Preoperative Echocardiographic Clues For Repair of Degenerative Mitral Valve and Intraoperative Decision Making

 National repair rates generally approximate less than 60% of operated patients (degenerative mitral regurgitation), despite guideline recommendations-USA İn Turkey?

The Echocardiographer’s Role in Mitral Surgery  Prereferral echocardiographic assessment plays a pivotal role in directing patients Careful echocardiographic assessment “road map for the repair strategy” appropriate matching of surgical expertise to degenerative valve complexity Experienced Surgeon Mitral Super-specialists

The Echocardiographer’s Role in Mitral Surgery

2013

Carpentier’s Functional Classification Type I Leaflet Perforation/Annular Dilation Type II Excessive Leaflet Mobility-DMR TypeIIIaRestrictive Leaflet Motion-Systole/Diastole-RMR Type IIIbRestrictive Leaflet Motion-Systole-FMR

Degenerative Mitral Valve Disease  Degenerative mitral valve disease is the most common etiology of MR  Affects relatively healthy individuals  Natural history is insidious  Repair (not replacement) is the surgical treatment of choice  The restoration of life expectancy can be expected

Degenerative Mitral Valve Disease Morphologic changes in the connective tissue of the mitral valve Structural Lesions (chordal elongation, chordal rupture, leaflet tissue expansion, annular dilation) Leaflet Prolapse MR

Degenerative Mitral Valve Disease FEDBarlow

Barlow’s and Fibroelastic Deficiency Anyanyu AC, Semin Thorac Cardiovasc Surg, 2007 Annulus Severely dilated Near normal size 32 mm

Fibroelastic Deficiency-P2 chordal rupture

Barlow’s Disease

Echocardiography  Precise morphologic assessment is necessary to predict the rates of successful reconstructive valve surgery  Preop TTE-TEE  Periop TEE  3D imaging  Quantification of mitral regurgitation severity  PAP, LV size, LV function

Echocardiography The echocardiographic report should provide clues on the likelihood of the valve repair

Echocardiography ACC-AHA-2006 ESC-2012 Experienced surgical centers!! Proper differentiation of the degenerative disease!! (critical step)

Echocardiography Studying the Preoperative Echocardiogram/Clinical Senario (experienced surgeon and cardiologist) (speaking common language) Etiology and Lesions Mental Plan (Surgeon) Incision type? Technique? Cross-clamp time?

Echocardiography “road map for the repair strategy” Barlow’s disease with bileaflet multi-segmental prolapse and annular calcification (complex) Median sternotomy/larger lateral thoracotomy-posterior leaflet resection, sliding leaflet plasty, annular decalcification, chordal transfer/substitution, papillary muscle sliding, and large-ring annuloplasty Simple P2 prolapse Minimally invasive approache-posterior leaflet resection, ring annuloplasty

Quantification of MR Color Flow Jet Area Lancellotti p.

Quantification of MR EAE Recommendation 2010

Quantification of MR

Lancellotti P-EJE 2010

Vena Contracta Width-2D(TTE-TEE)

Intermediate vena contracta values (3-7 mm) need confirmation by a more quantitive method!!

Vena Contracta Area-3D (TTE-TEE)

 A cutoff of 0.41 cm2 using 3D-VCA to differentiate moderate from severe MR showed an 82% sensitivity and 97% specificity Prognostic value?

EROA and RV-2D (TTE-TEE)PISA

Mitral Inflow and Aortic Outflow Stroke Volume Measurement

EROA and RV-3D (TTE-TEE)PISA Need Validation

Quantification of MR Accurate Estimation of MR Traditional 2D- VC/ EROA / RV-RF For multiple or complicated jets- 3D For difficult surface imaging- MRI (esp RV)

Left Ventricular Dimensions ESD>40 mm or ESD> 22 mm/m²

Left Ventricular Function Chronic MR Preload Afterload N or LV EF may still be in normal range despite the presence of significant muscle dysfunction !!!!!!

Preoperative Left Ventricular Function Repair MVR Enriquez-Sarano M,Circulation 1994

Subclinical LV dysfunction  An inability to increase the left ventricular ejection fraction or reduce the end-systolic volume with stress reflects the presence of an impaired contractile reserve.

Subclinical LV Dysfunction Predictors of Subclinical LV dysfunction in asymptomatic MR: Lateral annulus systolic tissue Doppler velocity <10.5 cm/s Longitudinal Strain rate <1.07/s (avarage of basal and mid 12 segments) Global Longitudinal Strain (STE) <18.1%

Left Atrial Size LA volume >40 mL/m²

Left Atrial Size LA >55 mm

Pulmonary Artery Pressure MedikalPostoperative PASP >50 mm Hg

ERO ≥ 0.4 cm² and/or RV ≥ 60 mL EF >60% and ESD <40 mm Watchful waiting? Early Surgery? Echocardiographic predictors of postop LV dysfunction? Asymptomatic Severe MR

Risk Factors for Post-op LV Dysfunction in Asymptomatic Organic MR Chordal rupture Massive MR (RVol >100 mL and ERO >0.5 cm²) ESD mm, or >22 mm/m² in small patients Age >55 AF/Pulmonary Hypertension BNP >105 pg/mL Unfavourable exercise echocardiography findings Michelena HI, Rev Esp Cardiol ???

Exercise Echocardiography in DMR Magne J, et al

Exercise Echocardiography in Asymptomatic Organic MR Lancellotti P, Curr Opin Cardiol 2012

3D-TEE  Three-dimensional TEE was more accurate (92%–100%) than 2D TEE (80%–96%) in identifying prolapsed segments¹.  Three-dimensional TEE was more accurate (96.5%) than 2D TEE (70%) in identifying >1 segment or commissural prolapsus². 1.Biaggi P, JASE, Canna LG,AJC,2011

3D-TEE Biaggi P, JASE, 2012

Real-Time 3D- Morphologic Analysis of Mitral Valve and Annulus

3D-TEE Canna LG,AJC,2011

3D-TEE Canna LG,AJC,2011

3D-TEE  The diagnosis of leaflet prolapse is made on the basis of the measurement of leaflet-tip displacement above the highest point of the nonplanar, saddle-shaped annulus.  Secondary, nondominant prolapses, which are often missed using 2D ‑ echocardiography, can be detected, since their surgical correction is likely to reduce the occurrence of late postoperative MR.

3D-TEE Anterior Posterior De Bonis M, Nat Rev Cardiol-2012

Predictors of Successful Repair  Freedom from recurrence of non-trivial degrees of regurgitation (>1/4): % at 1 month % at 5 years % at 7 years  Freedom from failing repair (regurgitation>2/4): % at 1 month % at 5 years % at 7 years Flameng W, Circulation 2003

Predictors of Successful Repair

Predictors of Unsuccessful Repair Anatomic predictors of lower likelihood of repair are: Involvement of the anterior leaflet Involvement of ≥3 segments Posterior leaflet height Extent of mitral annular disease (Barlow) (Anulus>50 mm) Extensive annular calcification Severe central jet

Predictors of Unsuccessful Repair Iglesias I,SCVA-2007

Post-Repair Assessment- Intraoperatif TEE Real-time cardiovascular diagnosis Surgical decision-making

Post-Repair Assessment-Intraoperatif TEE Residual mitral regurgitation Segmental assessment of the coaptation surface (including commissures) Depth of coaptation should be at least 5 mm (LVOT view-systole) Mitral stenosis-Mean gradient >5 mm Hg Aortic regurgitation (stitch taken through AML close to LCC or NCC) Cx artery occlusion (stitch taken close to AL commissure) severe LV dysfunction LV and/or RV failure

Post-Repair Assessment-Intraoperatif TEE Common causes of a residual leak (other than trivial to mild regurgitation):  Uncorrected segmental prolapse or restriction  Residual restricted leaflet indentation  Incorrectly sized or positioned ring that distorts the coaptation zone  Ring dehiscence  Perforation of the leaflet from an annuloplasty suture  Defect in a leaflet closure line  Systolic anterior movement (SAM)

Ring dehiscence

Aortic Regurgitation After MVR

Unsuccessful Repair

Post-Repair Assessment- Intraoperatif TEE  Any significant degree of mitral valve regurgitation (other than trivial to mild regurgitation) should prompt a return to cardiopulmonary bypass and valve re- exploration to correct residual or new defects!!!

Systolic Anterior Motion (SAM)  Dynamic movement of the mitral valve anteriorly towards the LVOT during systole Clinically silent severe LVOTO with haemodynamic compromise

Systolic Anterior Motion (SAM)  Post-operative (mitral) incidence is %  Cause of late valve failure in 2 - 7% of patients after mitral valve repair

Factors predisposing to SAM Ibrahim M., et al. EJTS-2012

Factors predisposing to SAM-Preop  Excessive anterior or posterior leaflet tissue  Mitral–aortic angle of <120°  Increased AML (35 mm) or PML (15 mm) length  AML length/PML length <1.3 (systolic)  AML+PML >MV anulus+15 mm  C-Septal distance <2.5 cm  Excess tissue with respect to the annulus  Bulging subaortic septum (IVS> 15 mm)  Nondilated, small left ventricle (EDD <45mm)

Factors predisposing to SAM-Postop  Disruption of mitral annular and aortic root dynamics (rigid rings)  Annular undersizing (small ring)  Persistant AML redundancy  Excessive PML resection  Tachycardia, excess of inotropes  Hypovolemia, hypotension  RV failure, ventricular pacing

C-Septal distance

Factors predisposing to SAM

Post Mitral Repair SAM Manabe S et al-Interact CardioVasc Thorac Surg (2012)

SAM??