Intraoperative transesophageal Doppler color flow imaging used to guide patient selection and operative treatment of ischemic mitral regurgitation.

Abstract

These results indicate that TDCF is useful in guiding patient selection and operative treatment of ischemic MR and that in such patients, intraoperative TDCF should be performed routinely.

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.…”

Ischemic Mitral Regurgitation on the Threshold of a Solution

“…This frequent scenario has led to recognition that anesthetic induction and inotropic agents can substantially reduce MR, confounding decisions regarding repair. [47][48][49] Phenylephrine can restore representative driving pressures but may fail to reproduce volume-dependent tethering, so intravenous volume loading has also been advocated, titrated to ventricular diameter, mean blood pressure Ն90 mm Hg, and wedge pressure of 12 mm Hg. 47 Practically, some surgeons advocate decisions based on the appearance of restricted leaflet closure and prior MR assessment under routine loading conditions.…”

“…43 Evaluation at rest may underrepresent the burden on the active patient, 50 and intraoperative evaluation is heavily influenced by changes in load and tethering. [47][48][49] …”

Trends in the surgical management of ischemic mitral regurgitation

“…Proponents argue that the results of TEE will often change the assessment of MR degree and, hence, the procedure performed [31]; however, as noted above, the degree of regurgitation will be dependent on loading conditions [8•]. Although efforts to correct for this effect including volume loading and the administration of vasopressors may enhance the degree of MR [31], it may be argued that if these maneuvers render the as yet unrevascularized myocardium ischemic, this too may poorly predict the response to revascularization alone.…”