Intraoperative evaluation of mitral valve regurgitation and repair by transesophageal echocardiography: Incidence and significance of systolic anterior motion

AbstractObjectives. This study was designed to delineate the utility and results of intraoperative transesophageal echocardiography in the evaluation of patients undergoing mural valve repair for mitral regurgitation.Background. Mitral valve reconstruction offers many advantages over prosthetic valve replacement. Intraoperative assessment of valve competence after repair is vital to the effectiveness of this procedure.Methods. Intraoperative transesophageal echocardiography was performed in 143 patients undergoing mitral valve repair over a period of 23 months, Before and after repair, the functional morphology of the mitral apparatus was defined by twodimensional echocardiography; Doppler color flow imaging was used to clarify the mechanism of mitral regurgitation and to semiquantitate its severity.Results. There was significant improvement in the mean mitral regurgitation grade by composite intraoperative transesophageal echocardiography after valve repair (3.6 ± 0.8 to 0.7 ± 0.7; p < 0.00001). Excellent results from initial repair with grade ≤ 1 residual mitral regurgitation were observed in 88.1% of patients. Significant residual mitral regurgitation (grade ≥ 3) was identified in 11 patients (7.7%); 5 underwent prosthetic valve replacement, 5 had revision of the initial repair and 1 patient had observation only. Of the 100 patients with a myxomatous mitral valve, the risk of grade ≥ 3 mitral regurgitation after initial repair was 1.7% in patients with isolated posterior leaflet disease compared with 22.5% in patients with anterior or bileaflet disease.Severe systolic anterior motion of the mitral apparatus causing grade 2 to 4 mitral regurgitation was present in 13 patients (9.1%) after cardiopulmonary bypass. In 8 patients (5.6%), systolic anterior motion resolved immediately with correction of hyperdynamic hemodynamic status, resulting in grade ≤ 1 residual mitral regurgitation without further operative intervention.Transthoracic echocardiography before hospital discharge demonstrated grade ≤ 1 residual mitral regurgitation in 86.4% of 132 patients studied. A significant discrepancy (> 1 grade) in residual mitral regurgitation by predischarge transthoracic versus intraoperative transesophageal echocardiography was noted in 17 patients (12.9%).Conclusions. Transesophageal echocardiography is a valuable adjunct in the intraoperative assessment of mitral valve repair

Functional anatomy of mitral regurgitation Accuracy and outcome implications of transesophageal echocardiography

AbstractOBJECTIVESThis study was performed to determine the accuracy and outcome implications of mitral regurgitant lesions assessed by echocardiography.BACKGROUNDIn patients with mitral regurgitation (MR), valve repair is a major incentive to early surgery and is decided on the basis of the anatomic mitral lesions. These lesions can be observed easily with transesophageal echocardiography (TEE), but the accuracy and implications for outcome and clinical decision-making of these observations are unknown.METHODSIn 248 consecutive patients operated on for MR, the anatomic lesions diagnosed with TEE were compared with those observed by the surgeon and those seen on 216 transthoracic echocardiographic (TTE) studies, and their relationship to postoperative outcome was determined.RESULTSCompared with surgical diagnosis, the accuracy of TEE was high: 99% for cause and mechanism, presence of vegetations and prolapsed or flail segment, and 88% for ruptured chordae. Diagnostic accuracy was higher for TEE than TTE for all end points (p < 0.001), but the difference was of low magnitude (<10%) except for mediocre TTE imaging or flail leaflets (both p < 0.001). The type of mitral lesions identified by TEE (floppy valve, restricted motion, functional lesion) were determinants of valve repairability and postoperative outcome (operative mortality and long-term survival; all p < 0.001) independent of age, gender, ejection fraction and presence of coronary artery disease.CONCLUSIONSTransesophageal echocardiography provides a highly accurate anatomic assessment of all types of MR lesions and has incremental diagnostic value if TTE is inconclusive. The functional anatomy of MR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome. Therefore, the mitral lesions assessed by echocardiography represent essential information for clinical decision making, particularly for the indication of early surgery for MR

Unlocking the Mysteries of Diastolic Function Deciphering the Rosetta Stone 10 Years Later

It has now been a quarter of a century since the first description by Kitabatake and his associates of the use of echo-Doppler to characterize the transmitral flow velocity curves in various disease states. A decade ago we described the role of echocardiography in the “Evaluation of Diastolic Filling of Left Ventricle in Health and Disease: Doppler Echocardiography Is the Clinician’s Rosetta Stone.” Over the ensuing decade, advances in echo-Doppler have helped to further decipher the morphologic and physiological expression of cardiovascular disease and unlock additional mysteries of diastology. The purpose of this review is to highlight the developments in echo-Doppler and refinements in our knowledge that have occurred over the past decade that enhance our understanding of diastology

Telemedicine: An Application in Search of Users

http://acts.grc.nasa.gov/docs/SCAN_20010911140845.pdf Telemedicine involves the use of telecommunication technologies as a medium for the providion of medical information and services to consumers at sites that are at a distance from the provider. The concept encompasses everything from the telephone system to high-speed, wide-bandwidth transmission with use of fiberoptics, satellites, or a combination of terrestrial and satellite-communication technologies. The peripheral software could be as simple as a typewriter used to type a letter requesting an opinion or as complex as high-capacity parallel processing computers and imaging devices. Although the definition includes telephone, facsimile, and distance learning, the term telemedicine is currently used as a generic laber for remote consultation and diagnosis. Telemedicine is not a meducal subspecialty but a facilitator of all medical and surgical specialties

Dr. Bijoy Khandheria, Assistant Professor at Mayo Clinic on speech pathology discussing an application of telemedicine (Critical Perspectives From the Industry)

Dr. Bijoy Khandheria, Assistant Professor at Mayo Clinic on speech pathology discussing an application of telemedicin