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Prasad P, Chandrashekar P, Golwala H, Macon CJ, Steiner J. Functional Mitral Regurgitation: Patient Selection and Optimization. Interv Cardiol Clin 2024; 13:167-182. [PMID: 38432760 DOI: 10.1016/j.iccl.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Functional mitral regurgitation appears commonly among all heart failure phenotypes and can affect symptom burden and degree of maladaptive remodeling. Transcatheter mitral valve edge-to-edge repair therapies recently became an important part of the routine heart failure armamentarium for carefully selected and medically optimized candidates. Patient selection is considering heart failure staging, relevant comorbidities, as well as anatomic criteria. Indications and device platforms are currently expanding.
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Affiliation(s)
- Pooja Prasad
- Division of Cardiology, University of California-San Francisco, 505 Parnassus Avenue, Suite M1182, Box 0124, San Francisco, CA 94143, USA
| | - Pranav Chandrashekar
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Harsh Golwala
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Conrad J Macon
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Johannes Steiner
- Knight Cardiovascular Institute, Oregon Health & Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA.
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2
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Wang H, Oran A, Butler CG, Fox JA, Shernan SK, Muehlschlegel JD. Preoperative Tricuspid Regurgitation Is Associated With Long-Term Mortality and Is Graded More Severe Than Intraoperative Tricuspid Regurgitation. J Cardiothorac Vasc Anesth 2023; 37:1904-1911. [PMID: 37394388 DOI: 10.1053/j.jvca.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 05/03/2023] [Accepted: 06/09/2023] [Indexed: 07/04/2023]
Abstract
OBJECTIVES To determine whether preoperative (preop) tricuspid regurgitation (TR) severity grade was associated with postoperative mortality, to examine the correlation between pre-op and intraoperative (intraop) TR grades, and to understand which TR grade had better prognostic predictability in cardiac surgery patients. DESIGN Retrospective. SETTING Single institution. PARTICIPANTS Patients. INTERVENTIONS Preop and intraop echocardiography TR grades of 4,232 patients who had undergone cardiac surgeries between 2004 and 2014 were examined. MEASUREMENTS AND MAIN RESULTS Kaplan-Meier curves and Cox proportional hazard models were used to determine the association between TR grades and the primary endpoint of all-cause mortality. The Wilcoxon signed-rank test and Spearman's rank correlation were analyzed to assess the similarity and correlation between preop and intraop-grade pairs. Multivariate logistic regression models of the area under the curve characteristics were compared for prognostic implications. Kaplan-Meier curves demonstrated a strong relationship between preop grades and survival. Multivariate models showed significantly increased mortality starting at mild preop TR (mild TR: hazard ratio [HR] 1.24; 95% CI 1.05-1.46, p = 0.013; moderate TR: HR 1.60; 95% CI 1.05-1.97, p < 0.001; severe TR: HR 2.50; 95% CI 1.74-3.58, p < 0.001). Preop TR grades were mostly higher than intraop grades. Spearman's correlation was 0.55 (p < 0.001). The area under the curves of preop and intraop TR-based models were almost identical (0.704 v 0.702 1-year mortality and 0.704 v 0.700 2-year mortality). CONCLUSIONS The authors found that echocardiographically-determined preop TR grade at the time of surgical planning was associated with long-term mortality, starting even at a mild grade. Preop grades were higher than intraop grades, with a moderate correlation. Preop and intraop grades exhibited similar prognostic implications.
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Affiliation(s)
- Huan Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ali Oran
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Carolyn G Butler
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - John A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stanton K Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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Duncan CF, Bowcock E, Pathan F, Orde SR. Mitral regurgitation in the critically ill: the devil is in the detail. Ann Intensive Care 2023; 13:67. [PMID: 37530859 PMCID: PMC10397171 DOI: 10.1186/s13613-023-01163-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/03/2023] [Indexed: 08/03/2023] Open
Abstract
Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.
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Affiliation(s)
- Chris F Duncan
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia.
| | - Emma Bowcock
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
| | - Faraz Pathan
- Department of Cardiology, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- Nepean Clinical School of Medicine, Charles Perkin Centre Nepean, University of Sydney, Kingswood, Sydney, NSW, 2747, Australia
| | - Sam R Orde
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, Sydney, NSW, 2747, Australia
- University of Sydney, Camperdown, Sydney, NSW, 2006, Australia
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Bieliauskienė G, Kažukauskienė I, Janušauskas V, Zorinas A, Ručinskas K, Mainelis A, Zakarkaitė D. The Early Effects on Tricuspid Annulus and Right Chambers Dimensions in Successful Tricuspid Valve Bicuspidization. J Clin Med 2023; 12:4093. [PMID: 37373786 DOI: 10.3390/jcm12124093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/10/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND It is unclear to what degree of tricuspid annulus (TA) reduction is necessary to achieve good postoperative results in surgical bicuspidization. The study aimed to evaluate TA and right heart chamber's dimensions before and after heart surgery; and to compare TA parameters assessed by different modalities. METHODS Forty patients underwent mitral valve surgery with or without concomitant tricuspid valve (TV) bicuspidization. Preoperative and postoperative measurements of TA dimensions were performed prospectively using two-dimensional (2D) and three-dimensional (3D) transthoracic echocardiography (TTE). Additionally, preoperative transesophageal echocardiography (TOE) was performed in the operating room prior to surgery. RESULTS All patients had no or mild TR immediately after surgery. There was a significant reduction in 2D and 3D parameters of the TV and right chambers in the TV bicuspidization group. However, TV leaflets' tethering parameters did not change significantly. Preoperative 3D TTE measurements were smaller than those obtained through 3D TOE in the operation room, before surgery under general anesthesia. The 2D systolic apical 4Ch diameter and the parasternal short axis diameter mainly represent the 3D minor axis of the TA and are smaller than its 3D major axis. CONCLUSIONS Although bicuspidization results in a one-third reduction of the TV area, tethering of the TV leaflets remains unchanged. Moreover, 3D TOE parameters of the TV under general anesthesia are larger than preoperative 3D TTE measurements. Conventional 2D measurements are insufficient for evaluating the maximum diameter of the TA.
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Affiliation(s)
- Gintarė Bieliauskienė
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Čiurlionio 21, 03101 Vilnius, Lithuania
| | - Ieva Kažukauskienė
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Čiurlionio 21, 03101 Vilnius, Lithuania
| | - Vilius Janušauskas
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Čiurlionio 21, 03101 Vilnius, Lithuania
| | - Aleksejus Zorinas
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Čiurlionio 21, 03101 Vilnius, Lithuania
| | - Kęstutis Ručinskas
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Čiurlionio 21, 03101 Vilnius, Lithuania
| | - Antanas Mainelis
- Faculty of Mathematics and Informatics, Vilnius University, Naugarduko 24, 03225 Vilnius, Lithuania
| | - Diana Zakarkaitė
- Clinic of Cardiovascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, M. K. Čiurlionio 21, 03101 Vilnius, Lithuania
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Alachkar MN, Kirschfink A, Grebe J, Schälte G, Almalla M, Frick M, Schröder JW, Vogt F, Marx N, Altiok E. General Anesthesia Leads to Underestimation of Regurgitation Severity in Patients With Secondary Mitral Regurgitation Undergoing Transcatheter Mitral Valve Repair. J Cardiothorac Vasc Anesth 2021; 36:974-982. [PMID: 34799263 DOI: 10.1053/j.jvca.2021.10.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/25/2021] [Accepted: 10/16/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To evaluate the effect of general anesthesia (GA) on severity of mitral regurgitation (MR) in patients undergoing transcatheter mitral valve repair (TMVR). DESIGN Retrospective cohort study. SETTING Tertiary care university hospital. PARTICIPANTS Fifty consecutive patients with symptomatic severe MR and extremely high surgical risk. INTERVENTION TMVR under GA. MEASUREMENTS AND RESULTS Transesophageal echocardiography was performed during the preprocedural workup under conscious sedation and during TMVR under GA. After the parameters of MR were assessed, color-flow jet area (CJA), vena contracta (VC), effective regurgitant orifice area (EROA), regurgitant volume (RVOL), three-dimensional (3D) vena contracta area (VCA), and severity of MR were compared between the two examinations. In patients with primary MR (n = 11), there were no significant differences in CJA, VC, EROA, RVOL, or 3D-VCA between pre- and intraprocedural transesophageal echocardiography. In patients with secondary MR (n = 39), GA led to significant decreases of CJA (10 ± 7 v 7 ± 3 cm², p < 0.001), VC (5.5 ± 1.6 v 4.7 ± 1.5 mm, p = 0.002), EROA (30 ± 11 v 24 ± 10 mm², p < 0.001), and RVOL (47 ± 17 v 34 ± 13 mL/beat, p < 0.001). Consequently, GA led to a downgrade of regurgitation severity classification in 44% of patients when assessed by two-dimensional analysis. When evaluated by 3D analysis, GA also led to a significant but less extensive decrease of MR (3D-VCA: 66 ± 27 v 60 ± 29 mm², p = 0.002), and subsequent downgrade of MR classification in 20% of patients. CONCLUSIONS GA underestimates regurgitation severity in patients with secondary, but not primary MR, undergoing TMVR. This effect must be considered when evaluating the immediate result of the procedure.
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Affiliation(s)
- Mhd Nawar Alachkar
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany.
| | - Annemarie Kirschfink
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Julian Grebe
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Gereon Schälte
- Department of Anaesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Mohammad Almalla
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Frick
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Jörg W Schröder
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Felix Vogt
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
| | - Ertunc Altiok
- Department of Cardiology, Angiology and Intensive Care, University Hospital RWTH Aachen, Aachen, Germany
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Bedair AH. This Time, It's Really Anesthesia's Fault. J Cardiothorac Vasc Anesth 2021; 36:338-339. [PMID: 34598865 DOI: 10.1053/j.jvca.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Ali H Bedair
- Division of Cardiothoracic and Vascular Anesthesiology, Baptist Memorial Hospital Memphis, TN; Department of Anesthesiology, College of Medicine, University of Tennessee Health Science Center Memphis, TN.
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Richter EW, Shehata IM, Elsayed-Awad HM, Klopman MA, Bhandary SP. Mitral Regurgitation in Patients Undergoing Noncardiac Surgery. Semin Cardiothorac Vasc Anesth 2021; 26:54-67. [PMID: 34467794 DOI: 10.1177/10892532211042827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Mitral regurgitation (MR) is one of the most frequently encountered types of valvular heart disease in the United States. Patients with significant MR (moderate-to-severe or severe) undergoing noncardiac surgery have an increased risk of perioperative cardiovascular complications. MR can arise from a diverse array of causes that fall into 2 broad categories: primary (diseases intrinsic to the valvular apparatus) and secondary (diseases that disrupt normal valve function via effects on the left ventricle or mitral annulus). This article highlights key guideline updates from the American College of Cardiologists (ACC) and the American Heart Association (AHA) that inform decision-making for the anesthesiologist caring for a patient with MR undergoing noncardiac surgery. The pathophysiology and natural history of acute and chronic MR, staging of chronic primary and secondary MR, and considerations for timing of valvular corrective surgery are reviewed. These topics are then applied to a discussion of anesthetic management, including preoperative risk evaluation, anesthetic selection, hemodynamic goals, and intraoperative monitoring of the noncardiac surgical patient with MR.
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Asher SR, Malzberg GW, Ong CS, Malapero RJ, Wang H, Shekar P, Kaneko T, Pelletier MP, Mallidi H, Heydarpour M, Shook DC, Shernan SK, Fox JA, Muehlschlegel JD, Xu X, Nguyen TB, Sundt TM, Body SC. Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality. Interact Cardiovasc Thorac Surg 2021; 32:9-19. [PMID: 33313764 DOI: 10.1093/icvts/ivaa230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 08/10/2020] [Accepted: 09/03/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P. METHODS Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics. RESULTS In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)]. CONCLUSIONS In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.
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Affiliation(s)
- Shyamal R Asher
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI, USA
| | - Gregory W Malzberg
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Chin Siang Ong
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Raymond J Malapero
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Huan Wang
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Prem Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Marc P Pelletier
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Hari Mallidi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mahyar Heydarpour
- Division of Endocrinology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Douglas C Shook
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Stanton K Shernan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - John A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - J Daniel Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Xinling Xu
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Thy B Nguyen
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Simon C Body
- Department of Anesthesiology, Boston University School of Medicine, Boston, MA, USA
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Carmona García P, García Fuster R, Mateo E, Badía Gamarra S, López Cantero M, Gutiérrez Carretero E, Maestre ML, Legname V, Fita G, Vives M, Koller Bernhard T, Sánchez Pérez E, Miralles Bagán J, Italiano S, Darias-Delbey B, Barrio JM, Hortal J, Sáez de Ibarra JI, Hernández A. Intraoperative transesophageal echocardiography in cardiovascular surgery. Consensus document from the Spanish Society of Anesthesia and Critical Care (SEDAR) and the Spanish Society of Endovascular and Cardiovascular Surgery (SECCE). ACTA ACUST UNITED AC 2020; 67:446-480. [PMID: 32948329 DOI: 10.1016/j.redar.2020.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 06/17/2020] [Indexed: 12/15/2022]
Abstract
Transesophageal echocardiography is a semi-invasive technique that allows an evaluation of cardiac morphology and function in real time and it is a quality standard in cardiovascular surgery. It has become a fundamental tool for both monitoring and diagnosis in the intraoperative period that allows decide the correct surgical planning and pharmacological management. The goal of this document is to answer the questions of when and how the perioperative TEE should be performed in cardiovascular surgery, what are their applications in the intraoperative, who should perform it and how the information should be transmitted. The authors made a systematic review of international guidelines, review articles and clinical trials to answer by consensus to these questions.
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Affiliation(s)
- P Carmona García
- Servicio de Anestesiología y Reanimación, Hospital Universitario la Fe, Valencia, España. Miembro del grupo de trabajo en Ecografía de la Sección de Cuidados Críticos de la SEDAR. Coordinadora del grupo de trabajo en Ecocardiografía, transesofágica intraoperatoria de la SEDAR
| | - R García Fuster
- Servicio de Cirugía Cardiaca, Consorcio Hospital General Universitario de Valencia, España. Coordinador del grupo de trabajo en Ecocardiografía, transesofágica intraoperatoria de la SECCE.
| | - E Mateo
- Servicio de Anestesiología y Reanimación, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - S Badía Gamarra
- Servicio de Cirugía Cardiaca, Hospital Universitario Trías y Pujol, Badalona, España
| | - M López Cantero
- Servicio de Anestesiología y Reanimación, Hospital Universitario la Fe, Valencia, España
| | - E Gutiérrez Carretero
- Servicio de Cirugía Cardiaca, Hospital, Universitario Virgen del Rocío, Sevilla, España
| | - M L Maestre
- Sección Cardiotorácica, Servicio de Anestesiología y Reanimación, Hospital Sant Pau, Barcelona, España
| | - V Legname
- Servicio de Cirugía Cardiaca, Centro Médico Teknon, Barcelona, España
| | - G Fita
- Sección Cardiotorácica, Servicio de Anestesiología y Reanimación. Hospital Clínic, Barcelona, España
| | - M Vives
- EDAIC. PhD. Sección Cardiotorácica, Servicio de Anestesiología y Reanimación, Hospital Universitario Dr Josep Trueta de Girona, España. Representante de España en la EACTA. Co-director del grupo de trabajo en Ecografía de la Sección de Cuidados Críticos de la SEDAR. Representante del subcomité de Educación de EACTA. Co-director grupo EchoSim
| | - T Koller Bernhard
- Sección Cardiotorácica, Servicio de Anestesiología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - E Sánchez Pérez
- EDAIC. Sección de Cirugía Cardiaca, Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, España. Miembro del grupo de trabajo en Ecografía de la Sección de Cuidados Críticos de la SEDAR
| | - J Miralles Bagán
- Sección Cardiotorácica, Servicio Anestesiología y Reanimación, Hospital Sant Pau, Barcelona, España
| | - S Italiano
- Sección Cardiotorácica, Servicio de Anestesiología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - B Darias-Delbey
- Servicio Anestesiología y Reanimación, Proceso del Paciente, Cardioquirúrgico, Complejo Hospitalario Universitario de Canarias, Santa Cruz de Tenerife, España
| | - J M Barrio
- Sección Anestesia y Reanimación Cardiovascular, Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - J Hortal
- Servicio de Anestesiología y Reanimación, Hospital General. Universitario Gregorio Marañón, Madrid, España
| | - J I Sáez de Ibarra
- Servicio de Cirugía Cardiaca, Hospital Universitario Son Espases, Palma de Mallorca, España
| | - A Hernández
- Departamento de Anestesia y Cuidados Intensivos, Grupo Policlínica, Ibiza, España. Miembro del grupo de trabajo en Ecografía de la Sección de Cuidados Críticos, de la SEDAR Representante del subcomité de Educación de EACTA, EDAIC, Codirector grupo EchoSim
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Carmona García P, García Fuster R, Mateo E, Badía Gamarra S, López Cantero M, Gutiérrez Carretero E, Maestre ML, Legname V, Fita G, Vives M, Koller Bernhard T, Sánchez Pérez E, Miralles Bagán J, Italiano S, Darias-Delbey B, Barrio JM, Hortal J, Sáez de Ibarra JI, Hernández A. Ecocardiografía transesofágica intraoperatoria en cirugía cardiovascular. Documento de consenso de la Sociedad Española de Anestesiología y Reanimación (SEDAR) y Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE). CIRUGIA CARDIOVASCULAR 2020. [DOI: 10.1016/j.circv.2020.03.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Kagiyama N, Mondillo S, Yoshida K, Mandoli GE, Cameli M. Subtypes of Atrial Functional Mitral Regurgitation. JACC Cardiovasc Imaging 2020; 13:820-835. [DOI: 10.1016/j.jcmg.2019.01.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/08/2019] [Accepted: 01/10/2019] [Indexed: 10/26/2022]
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Linganna RE, Strickler EM, Yeom RS. Pro: Preoperative Echocardiography Should Be Reviewed Prior to Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 34:827-829. [PMID: 31837961 DOI: 10.1053/j.jvca.2019.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 10/23/2019] [Accepted: 11/13/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Regina E Linganna
- Department of Anesthesiology and Critical Care, Thomas Jefferson University, Sidney Kimmel College of Medicine, Philadelphia, PA.
| | - Elise M Strickler
- Department of Anesthesiology and Critical Care, Thomas Jefferson University, Sidney Kimmel College of Medicine, Philadelphia, PA
| | - Richard S Yeom
- Department of Anesthesiology and Critical Care, Thomas Jefferson University, Sidney Kimmel College of Medicine, Philadelphia, PA
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Ahn JH, Ahn HJ, Yi JW. Total Intravenous Anesthesia Maintained the Degree of Pre-Existing Mitral Regurgitation Better than Isoflurane Anesthesia in Cardiac Surgery: A Randomized Controlled Trial. J Clin Med 2019; 8:jcm8081104. [PMID: 31349682 PMCID: PMC6723839 DOI: 10.3390/jcm8081104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 07/23/2019] [Accepted: 07/24/2019] [Indexed: 11/16/2022] Open
Abstract
Accurate assessment of mitral regurgitation (MR) is critical during mitral valve repair surgery. However, anesthesia may influence the degree of mitral regurgitation by changing pre- and after-load or cardiac contractility. Therefore, we compared changes in mitral regurgitation by total intravenous anesthesia (TIVA) and inhalation anesthesia in patients with pre-existing mitral regurgitation. This was a double-blind randomized controlled study conducted at a tertiary care center in 2018. Fifty-four mitral regurgitation patents undergoing elective cardiac surgery were randomly assigned to receive TIVA or isoflurane. Primary endpoint was change of regurgitation volume by anesthesia. The reduction of regurgitation volume by anesthesia was greater in the isoflurane group than in the TIVA group (mean (95% confidence interval CI): -0.20 (-6.15, 5.75) vs. -9.66 (-15.77, -3.56), mL·beat-1, p = 0.0266) and this phenomenon was more prominent with severe mitral regurgitation (grade 3 or 4) (mean (95% CI): -0.33 (-9.10, 8.44) vs. -16.20 (-24.22, -8.18), mL·beat-1, p = 0.0079). Among patients with MR grade 3 or 4, 94% remained the same with TIVA during anesthesia compared to 56% with isoflurane. In conclusion, TIVA maintained the pre-anesthetic state of mitral regurgitation relatively well, while the severity of mitral regurgitation tended to decrease with isoflurane anesthesia.
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Affiliation(s)
- Jin Hee Ahn
- Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul 03181, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Graduate School, Kyung Hee University, Seoul 02447, Korea
| | - Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
| | - Jae-Woo Yi
- Department of Anesthesiology and Pain Medicine, College of Medicine, Kyung Hee, University, Seoul 02447, Korea
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14
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Vignau-Cano JM, Cabeza-Laínez P, Daroca-Martínez T, Gómez MA, Bermúdez A, Macías D. Hallazgos intraoperatorios con ecocardiografía transesofágica en cirugía cardiovascular. CIRUGIA CARDIOVASCULAR 2019. [DOI: 10.1016/j.circv.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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15
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Tempe DK. A Quick and Simple Method to Assess Reliably the Left Ventricular Function With TEE: Is MAPSE the Answer? J Cardiothorac Vasc Anesth 2019; 33:1340-1342. [DOI: 10.1053/j.jvca.2018.11.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Indexed: 11/11/2022]
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16
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Liu L, Li S, Ye M, Li Y, Tian J, Tan Y. Utility of transesophageal echocardiography for intra-operatively assessing pulmonary artery pressure across an isolated ventricular septal defect in children. Echocardiography 2019; 36:948-953. [PMID: 30908738 DOI: 10.1111/echo.14316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/14/2019] [Accepted: 02/22/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The magnitude of pulmonary hypertension (PH) is extremely important with respect to the intra-operative management of children and infants with an isolated ventricular septal defect (VSD). This study aimed to assess the feasibility and accuracy of transesophageal echocardiography for estimating pulmonary arterial systolic pressure (PASP) across isolated VSD. METHODS We compared the results of transesophageal echocardiography vs invasive PASP measured simultaneously. This study included 40 patients (age: 6 months to 6 years; weight: >5 kg) who were undergoing elective surgery for isolated VSDs. Flow signals across the VSDs were identified as high velocity turbulent signals in systole via continuous wave Doppler at 0-120° at the mid-esophageal level. Peak velocities were recorded. Radial artery systolic pressures were assessed invasively, and PASPs were obtained after exposing the pulmonary artery intra-operatively. RESULTS After excluding five patients because of unusable measurements, invasive PASP measurements were obtained in 35 patients (87.5%). There were no significant biases between echocardiographic and catheterization measurements of PASP, with a tight confidence interval measuring, on average, up to 2.6 mmHg. However, the ± 2 standard deviation limits of agreement for mean PASP were -3.8 and 10.6 mmHg. CONCLUSION PASP measurements via transesophageal echocardiography in cardiac surgical patients under general anesthesia are recommended for use as a screening and monitoring tool for PH in children and infants, but cannot be used as a diagnostic tool.
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Affiliation(s)
- Lifei Liu
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Shangyingying Li
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Mao Ye
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yonggang Li
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jie Tian
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China.,Chongqing Key Laboratory of Pediatrics, Chongqing, China.,Chongqing International Science and Technology Cooperation Center for Child Development and Disorders, Chongqing, China
| | - Yanzhe Tan
- Department of Anesthesiology, Children's Hospital of Chongqing Medical University, Chongqing, China
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17
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Gillham M, Diprose P, Ambler J. A Comparison of the Degree of Residual Mitral Regurgitation by Intraoperative Transoesophageal and Follow-up Transthoracic Echocardiography following Mitral Valvuloplasty. Anaesth Intensive Care 2019; 35:194-8. [PMID: 17444307 DOI: 10.1177/0310057x0703500206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients who undergo mitral valve repair for mitral regurgitation and have mild residual mitral regurgitation may have an increased risk of re-operation in future years. Intraoperative transoesophageal echocardiography has now become a standard of practice for mitral valve repair surgery. We identified 106 patients who underwent attempted mitral valve repair over a three-year period in our institution. We retrospectively reviewed the grade of residual mitral regurgitation assigned following successful mitral valve repair (‘mild’ or less residual regurgitation) by intraoperative transoesophageal echocardiography and compared it to the observed grade of mitral regurgitation seen at follow-up transthoracic echocardiography. No patient had unexpected moderate or severe mitral regurgitation postoperatively, suggesting that intraoperative transoesophageal echocardiography performed in a medium-sized department is a sensitive tool for the early detection of failed mitral repair. Mild residual mitral regurgitation on intraoperative transoesophageal echocardiography was not reliably associated with mild mitral regurgitation on follow-up transthoracic echocardiography. In fact, 61% of patients with mild mitral regurgitation identified by intraoperative transoesophageal echocardiography had reduced mitral regurgitation at follow-up transthoracic echocardiography (to nil/trace residual mitral regurgitation). This observation, in conjunction with the limitations of the data supporting the goal of ‘echo perfect’ repair, suggests that a second attempt at repair should not be made based on the intraoperative transoesophageal echocardiography finding of mild residual mitral regurgitation alone.
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Affiliation(s)
- M Gillham
- Green Lane Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
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18
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Tricuspid valvular dynamics and 3-dimensional geometry in awake and anesthetized sheep. J Thorac Cardiovasc Surg 2018; 156:1503-1511. [DOI: 10.1016/j.jtcvs.2018.04.065] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/04/2018] [Accepted: 04/13/2018] [Indexed: 11/17/2022]
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19
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Affiliation(s)
- Yaron Shapira
- Department of Cardiology, Rabin Medical Center, Beilinson Hospital, 100 Jabotinsky Str, Petah-Tiqva, 49100; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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20
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Hathaway J. The Right Answer. J Cardiothorac Vasc Anesth 2018; 32:393-394. [DOI: 10.1053/j.jvca.2017.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Indexed: 11/11/2022]
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21
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Waldron NH, Haney JC, Suarez A, Swaminathan M. The Value of Echocardiography in Unexpected Valve Disease in a Patient With Ischemic Cardiomyopathy: Less Is Not Always the Right Answer. J Cardiothorac Vasc Anesth 2018; 32:389-392. [DOI: 10.1053/j.jvca.2017.06.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Indexed: 11/11/2022]
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22
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Schoechlin S, Brennemann T, Allali A, Ruile P, Jander N, Allgeier M, Gick M, Richardt G, Neumann FJ, Abdel-Wahab M. Hemodynamic classification of paravalvular leakage after transcatheter aortic valve implantation compared with angiographic or echocardiographic classification for prediction of 1-year mortality. Catheter Cardiovasc Interv 2017; 91:E56-E63. [DOI: 10.1002/ccd.27384] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 09/29/2017] [Accepted: 10/01/2017] [Indexed: 12/27/2022]
Affiliation(s)
- Simon Schoechlin
- Department of Cardiology & Angiology II; University Heart Center Freiburg-Bad Krozingen; Germany
| | - Tim Brennemann
- Department of Cardiology & Angiology II; University Heart Center Freiburg-Bad Krozingen; Germany
| | - Abdelhakim Allali
- Department of Cardiology; Heart Center Bad Segeberg, Segeberger Kliniken; Germany
| | - Philip Ruile
- Department of Cardiology & Angiology II; University Heart Center Freiburg-Bad Krozingen; Germany
| | - Nikolaus Jander
- Department of Cardiology & Angiology II; University Heart Center Freiburg-Bad Krozingen; Germany
| | - Martin Allgeier
- Department of Cardiology & Angiology II; University Heart Center Freiburg-Bad Krozingen; Germany
| | - Michael Gick
- Department of Cardiology & Angiology II; University Heart Center Freiburg-Bad Krozingen; Germany
| | - Gert Richardt
- Department of Cardiology; Heart Center Bad Segeberg, Segeberger Kliniken; Germany
| | - Franz-Josef Neumann
- Department of Cardiology & Angiology II; University Heart Center Freiburg-Bad Krozingen; Germany
| | - Mohamed Abdel-Wahab
- Department of Cardiology; Heart Center Bad Segeberg, Segeberger Kliniken; Germany
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23
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Sanfilippo F, Johnson C, Bellavia D, Morsolini M, Romano G, Santonocito C, Centineo L, Pastore F, Pilato M, Arcadipane A. Mitral Regurgitation Grading in the Operating Room: A Systematic Review and Meta-analysis Comparing Preoperative and Intraoperative Assessments During Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1681-1691. [DOI: 10.1053/j.jvca.2017.02.046] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Indexed: 11/11/2022]
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24
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Capdeville M, Alfirevic A. Are Transthoracic and Transesophageal Echocardiography Equal "PARTNERS" in the Assessment of Paravalvular Leak After TAVR? J Cardiothorac Vasc Anesth 2017; 31:1285-1289. [PMID: 28800986 DOI: 10.1053/j.jvca.2017.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Indexed: 11/11/2022]
Affiliation(s)
| | - Andrej Alfirevic
- Department of Cardiothoracic Anesthesia Cleveland Clinic Cleveland, OH
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25
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Analysis of circumflex artery anatomy by real time 3D transesophageal echocardiography compared to cardiac computed tomography. Int J Cardiovasc Imaging 2017; 33:1703-1710. [DOI: 10.1007/s10554-017-1162-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/08/2017] [Indexed: 11/27/2022]
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26
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Kagiyama N, Hayashida A, Toki M, Fukuda S, Ohara M, Hirohata A, Yamamoto K, Isobe M, Yoshida K. Insufficient Leaflet Remodeling in Patients With Atrial Fibrillation. Circ Cardiovasc Imaging 2017; 10:CIRCIMAGING.116.005451. [DOI: 10.1161/circimaging.116.005451] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 01/27/2017] [Indexed: 12/17/2022]
Abstract
Background—
The relationship between annular dilatation caused by atrial fibrillation (AF) and mitral regurgitation (MR) remains controversial. We hypothesized that the small ratio of total leaflet area/annulus area (TLA/AA), reflecting insufficient leaflet remodeling to annular dilatation, is a main component of MR in patients with AF.
Methods and Results—
Three-dimensional transesophageal echocardiographic data of the mitral valve were analyzed in 28 AF patients with moderate or severe MR (MR group), age- and sex-matched 56 AF patients with mild or less MR (non-MR group), and 16 control subjects. AA was significantly greater in both the MR (645±126 mm
2
/m
2
,
P
<0.001) and non-MR groups (568±121 mm
2
/m
2
,
P
=0.001) compared with control subjects (444±108 mm
2
/m
2
). However, TLA/AA was significantly smaller in the MR (1.29±0.10,
P
<0.001), but not in the non-MR group (1.65±0.24,
P
>0.99), compared with control subjects (1.70±0.29). In linear regression analysis, TLA/AA was inversely associated with the effective regurgitant orifice (
r
=−0.73,
P
<0.001). The area under the receiver-operating-characteristics curve of TLA/AA was significantly greater than that of AA (0.95 versus 0.72,
P
<0.001). Multivariable analysis revealed that small TLA/AA (
P
<0.001) was independently associated with significant MR, while AA was not (
P
=0.26).
Conclusions—
In patients with AF, insufficient leaflet remodeling to annular dilatation, rather than crude annular dilatation, was strongly associated with the severity of MR.
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Affiliation(s)
- Nobuyuki Kagiyama
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Akihiro Hayashida
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Misako Toki
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Shota Fukuda
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Minako Ohara
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Atsushi Hirohata
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Keizo Yamamoto
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Mitsuaki Isobe
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
| | - Kiyoshi Yoshida
- From the Departments of Cardiology (N.K., A.H., M.O., A.H., K.Y., K.Y.) and Department of Clinical Laboratory (M.T.), The Sakakibara Heart Institute of Okayama, Japan; Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Japan (N.K., M.I.); and Second Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan (S.F.)
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27
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McCartney SL, Cooter M, Samad Z, Sivak J, Castleberry A, Gregory S, Haney J, Hartwig M, Swaminathan M. Mitral Regurgitation After Orthotopic Lung Transplantation: Natural History and Impact on Outcomes. J Cardiothorac Vasc Anesth 2017; 31:924-930. [PMID: 28082025 DOI: 10.1053/j.jvca.2016.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Progression of mitral regurgitation (MR) after orthotopic lung transplantation (OLT) may be an underrecognized phenomenon due to the overlapping symptomatology of pulmonary and valvular disease. Literature evaluating the progression of MR after OLT currently is limited to case reports. Therefore, the hypothesis that MR progresses after OLT was tested and the association of preprocedure MR with postoperative mortality was assessed. DESIGN A retrospective cohort. SETTING A tertiary-care hospital. PARTICIPANTS Patients who underwent OLT between January 1, 2003 and February 4, 2012. INTERVENTIONS After receiving institutional review board approval, a preprocedure transesophageal echocardiogram was compared with a postoperative transthoracic echocardiogram (TTE) to determine the progression of MR. Univariate and multivariate association between preprocedure MR grade and 1- and 5-year mortality was assessed. A p value of<0.05 was considered statistically significant. MEASUREMENTS AND MAIN RESULTS From 715 patients who underwent OLT, 352 had a postoperative TTE and were included in the evaluation of progression of MR. Five patients had progression of MR postoperatively, and the mean change in MR score of -0.04 was found to be nonsignificant (p = 0.25). Mortality data were available for 634 of the 715 patients. After covariate adjustment, there was no significant association between MR grade and 1-year mortality (p = 0.20) or 5-year mortality (p = 0.46). CONCLUSIONS This study rejected the hypothesis that primary and secondary MR progresses after OLT and found that preprocedure MR was not associated with increased postoperative mortality. Despite the findings that MR does not progress in all patients, there is a subset of patients for whom MR progression is clinically significant.
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Affiliation(s)
- Sharon L McCartney
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Mary Cooter
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Zainab Samad
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC
| | - Joseph Sivak
- Division of Cardiology, Department of Internal Medicine, Duke University Medical Center, Durham, NC
| | - Anthony Castleberry
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Stephen Gregory
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - John Haney
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Matthew Hartwig
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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28
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Goncalves A, Nyman C, Okada DR, Singh A, Swanson J, Cheezum M, Steigner M, Di Carli M, Solomon S, Shah PB, Bhatt DL, Shook D, Blankstein R. Transthoracic Echocardiography to Assess Aortic Regurgitation after TAVR: A Comparison with Periprocedural Transesophageal Echocardiography. Cardiology 2016; 137:1-8. [DOI: 10.1159/000452617] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 09/27/2016] [Indexed: 11/19/2022]
Abstract
Background: We aimed to compare periprocedural transesophageal echocardiography (TEE) with postprocedural transthoracic echocardiography (TTE) for the diagnosis of aortic regurgitation (AR). Methods and Results: TEE and TTE images of 163 transcatheter aortic valve replacement (TAVR) patients (mean age 81 ± 8 years; 56% men) were reviewed separately and blinded to each other as well as to all clinical data. The median time between TEE during TAVR (TEE/TAVR) and TTE was 4 days (IQR 2-10 days). After TAVR, 48% of the patients had at least trace AR by TEE, 56% by angiography and 67% by TTE. The majority of AR was paravalvular (78%). More patients were classified with mild-to-moderate AR by TTE than by TEE (44 vs. 22%, p < 0.01). When examining the 46 patients with AR by TTE which was not at TEE/TAVR, both systolic and diastolic blood pressure (SBP and DBP) were significantly higher during TTE than during TEE (mean ΔSBP = 9 ± 4 mm Hg and mean ΔDBP = 6 ± 2 mm Hg, p < 0.01 for both). No differences in BP between TEE and TTE were found among patients with no AR or among those who had AR in both studies. At a median follow-up of 185 days (IQR 39-424 days), the overall mortality was 17%, but this was not associated with the presence of AR on TTE or TEE. Conclusions: Patients' hemodynamic conditions may result in underdiagnosis of paravalvular regurgitation in periprocedural TEE. Our findings suggest that a postprocedural evaluation for AR by TTE could serve as a reasonable alternative to TEE for the evaluation of AR.
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29
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Owais K, Montealegre-Gallegos M, Jeganathan J, Matyal R, Khabbaz KR, Mahmood F. Dynamic changes in the ischemic mitral annulus: Implications for ring sizing. Ann Card Anaesth 2016; 19:15-9. [PMID: 26750668 PMCID: PMC4900374 DOI: 10.4103/0971-9784.173014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Contrary to the rest of the mitral annulus, inter-trigonal distance is known to be relatively less dynamic during the cardiac cycle. Therefore, intertrigonal distance is considered a suitable benchmark for annuloplasty ring sizing during mitral valve (MV) surgery. The entire mitral annulus dilates and flattens in patients with ischemic mitral regurgitation (IMR). It is assumed that the fibrous trigone of the heart and the intertrigonal distance does not dilate. In this study, we sought to demonstrate the changes in mitral annular geometry in patients with IMR and specifically analyze the changes in intertrigonal distance during the cardiac cycle. METHODS Intraoperative three-dimensional transesophageal echocardiographic data obtained from 26 patients with normal MVs undergoing nonvalvular cardiac surgery and 36 patients with IMR undergoing valve repair were dynamically analyzed using Philips Qlab ® software. RESULTS Overall, regurgitant valves were larger in area and less dynamic than normal valves. Both normal and regurgitant groups displayed a significant change in annular area (AA) during the cardiac cycle (P < 0.01 and P < 0.05, respectively). Anteroposterior and anterolateral-posteromedial diameters and inter-trigonal distance increased through systole (P < 0.05 for all) in accordance with the AAs in both groups. However, inter-trigonal distance showed the least percentage change across the cardiac cycle and its reduced dynamism was validated in both cohorts (P > 0.05). CONCLUSIONS Annular dimensions in regurgitant valves are dynamic and can be measured feasibly and accurately using echocardiography. The echocardiographically identified inter-trigonal distance does not change significantly during the cardiac cycle.
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Affiliation(s)
| | | | - Jelliffe Jeganathan
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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30
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Papel de la ecocardiografía transesofágica en la cirugía mínimamente invasiva sobre la válvula mitral. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2015.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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31
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Whitener G, McKenzie J, Akushevich I, White WD, Dhakal IB, Nicoara A, Swaminathan M. Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography. Anesth Analg 2016; 122:953-8. [DOI: 10.1213/ane.0000000000001099] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Obase K, Weinert L, Hollatz A, Farooqui F, Roberts JD, Minhaj MM, Tung A, Chaney M, Ota T, Jeevanandam V, Yoshida K, Mor-Avi V, Lang RM. Elongation of chordae tendineae as an adaptive process to reduce mitral regurgitation in functional mitral regurgitation. Eur Heart J Cardiovasc Imaging 2015; 17:500-9. [PMID: 26710820 DOI: 10.1093/ehjci/jev314] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 11/08/2015] [Indexed: 11/13/2022] Open
Abstract
AIMS In functional mitral regurgitation (FMR), increased leaflet area has been described as a remodelling compensatory mechanism. We hypothesized that chordae tendineae elongation would also occur as part of this remodelling. In this study, the lengths of primary chords and measurements of mitral leaflets and annulus were compared with varying degrees of mitral regurgitation (MR). METHODS AND RESULTS We studied 58 patients who underwent three-dimensional (3D) transoesophageal echocardiography, including 38 with FMR and 20 with normal mitral valves (NL). The FMR group was divided into two subgroups according to two-dimensional vena contracta width (VCW). Three-dimensional datasets from transgastric or mid-oesophageal approach were used to measure primary chordal length, coaptation length, inter-papillary muscle distances, and quantitative 3D measurements of the annulus and leaflets. Leaflet surface area was increased and coaptation length was decreased in FMR compared with NL. While no difference in other 3D measurement of annulus/leaflets was noted between the FMR subgroups, averaged chordal length was shorter in patients with more severe FMR. Chords of the anterior leaflet in FMR with larger VCW were shorter compared with both NL and FMR with smaller VCW. In contrast, the chords of the posterior leaflet were longer in FMR with smaller VCW compared with the other two groups. CONCLUSION Our results suggest the posterior leaflet chords possibly remodel by elongating and contribute to reduced MR and that in a subgroup of FMR patients, the primary chords may remodel by shortening, resulting in augmented MR. This information could be useful in choosing strategy for FMR correction.
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Affiliation(s)
- Kikuko Obase
- Noninvasive Cardiac Imaging Laboratory, Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Lynn Weinert
- Noninvasive Cardiac Imaging Laboratory, Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Andrew Hollatz
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Farhan Farooqui
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Joseph D Roberts
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Mohammed M Minhaj
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Avery Tung
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Mark Chaney
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, IL, USA
| | - Takeyoshi Ota
- Cardiovascular Surgery, University of Chicago, Chicago, IL, USA
| | | | - Kiyoshi Yoshida
- Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan
| | - Victor Mor-Avi
- Noninvasive Cardiac Imaging Laboratory, Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Roberto M Lang
- Noninvasive Cardiac Imaging Laboratory, Section of Cardiology, Department of Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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Levine RA, Hagége AA, Judge DP, Padala M, Dal-Bianco JP, Aikawa E, Beaudoin J, Bischoff J, Bouatia-Naji N, Bruneval P, Butcher JT, Carpentier A, Chaput M, Chester AH, Clusel C, Delling FN, Dietz HC, Dina C, Durst R, Fernandez-Friera L, Handschumacher MD, Jensen MO, Jeunemaitre XP, Le Marec H, Le Tourneau T, Markwald RR, Mérot J, Messas E, Milan DP, Neri T, Norris RA, Peal D, Perrocheau M, Probst V, Pucéat M, Rosenthal N, Solis J, Schott JJ, Schwammenthal E, Slaugenhaupt SA, Song JK, Yacoub MH. Mitral valve disease--morphology and mechanisms. Nat Rev Cardiol 2015; 12:689-710. [PMID: 26483167 DOI: 10.1038/nrcardio.2015.161] [Citation(s) in RCA: 227] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.
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Affiliation(s)
- Robert A Levine
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Yawkey 5E, Boston, MA 02114, USA
| | - Albert A Hagége
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | - Jacob P Dal-Bianco
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | | | | | - Nabila Bouatia-Naji
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Patrick Bruneval
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | - Alain Carpentier
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | | | | | | | - Francesca N Delling
- Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | | | - Christian Dina
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Ronen Durst
- Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Leticia Fernandez-Friera
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Mark D Handschumacher
- Massachusetts General Hospital, Cardiac Ultrasound Laboratory, Harvard Medical School, Boston, MA, USA
| | | | - Xavier P Jeunemaitre
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Hervé Le Marec
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Thierry Le Tourneau
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Jean Mérot
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Emmanuel Messas
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - David P Milan
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Tui Neri
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - David Peal
- Cardiovascular Research Center, Harvard Medical School, Boston, MA, USA
| | - Maelle Perrocheau
- Hôpital Européen Georges Pompidou, Université René Descartes, UMR 970, Paris, France
| | - Vincent Probst
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | - Michael Pucéat
- Aix-Marseille University, INSERM UMR 910, Marseille, France
| | | | - Jorge Solis
- Hospital Universitario HM Monteprincipe and the Centro Nacional de Investigaciones Cardiovasculares, Carlos III (CNIC), Madrid, Spain
| | - Jean-Jacques Schott
- University of Nantes, Thoracic Institute, INSERM UMR 1097, CNRS UMR 6291, Nantes, France
| | | | - Susan A Slaugenhaupt
- Center for Human Genetic Research, MGH Research Institute, Harvard Medical School, Boston, MA, USA
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Transcatheter mitral valve repair with the MitraClip(®) can be performed without general anesthesia and without conscious sedation. Clin Res Cardiol 2015; 105:297-306. [PMID: 26377429 DOI: 10.1007/s00392-015-0918-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 09/09/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND General anesthesia is known to be associated with an increased risk for complications, especially in elderly and multi-morbid patients, the primary target population of the MitraClip(®) technique. The aim is to assess whether general anesthesia and even conscious sedation can be avoided during the MitraClip(®) procedure. METHODS A total of 91 consecutive patients who underwent MitraClip(®) implantation [median 77 years, (IQR 72-83), 40 % female] were retrospectively analyzed. The first 26 patients were treated in general anesthesia. Afterwards, local anesthesia was chosen as primary anesthetic approach. Altogether, 28 (31 %) patients received general anesthesia, local anesthesia was performed in 35 (38 %) patients with sedation and in 28 (31 %) patients without sedation. RESULTS The respective patient groups were similar regarding their baseline characteristics. Procedural success (successful implantation of at least one clip and post-procedure MR grade ≤2) was achieved in 89 % with no difference between the groups (93 % in general anesthesia, 89 % in local anesthesia with sedation, 86 % in local anesthesia without sedation, p = ns). No difference regarding hospital complications was noted. Local anesthesia with and without sedation was associated with less necessity for ICU/IMC stay (100 % in general anesthesia, 14 % in local anesthesia with sedation, 14 % in local anesthesia without sedation; p < 0.0001). One-year estimated survival was not significantly different among the groups (63, 82 and 75 %; p = ns). CONCLUSIONS Transcatheter mitral valve repair with the MitraClip(®) can be performed without general anesthesia and even without conscious sedation with similar procedural success and complication rates.
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A Quantitative Approach to the Intraoperative Echocardiographic Assessment of the Mitral Valve for Repair. Anesth Analg 2015; 121:34-58. [DOI: 10.1213/ane.0000000000000726] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Grimaldi A, De Gennaro L, Brunetti ND, Ammirati E, Arioli F, Arendar I, De Concilio A, Alfieri O, La Canna G. Downgrading mitral regurgitation in the echo laboratory. J Cardiovasc Med (Hagerstown) 2015; 16 Suppl 1:S55-7. [DOI: 10.2459/jcm.0b013e3283435936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Soliman D, Bolliger D, Skarvan K, Kaufmann BA, Lurati Buse G, Seeberger MD. Intra-operative assessment of pulmonary artery pressure by transoesophageal echocardiography. Anaesthesia 2014; 70:264-71. [DOI: 10.1111/anae.12920] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2014] [Indexed: 02/06/2023]
Affiliation(s)
- D. Soliman
- Department of Anaesthesia; Surgical Intensive Care; Prehospital Emergency Medicine and Pain Therapy; Basel Switzerland
- Department of Anaesthesiology; Kasr El-Aini University Hospital; Cairo University; Cairo Egypt
| | - D. Bolliger
- Department of Anaesthesia; Surgical Intensive Care; Prehospital Emergency Medicine and Pain Therapy; Basel Switzerland
| | - K. Skarvan
- Medical Faculty; University Hospital Basel; Basel Switzerland
| | - B. A. Kaufmann
- Division of Cardiology; University Hospital Basel; Basel Switzerland
| | - G. Lurati Buse
- Department of Anaesthesia; Surgical Intensive Care; Prehospital Emergency Medicine and Pain Therapy; Basel Switzerland
| | - M. D. Seeberger
- Medical Faculty; University Hospital Basel; Basel Switzerland
- Klinik Hirslanden; Zürich Switzerland
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Intraoperative Transesophageal Echocardiography for Surgical Repair of Mitral Regurgitation. J Am Soc Echocardiogr 2014; 27:345-66. [DOI: 10.1016/j.echo.2014.01.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Indexed: 12/14/2022]
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Connell JM, Worthington A, Chen FY, Shernan SK. Ischemic mitral regurgitation: mechanisms, intraoperative echocardiographic evaluation, and surgical considerations. Anesthesiol Clin 2014; 31:281-98. [PMID: 23711645 DOI: 10.1016/j.anclin.2013.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ischemic mitral regurgitation (IMR) is a subcategory of functional rather than organic, mitral valve (MV) disease. Whether reversible or permanent, left ventricular remodeling creates IMR that is complex and multifactorial. A comprehensive TEE examination in patients with IMR may have important implications for perioperative clinical decision making. Several TEE measures predictive of MV repair failure have been identified. Current practice among most surgeons is to typically repair the MV in patients with IMR. MV replacement is usually reserved for situations in which the valve cannot be reasonably repaired, or repair is unlikely to be tolerated clinically.
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Affiliation(s)
- John M Connell
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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Ender J, Sgouropoulou S. Value of transesophageal echocardiography (TEE) guidance in minimally invasive mitral valve surgery. Ann Cardiothorac Surg 2013; 2:796-802. [PMID: 24349984 DOI: 10.3978/j.issn.2225-319x.2013.10.09] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 08/20/2013] [Indexed: 11/14/2022]
Abstract
The role of intraoperative transesophageal echocardiography (TEE) has increased tremendously since its first use in 1979. Today intraoperative TEE is a class I indication for surgical mitral valve reconstruction for evaluation of mitral valve pathology, graduation of mitral regurgitation and detection of potential risk factors as well as post-repair assessment. Real-time three-dimensional TEE offers anatomical visualization of the mitral valve apparatus, fundamental for virtual surgical planning of proper annuloplasty ring size. As minimally invasive and even off-pump techniques for mitral valve repair become more popular, image guidance by intraoperative TEE will play an essential role.
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Affiliation(s)
- Jörg Ender
- Department of Anesthesiology and Intensive Care Medicine, Heartcenter Leipzig, University Leipzig, Germany
| | - Sophia Sgouropoulou
- Department of Anesthesiology and Intensive Care Medicine, Heartcenter Leipzig, University Leipzig, Germany
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The Contemporary Role of Intraoperative Echocardiography: Is it Underused or Overused? CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-013-9232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Bartels K, Thiele RH, Phillips-Bute B, Glower DD, Swaminathan M, Kisslo J, Burkhard Mackensen G. Dynamic indices of mitral valve function using perioperative three-dimensional transesophageal echocardiography. J Cardiothorac Vasc Anesth 2013; 28:18-24. [PMID: 24011875 DOI: 10.1053/j.jvca.2013.03.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Perioperative transesophageal echocardiography is essential for decision-making for mitral valve surgery. While two-dimensional transesophageal echocardiography represents the standard of care, tracking of dynamic changes using three-dimensional imaging permits assessment of morphologic and functional characteristics of the mitral valve. The authors hypothesized that quantitative three-dimensional analysis would reveal distinct differences among diseased, repaired, and normal mitral valves. DESIGN Case-control observational clinical study. SETTING Tertiary care hospital. PARTICIPANTS Using novel mitral valve quantification software, the authors retrospectively analyzed 80 datasets of cardiac surgery patients who underwent intraoperative transesophageal echocardiographic imaging. Twenty patients with degenerative mitral regurgitation were evaluated before and after mitral valve repair. Twenty patients had functional mitral regurgitation, and 20 patients had no mitral valve disease. MEASUREMENTS AND MAIN RESULTS Primary outcome measures of dynamic mitral valve function were: 1) three-dimensional annulus area, 2) annular displacement distance, 3) annular displacement velocity, and 4) annular area fraction. Other mitral annular tracking indices, in addition to intraobserver reliability and interobserver agreement, also were reported. Annulus area was enlarged in degenerative and functional mitral regurgitation. Annular displacement distance was decreased in functional mitral regurgitation and repaired valves. Annular displacement velocity was decreased in functional mitral regurgitation. Annular area fraction was decreased in functional mitral regurgitation and repaired valves. Intraobserver reliability and interobserver agreement were high for all 4 analyzed indices. CONCLUSIONS Normal, functional regurgitant, degenerative, and repaired mitral valves have distinctly different dynamic signatures of anatomy and function as reliably determined by perioperative echocardiographic tracking.
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Affiliation(s)
- Karsten Bartels
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Robert H Thiele
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University Medical Center, Durham, NC; Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA
| | - Barbara Phillips-Bute
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Donald D Glower
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery
| | - Madhav Swaminathan
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Joseph Kisslo
- Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC
| | - G Burkhard Mackensen
- Department of Anesthesiology and Pain Medicine, Division of Cardiothoracic Anesthesiology, University of Washington, Seattle, WA.
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Shakil O, Jainandunsing JS, Ilic R, Matyal R, Mahmood F. Ischemic Mitral Regurgitation: An Intraoperative Echocardiographic Perspective. J Cardiothorac Vasc Anesth 2013; 27:573-85. [DOI: 10.1053/j.jvca.2012.06.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Indexed: 11/11/2022]
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Chin JH, Lee EH, Choi DK, Choi IC. The Effect of Depth of Anesthesia on the Severity of Mitral Regurgitation as Measured by Transesophageal Echocardiography. J Cardiothorac Vasc Anesth 2012; 26:994-8. [DOI: 10.1053/j.jvca.2012.05.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Indexed: 11/11/2022]
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Harling L, Saso S, Jarral OA, Kourliouros A, Kidher E, Athanasiou T. Aortic valve replacement for aortic stenosis in patients with concomitant mitral regurgitation: should the mitral valve be dealt with? Eur J Cardiothorac Surg 2011; 40:1087-96. [PMID: 21570860 DOI: 10.1016/j.ejcts.2011.03.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 03/16/2011] [Accepted: 03/22/2011] [Indexed: 10/18/2022] Open
Abstract
Co-existent mitral regurgitation may adversely influence both morbidity and mortality in patients undergoing aortic valve replacement for severe aortic stenosis. Whilst it is accepted that concomitant mitral intervention is required in severe, symptomatic mitral regurgitation, in cases of mild-moderate non-structural mitral regurgitation, improvement may be seen following aortic valve replacement alone, avoiding the increased risk of double-valve surgery. The exact benefit of such a conservative approach is, however, yet to be adequately quantified. We performed a systematic literature review identifying 17 studies incorporating 3053 patients undergoing aortic valve replacement for aortic stenosis with co-existing mitral regurgitation. These were meta-analysed using random effects modelling. Heterogeneity and subgroup analysis were assessed. Primary end points were change in mitral regurgitation severity and 30-day, 3-, 5- and 10-year mortality. Secondary end points were end-organ dysfunction (neurovascular, renal and respiratory), and the extent of ventricular remodelling following aortic valve replacement. Our results revealed improvement in the severity of mitral regurgitation following aortic valve replacement in 55.5% of patients, whereas 37.7% remained unchanged, and 6.8% worsened. No significant difference was seen between overall data and either the functional or moderate subgroups. The overall 30-day mortality following aortic valve replacement was 5%. This was significantly higher in moderate-severe mitral regurgitation than nil-mild mitral regurgitation both overall (p=0.002) and in the functional subgroup (p=0.004). Improved long-term survival was seen at 3, 5 and 10 years in nil-mild mitral regurgitation when compared with moderate-severe mitral regurgitation in all groups (overall p<0.0001, p<0.00001 and p=0.02, respectively). The relative risk of respiratory, renal and neurovascular complications were 7%, 6% and 4%, respectively. Reverse remodelling was demonstrated by a significant reduction in left-ventricular end-diastolic diameter and left-ventricular mass (p=0.0007 and 0.01, respectively), without significant heterogeneity. No significant change was seen in left-ventricular end-systolic diameter (p=0.10), septal thickness (p=0.17) or left atrial area (p=0.23). We conclude that despite reverse remodelling, concomitant moderate-severe mitral regurgitation adversely affects both early and late mortality following aortic valve replacement. Concomitant mitral intervention should therefore be considered in the presence of moderate mitral regurgitation, independent of the aetiology.
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Affiliation(s)
- Leanne Harling
- Department of Surgery and Cancer, Imperial College London, London, UK.
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Rodríguez-Roda J, Ruiz M, Rodríguez-Abella H, Cuerpo G, Donado A, Pita A, Otero J, Sánchez D, Solís J, Fortuny R, Pinto ÁG. Situaciones especiales. Insuficiencia mitral isquémica. CIRUGIA CARDIOVASCULAR 2010. [DOI: 10.1016/s1134-0096(10)70084-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Kirkpatrick JN, Lang RM. Surgical Echocardiography of Heart Valves: A Primer for the Cardiovascular Surgeon. Semin Thorac Cardiovasc Surg 2010; 22:200.e1-22. [DOI: 10.1053/j.semtcvs.2010.10.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2010] [Indexed: 01/11/2023]
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Wang Y, Gao CQ, Wang JL, Yang M. The Role of Intraoperative Transesophageal Echocardiography in Robotic Mitral Valve Repair. Echocardiography 2010; 28:85-91. [DOI: 10.1111/j.1540-8175.2010.01274.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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50
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Michelena HI, Abel MD, Suri RM, Freeman WK, Click RL, Sundt TM, Schaff HV, Enriquez-Sarano M. Intraoperative echocardiography in valvular heart disease: an evidence-based appraisal. Mayo Clin Proc 2010; 85:646-55. [PMID: 20592170 PMCID: PMC2894720 DOI: 10.4065/mcp.2009.0629] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Intraoperative (IO) transesophageal echocardiography (TEE) is widely used for assessing the results of valvular heart disease (VHD) surgery. Epiaortic ultrasonography (EAU) has been recommended for prevention of perioperative strokes. To what extent does high-quality evidence justify the widespread use of these imaging modalities? In March 2009, we searched MEDLINE (PubMed and OVID interfaces) and EMBASE for studies published in English using database-specific controlled vocabulary describing the concepts of IOTEE, cardiac surgery, VHD, and EAU. We found no randomized trials or studies with control groups assessing the impact of IOTEE in VHD surgery. Pooled analysis of 8 observational studies including 15,540 patients showed an average incidence of 11% for prebypass surgical changes and 4% for second pump runs, suggesting that patients undergoing VHD surgery may benefit significantly from IOTEE, particularly from postcardiopulmonary bypass IOTEE in aortic repair and mitral repair and replacement, but less so in isolated aortic replacement. Further available indirect evidence was satisfactory in the test accuracy and surgical quality control aspects, with low complication rates for IOTEE. The data supporting EAU included 12,687 patients in 2 prospective randomized studies and 4 nonrandomized, controlled studies, producing inconsistent outcome-related results. Despite low-quality scientific evidence supporting IOTEE in VHD surgery, we conclude that indirect evidence supporting its use is satisfactory and suggests that IOTEE may offer considerable benefit in valvular repairs and mitral replacements. The value of IOTEE in isolated aortic valve replacement remains less clear. Evidence supporting EAU is scientifically more robust but conflicting. These findings have important clinical policy and research implications.
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Affiliation(s)
- Hector I Michelena
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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