Intraoperative Doppler color flow mapping for decision-making in valve repair for mitral regurgitation. Technique and results in 100 patients.

Abstract

Mitral valve repair provides substantial advantages over mitral valve replacement in patients with severe mitral regurgitation. However, because of the possibility of persistent regurgitation, an intraoperative technique is needed to provide an immediate and accurate assessment of the adequacy of the repair before closure of the chest. One hundred patients with pure mitral regurgitation were studied with intraoperative epicardial Doppler color flow mapping immediately before and after valve repair. Intraoperative assessment of the severity of mitral regurgitation showed good agreement with preoperative left ventriculography and with standard precordial Doppler echocardiography before and after surgery. Postrepair intraoperative Doppler studies showed satisfactory surgical results in 92 patients. Postrepair intraoperative Doppler studies in the remaining eight patients demonstrated unsatisfactory results: persistent significant regurgitation in four, systolic anterior motion of the mitral valve with dynamic left ventricular outflow tract obstruction in three, and a persistent flail leaflet in one. In six of the eight patients, further surgery was performed during the same thoracotomy. In two patients, the intraoperative postrepair Doppler findings of persistent regurgitation were confirmed on precordial Doppler studies within 5 days, and mitral reoperation was required. Intraoperative epicardial Doppler color flow mapping provided a "safety net" that ensured a successful outcome in all 100 patients by providing the surgeon with a direct means to assess the success of the operation and the need for further surgery. (Circulation 1990;81:556-566 persist at the end of the operation. Therefore, the results of mitral reconstruction might be further enhanced by a rapid and reliable intraoperative method of detecting and quantitating residual mitral regurgitation.The purpose of the present study was to determine the usefulness of intraoperative epicardial Doppler color flow mapping in evaluating the integrity of the mitral valve immediately after valve repair for mitral regurgitation. Methods PatientsDuring a 30-month period, 392 mitral operations were performed at our institution in patients with mitral regurgitation without significant concomitant stenosis. Of the 250 patients who had valve repair as the primary surgical treatment during this period, echocardiographic equipment was available in 100 patients to perform intraoperative echocardiography

Mitral valve repair with a malleable bovine pericardium ring

“…At a later date, the same group clinically confirmed this by reporting such rings to be a determinant for depressed ventricular function 14 , and supporting the use of malleable rings in carriers of a rheumatic valve pathology with reduced annular contractility, as occurred in 87.6% of the presently studied cases. Furthermore, the rigid ring may also cause the obstruction of the left ventricular outflow tract observed in 4.5 to 10% of the cases [15][16][17][18] , a fact not observed in annuloplasty with completely flexible rings 14,31 or with flexible posterior rings 26,28,29 , results of the present study included.…”

“…These techniques started to be used together with annuloplasty for recovery of valve function 7,12 . Accumulated experience and new concepts about the physiology of the mitral valve apparatus showed the limitations of this technique, such as fixation of the contractile annulus 13,14 and eventual obstruction of left ventricle outflow [15][16][17][18][19] .…”

2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

“…Studies have documented the impact of intraoperative transesophageal echocardiography on valve surgery, with changes in the operative plan based on transesophageal echocardiography findings reported in 11% to 14% of cases and detection of problems with surgical procedure and subsequent need to return to cardiopulmonary bypass reported in 2% to 6%. [923][924][925][926] Other important aspects of transesophageal echocardiography during valve surgery include assessment of ventricular function and detection of intracardiac air and aortic dissection.…”

“…Intraoperative transesophageal echocardiography may provide additional information about the mechanism of regurgitation and may be helpful to direct the decision whether to repair or replace the valve. 923,924,933 Thus, intraoperative transesophageal imaging should be used whenever a repair is contemplated. Intraoperative transesophageal echocardiography should also be used to evaluate the results of an MV repair immediately after cardiopulmonary bypass to assess for residual MR, systolic anterior motion of the valve leaflets, and restriction of mitral opening with stenosis.…”

Primary mitral valve regurgitation: Update and review

“…5,28 Transthoracic echocardiography can differentiate primary from secondary regurgitation and provide anatomic information that support repair over replacement of the valve. 29,30 Doppler echocardiography provides significant information on the severity of the mitral regurgitation. Qualitative assessment of the regurgitant jet area using color flow Doppler is influenced by the cause of the regurgitation and the jet eccentricity and it should not be used alone for the grading of the lesion severity.…”