mitral valve tee2013(dr dharmesh)
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TEE & MITRAL VALVE
DR. DHARMESH R. AGRAWAL
M.D., P.D.C.C., Adv PTEE(NBE,USA), IACTA TEE FELLOWSHIP, IACTA HONORARY TEE FELLOWSHIPCONSULTANT ANESTHESIOLOGISTFORTIS HOSPITALBANGLORE, INDIA
Perioperative TEE for Mitral Valve Repair
• TEE before Cardiopulmonary Bypass– Standard views for evaluation of the mitral valve– Carpentier classification– Quantification of mitral regurgitation– Important informations for the surgeon
• TEE after Cardiopumonary Bypass
MITRAL VALVE APPARATUS
• ANNULUS• AML,PML• CHORDAL TENDONS• PAPILLARY MUSCLES• LV MYOCARDIUM
Mitral Valve Cusp Nomenclature
L R
NP1
P2 P3
A1
A2 A3
Carpentier Duran
L R
NP1
PM P2
A1A2
C1
C2
Anterior
Posterior
Anterior
Posterior
• T
SURGEON’S VIEW TEE VIEW
TRANSTHORASIC VIEW
PROLAPSE AND BILLOWING
CARPENTIER’S CLASSIFICATION
NormalRingdilatationPerforationCleft
ExcessiveChordal-rupture,-elongationPapillary muscle-rupture,-elongation
Ventricle dilatation (DCM)PostischemicThickening calcification Leaflets Chords
Restrictive
ME MITRAL VALVE VIEWS
Midesophageal Long Axis130-150 degrees
LV
Ao
RV
LV
LA
RV
RA 4 Chamber0 degrees
Midesophageal Mitral Commissure60 degrees
2 Chamber LAA View90 degrees
LA LA
LA
LAA
LVLV
Transgastric View
Transgastric LV 2 Chamber
Transgastric LVSAX
LV LA
90 Degrees
LVRV
0 Derees
1. A1/P12. SAMA1
P1
ME 5 Chamber View
ME 4 Chamber View
A2/A3 P2/P3
ME COMMISURAL View
A2P1P3
AMLPMLLAA
Apex
LA
AW
IW
LV
ME 2CH 90 DEGREE VIEW
AMLPML
FW
Apex
LA
LV
PW
ASW
LVOT
ME 3CH LONG AXIS 120-150 DEGREE VIEW
TG LVSAX - Basal View
AnterolateralCommissure
PosteromedialCommissure
Anterior Mitral Leaflet
Posterior Mitral Leaflet
European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644
European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644
What is a repairable Mitral Valve?
• Before Cardiopulmonary Bypass:
– Confirmation of the diagnosis and the severity• Sometimes provocation maneuver necessary
– Exact localisation of the defect (jet direction,leaflet)– Can the valve be repaired?– Possible dangerous constellation for reconstruction
• SAM, LVOTO• CIRCUMFLEX LIGATION
– Additional pathological findings (PFO,PDA,AR,TR)– Assessment of ventricular function– Measurements:
• Mitralannulus• AML-,PML-Height• C-Sept- Distance
Perioperative TEE
Perioperative TEE
• Before Weaning CPB:– De-airing
– Ventricular function
– Regional Wall Motion Abnormalities
– Circumflex Artery
– Normal function of Aortic Valve
Perioperative TEE
• After Weaning from CPB:– Quantification of residual mitral regurgitation (residual
cleft, prolapse,annular dilatation and suture
dehiscence)
– Assessment of ventricular function
– Assessment of pressure gradients through the
reconstructed valve (mean >4 to 6 unless Alferi or
commissural stitch)
– Occurence of SAM
Risk for Postrepair SAM
• AML : PML < 1.4• PML Height > 1.5 cm• C-Sept. Distance < 2.6 cm
Carpentier 1988, Maslow 1999,Gillinov 2001,
• EDD <45 mm [odds ratio (OR) 3.90; P = 0.028]• Aorto-mitral angle <120° (OR 2.74; P = 0.041) • Coaptation-septum distance <25 mm (OR 5.09; P = 0.003) • Posterior leaflet height >15 mm (OR 3.80; P = 0.012) • Basal septal diameter ≥15 mm (OR 3.63; P = 0.039)
Independent predictors of developing SAM after valve repair
Eur J Cardiothorac Surg 2013 May 8. [Epub ahead of print]
GRADING OF SAM
• Easy to revert ( volume, ionotrop)• Difficult to revert ( beta blocker, afterload)• Persistent
Ann Card Anesth 2011;14:85-90
MV PERFORATION
VENA CONTRACTA LINE OFCOAPTATION
A1-P1 PREBYPASS
POSTBYPSASS
PREBYPASSA2 PROLAPSE
ANNULUS & PML HEIGHT
AML HEIGHT
NEO CHORDAE
POSTBYPASS
POST REPAIR
PREBYPASS TEE SHOWS FLAIL P1
POSTBYPASS
FLAIL PML PRE AND POST BYPASS
VEGETATION ON MITRAL VALVE
SAM AFTER MV REPAIR
POST TREATMENT
COLOUR M-MODE
SEVERE AR WITH MR
CIURCUMFLEX VISUALISATION
Foster et al
Ann Thorac Surg 1998;65:1025–31
Lambert et al
Anesth Analg 1999;88:1205–12
Bollen et al.
Journal of Cardiothoracic and Vascular Anesthesia, Vo114, No 3 (June), 2000: pp 330-338
Duran nomenclature
JASE. 2003; 16: 61 – 66
TEE view Identified leaflet segment (from
left to right of the image)
ME 4ch A3-P1
ME commissural P3-A2-P1
ME 2ch P3-A1
ME lax P2-A2
TG sax To localise the origin of the
jet JASE. 2003; 16: 61 – 66
Recommendations for the echocardiographicassessment of native valvular regurgitation: an
executive summary from the EuropeanAssociation of Cardiovascular Imaging
European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644
Journal of Cardiothoracic and Vascular Anesthesia, Vol 26, No 5 (October), 2012: pp 777-784
European Heart Journal – Cardiovascular Imaging (2012) 13, 605–611
MV SEGMENT ANALYSIS
• ME lv lax view ( A2 and P2)• ME commissural view ( P1 and P3)• ME 4ch view (A3) And ME 2ch view (A1) { This
should be corroborrated by TG MV sax view with color doppler for origin of the mr jet }
Summary
• Exact localisation of the defect is possible andessential for the surgeon doing a mitral valve repair.
• Identification of a SAM constellation helps to prevent complications after MVR.
• Detection and visulisation of the circumflex artery before and after mitral valve repair is possible.
a At heart rates between 60 and 80 bpm and in sinus rhythm.
Journal of the American Society of Echocardiography January 2009
THANK YOU
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