General Anesthesia Leads to Underestimation of Regurgitation Severity in Patients With Secondary Mitral Regurgitation Undergoing Transcatheter Mitral Valve Repair

Navigating the Dynamic Nature of Mitral Regurgitation With the Use of Multimodality Imaging in a Young Woman

The mechanism and severity of mitral valve (MV) regurgitation (MR) play a critical role in guiding treatment decisions. Transthoracic echocardiography (TTE) is the primary diagnostic modality for evaluating MV disease. Discordant findings on TTE can be further quantified through transesophageal echocardiography (TEE). We describe the case of a young woman with worsening exertional dyspnea who was found to have restricted posterior MV leaflet and moderate to severe eccentric MR on TTE. TEE was subsequently performed to determine the exact mechanism of MR revealing the prolapse of the A2 segment of the MV. However, TEE significantly underestimated MR severity, downgrading it to visually mild to moderate MR and quantitatively moderate MR. This discrepancy highlights the potential for significant variation in MR severity assessment under general anesthesia, emphasizing the impact of hemodynamic loading conditions. In our case, intravenous sedatives may have altered the loading conditions reducing MR severity on TEE compared to TTE. Given her symptom severity, MV pathology, left ventricular dilatation, and the higher MR severity observed on TTE, she underwent surgical MV repair, in alignment with the Class I recommendation by the American College of Cardiology/American Heart Association (ACC/AHA) valvular heart disease guidelines. Postoperatively, she experienced significant improvement in symptoms and quality of life.

Prognostic impact of vasopressor test in transcatheter edge-to-edge repair of secondary mitral regurgitation: The PETIT study

BACKGROUND

Vasopressor test (VPT) might be useful in patients with functional mitral regurgitation (MR) and left ventricular dysfunction (MITRA-FR-like patients) during transcatheter edge-to-edge repair (TEER).

AIMS

We aimed to evaluate the prognostic impact of VPT.

METHODS

MR treated with TEER were included in a multicenter prospective registry. VPT was used intraprocedurally in patients with left ventricular dysfunction and/or hypotension. The 1-year echocardiographic and clinical outcomes were compared according to the use of VPT. The primary endpoint was a combination of mortality + heart failure (HF) readmission at 1-year.

RESULTS

A total of 1115 patients were included, mean age was 72.8 ± 10.5 years and 30.4% were women. VPT was performed in 128 subjects (11.5%), more often in critically ill patients with biventricular dysfunction. Postprocedurally the VPT group had greater rate of MR ≥ 2+ (46.9% vs. 31.7%, p = 0.003) despite greater number of devices (≥2 clips, 52% vs. 40.6 p = 0.008) and device repositioning or new clip in 12.5%. At 1-year, the primary endpoint occurred more often in the VPT group (27.3% vs. 16.9%, p = 0.002) as well as all-cause mortality (21.9% vs. 8.1%, p ≤ 0.001) but no differences existed in HF readmission rate (14.8% vs. 13.2%, p = 0.610), cardiovascular mortality (4.4% vs. 3.9%, p = 0.713) or residual MR ≥ 2+ (51.1% vs 51.7%, p = 0.371).

CONCLUSIONS

Dynamic evaluation of MR during TEER procedure through VPT was performed in patients with worse baseline risk who also presented higher all-cause mortality at 1-year follow-up. However, 1-year residual MR, cardiovascular mortality and HF readmission rate remained comparable suggesting that VPT might help in the management of MITRA-FR-like patients.

The Year in Perioperative Echocardiography: Selected Highlights From 2022

THIS SPECIAL article is part of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the Editorial Board for the opportunity to continue this series, which focuses on the past year's research highlights that pertain to perioperative echocardiography in relation to cardiothoracic and vascular anesthesia. The major selected themes for 2022 include (1) updates on mitral valve assessments and interventions, (2) training and simulation updates, (3) outcomes and complications of transesophageal echocardiography, and (4) point-of-care cardiac ultrasound. The themes selected for this special article are just a sample of the advances in perioperative echocardiography during 2022. An appreciation and understanding of these highlights will help to ensure and improve the perioperative outcomes for patients with cardiovascular disease undergoing cardiac surgery.