors in regulation of MR. |