Mitral Regurgitation Grading in the Operating Room: A Systematic Review and Meta-analysis Comparing Preoperative and Intraoperative Assessments During Cardiac Surgery

The Emperor Has No Clothes: Recognizing the Limits of Current Echocardiographic Technology in Perioperative Quantification of Mitral Regurgitation

“…26 The meta-analysis by Sanfilippo et al highlight a profound problem with the current ability to assess mitral regurgitation in patients receiving anesthesia. 3 The way forward does not lie in complacency and stagnation. The way forward will be found through innovation and exploration.…”

“…Sanfilippo et al specifically addressed the discrepancies in mitral regurgitation assessment related to altered loading conditions associated with anesthesia. 3 Even though it would appear to be common sense that the altered physiologic state of patients under general anesthesia has a significant effect on measured hemodynamic metrics in perioperative echocardiography, there is a paucity of literature on this subject. In practice, perioperative measurements guide surgical decision-making and as such can lead to the inappropriate repair and replacement of valves.…”

“…In this issue of the Journal, the meta-analysis by Sanfilippo et al tackles the difficulty of assessing mitral regurgitation while patients are subjected to nonphysiologic loading conditions caused by general anesthesia. 3 They concluded that the principle goal of imaging should be to elucidate anatomic details relevant for procedural guidance, rather than grading the severity of mitral regurgitation. The decision to intervene or not should be made before administering anesthesia under normal physiologic loading conditions.…”

Echocardiographic and hemodynamic assessment for predicting early clinical events in severe acute mitral regurgitation

“…Nevertheless, this can be replaced by pulmonary capillary wedge pressure by right heart catheterization since good correlation between these variables has been shown in various settings [8]. Second, although all the animals underwent the same anesthesia protocol, we cannot exclude its impact on the degree of MR as well as hemodynamic parameter assessments [9]. Third, different etiologies of AMR may significantly impact patient segmentation, especially for active endocarditis cases with large or unstable vegetation.…”

The Right Answer

“…Recently, the guidelines published to assist with these decisions were revised in part due to new studies evaluating the appropriateness of surgical intervention for moderate ischemic mitral regurgitation (MR) at the time of CABG surgery and for mitral valve replacement (MVR) versus repair for severe symptomatic ischemic MR. [1][2][3][4][5][6] Known limitations of assessing the severity of MR with transesophageal echocardiography (TEE) in the operating room under general anesthesia with mechanical ventilation further complicate the decision-making process. 7,8 For these reasons, a skilled echocardiographer is essential as a member of the cardiac surgery team to interpret and present the echocardiographic findings with consideration for the patient's preoperative and present clinical condition and the skill and comfort level of the surgical team.…”