Intra-operative Transesophageal Echocardiology

Chong C Lee, MD, Marshfield Clinic Cardiovascular Surgeon on staff at Ministry Saint Clare’s Hospital

Jason Hanson, MD, Ministry Medical Group Anesthesiologist on staff at Ministry Saint Clare’s Hospital

Gregory Gilles, MD, Ministry Medical Group Anesthesiologist on staff at Ministry Saint Clare’s Hospital

Transesophageal echocardiography (TEE) plays a pivotal role in the intraoperative assessment of mitral valve disease. Specifically, as you’re about to read in the following case study, in a patient experiencing severe mitral regurgitation, TEE can affect the surgeon’s verdict on whether to completely replace the valve or rather to attempt repair. This critical choice of replace-versus-repair entails life-changing ramifications for the patient. As an adjunct in this decision process, intraoperative TEE adds a valuable tool to our armamentarium in the quest to provide optimal patient outcomes.

Case Study: Mitral Valve Repair

The patient is a 53-year-old gentleman who was seen in consultation in January 2010 for severe mitral regurgitation with mitral valve prolapse. The patient had a diagnosis of rheumatic fever as a child. He states that he has known that he had mitral valve disease at a very young age. He has been followed with echocardiogram as an adult. His most recent echocardiogram in December 2010 demonstrated the severe mitral regurgitation with continued myxomatous mitral valve prolapse with marked left atrial enlargement as well as moderate pulmonary hypertension. The patient was clinically developing more exertional shortness of breath and it was time to have further discussion about the mitral valve repair or replacement. The patient was otherwise healthy other than a history of hypertension. After a review of his echocardiogram and cardiac catheterization, recommendation was made to proceed with mitral valve repair. On May 20, 2010, the patient underwent mitral valve repair with resection of the posterior 2 segment with placement of a 30 mm annuloplasty band and closure of the left atrial appendage. The patient tolerated the procedure well and is doing excellent post-procedure.

TEE examination of the mitral valve involves both structural and functional evaluation.The mitral valve apparatus itself is comprised of several distinct components: valve annulus, anterior leaflet, posterior leaflet, chordae tendinae, and the ventricular papillary muscles. Pathology can occur at any of these locations, and thorough systematic inspection is requisite. Ultrasound modalities available to facilitate this interrogation include 2D-echo, color flow Doppler, spectral Doppler, and the rapidly improving technology of 3D-echo. Both qualitative and quantitative techniques are utilized to determine the mechanism of mitral regurgitation (MR), the anatomic lesion(s) involved, and severity of physiologic impact. This evidence is then taken in context (with other factors such as patient age, functional status, and co-morbidity, as well as the surgeon’s confidence in the likely success of a particular surgical approach) to determine whether valve replacement or repair will commence. In the case of mitral valve repair, post-procedure considerations would include evaluation of adequacy of repair, specifically looking for evidence of residual regurgitation; potential complications including systolic anterior motion (SAM) or LVOT obstruction, coronary injury, ventricular rupture, or aortic valve leaflet injury are also investigated.

A case such as this poses a challenge to today’s cardiac surgical team. The decision to repair a leaking mitral valve instead of replacing it is complex, and not one without significant potential consequences. Intraoperative TEE can provide help in that process. Ultimately it is a powerful and exciting technology that will only see a growing role within the cardiac surgery suite.

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