Mitral TEE What is the Surgeon Need

8/11/2019 Mitral TEE What is the Surgeon Need

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Mitral TEE :

What Is The Surgeon Need for Mitral Repair?

Presented by: Victor J. Nababan,MD

victor j nababan-jess


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INTRODUCTION

The prevalence of mitral regurgitation (MR) in the

western world is on the increasedespite the

substantial reduction in rheumatic disease.

Chronic organic MR (particularly when

degenerative in origin) is the most common

valvular disease: moderate or severe MR is found

in 1.7% of the general population, 6.4% ofpatients aged 65-74 years, and 9.3% of those >75

years.



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In the field of mitral valve repair surgery, Alain

Carpentier radically changed the prognosis

and clinical managementof patients with MR.

Since then, 2-dimensional, Doppler, and 3-

dimensional echocardiography have gained

much importance because they reveal the

functional anatomy of the mitral valve (MV)and its dynamic structure.



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Echocardiography should provide precise data

on the type and extent of valve lesions, the

regurgitation mechanism, and its etiology,

severity, and finallythe main objective of

the present studyprobability of repair



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The leaflets n commissures

2 leafletsant n postsimilar surface n thickness ( 1mm)

Ant n post leafletseperated by commissures at the basefibromuscular tissue of the anulus and free borders to the

subvalvulr aparatus by means the chordae Ant leaflettrapezoidal shape , extends vertically and

anchored 1/3 of annular circumference (intimate relationwith aortomitral curtain)

Post leaflettransfersal to MV orifice, fixed 2/3 of anullar

circumference closely related LV wall base (the point ofgreatest systolic stress)

8 segmentsA1,A2,A3,P1,P2,P3,AC,PC.

P2more redundancy n its thicknessimpact of greatersyst pressureprone to prolaps n lessions



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The mitral annulus D-shapedgreater eccentricity ( less circular) in systole than diastole.

Link between LA n LVfibrous tissue n MV motion begin An integral part of the fibrous skeleton of heart

Zone where the post leaflet is insertedconsist of a very thin band ofconnective tissue(not connected to any rigid structure)annulardilatation n calsification occur .

Zone where the ant leaflet is inserted continuation of the aortomitralcurtainreinforced at the base by 2 rigid structure: right fibrous trigonejoining the membranous septum, mitral anulus,

tricuspid anulus, and NCC

Left fibrous trigonecontiguous to LCC and mitral anulus.

Annular area

5-11 cm2

begin increases in size at end systole,maximum in end dyastole. Begin decrease in atrial contraction,maximum in halfway systolic cycle (optimal coaptation).

Normal anular contraction 25%.



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The chordae tendineae

Filament- like structures of connective fibroustissuejoin the LV surface and free border ofthe leaflets to the papillary muscle

Classified into 3: Marginal chordaeinserted into free borders of the

leafletsavoid leaflet prolap

Intermediate or 2nd order chordaeinserted in theventricular face of the leafletto relieve excess

tension in the valve tissue. Basal or 3rd order chordaeonly found on the post

leaflet and connect to the base n post mitral anulus.



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Papillary Muscles

Two organized groups of papillary muscles --> reference totheir position in relation to the mitral commissuresanterolateral n posteromedial.

1. The anterolateral papillary muscle:

has a single body,is larger irrigated by the first obtuse marginal branch of the circumflex

artery and the first diagonal branch of the anterior descendingartery.

2. The posteromedial papillary muscle 2 bodies, is smaller in size.

irrigated only by the posterior descending artery, a branch ofthe right descending coronary much more vulnerable toischemic episodes.



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The Left Ventricle

The continuum from the papillary muscles to theleft ventricle gives the latter a dominant role inmitral leaflet motion control, particularly inpatients with ischemic disease.

According to Starlings law, myocyte contractilitywould compensate for excess volume in thepresence of MR, especially in its early stages.

However, given that the left ventricle actively

sustains all the mitral apparatus, any amount ofpathologic dilatationwhether ischemic in originor notwould lead to functional MR.



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CarpentiersPathophysiologic

Triads

Etiology :

The cause of valve disease

Lesion :The result of the disease process

Dysfunction :

The result of the lesion



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The Etiologythe cause of valve disease

Organic (Primary) Functional (Secondary)

Degenerative Valve Disease

FED

Barlows Disease

Rheumatic Valve Disease

Infective Endocarditis

Congenital Valve Disease

Ischemic Mitral Disease

Dilated Cardiomyopathy

Hypertrophic Cardiomyopathy



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The Lession

Mitral Valve Nomenclature

TEE operator vs surgeonuse the same language



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ECHOCARDIOGRAPHIC EVALUATION

When conducted by an expert, systematic

examination of the MV using transthoracic

echocardiography (TTE) should reliably predict

repair.

However, more and more centers now opt for

transesophageal echocardiography (TEE),

particularly in complex cases, prior to referringpatients for surgical evaluation.



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Four-Chamber View

The classic apical 4-chamber TTE to analyze theanterior leaflet, especially A2 and A3, as well as thelateral segment of the P1 posterior leaflet.

In contrast, TEE enables us to observe practically all

segments as a function of the degree of rotation of thetransducer. At 0 degree, the transducer shows bothleaflets mid-segments (A2 and P2).

If the probe rotates 20 degree, it cuts the line of

coaptation obliquely and obtains detailed informationfor the most lateral segments, such as A2, A1, and P1.



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Figure 4. TTE using the apical 4-chamber view performed 15 weeks after surgery.

Zlotnick A Y et al. Circulation 2008;118:e73-e75

Copyright American Heart Associationvictor j nababan-jess


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View of Both Commissures

This can be obtained with an apical 2-chamber plane in TTE or by rotatingthe transesophageal probe approximately 60 degree so that the imageplane cuts perpendicularly through that which delimits both commissures,thus cutting through both valves to facilitate analysis of P3 (to the left ofthe image), A2 (in the center of theimage), and P1 (to the right of theimage).

In this plane, the papillary muscles can normally be seen. Moreover, this view is of great value in determining which segment is

pathologic because if the regurgitant jet begins to the left of the line ofcoaptation, we deduce it is secondary to a lesion in P3 or A3; if theregurgitant jet starts to the right of the line of coaptation, the segmentsinvolved will be P1 or A1.

The height of P1 and P3 can be calculated from this plane, which is highlyimportant when predicting repair complexity. If these segments are >1.5cm in height, we can assume anterior systolic movement is more likelyfollowing repair; consequently, under these circumstances, the repair willbe more complex as it requires partial resectioning of the leaflets.



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Two-Chamber View

If we continue rotating the transducer to 90

degree, we obtain a 2-chamber view. In this

plane, P3 can be seen to the left of the image and

all the anterior leaflet segments are located tothe right.

This view is crucial to analysis of the anterior

leaflet and complete evaluation of theposteromedial part of the line of coaptation (A3

and P3), as well as its corresponding commissure.



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Parasternal or Sagittal Long-Axis View The long axis of the parasternal plane, using TTE, or the sagittal

view with the probe rotated to 120 degree, using TEE, will cutthe line of coaptation perpendicularly, through P2 (to the leftof the image) and A2 (to the right of the image).

This view is especially important as prolapse of P2 is the mostfrequent, particularly in patients with degenerative disease.

Moreover, this view enables us to evaluate the annularsurface, extrapolating annular diameter from the anteriorleaflet surface.

Pathologic annular dilatation is considered present when theannulus:anterior leaflet ratio is >1.3 or annular diameter is >35

mm. Moreover, the surgeon should know of any substantial

calcification in the annulus or subvalvular apparatusurgicalstrategy changes radically when facing calcified segments orextremely rigid tissue



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P l Sh A i T i


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Parasternal Short-Axis or Transgastric

View

This view, although requiring an experiencedoperator, can be obtained by TTE (classicparasternal view) or TEE ( transgastric view).

In diastole, it enables us to evaluate all segments

and both commissures. In systole, we can deducethe localization of the pathologic segment byanalyzing regurgitant jet.

Moreover, we can obtain information about the

subvalvular apparatus and the distance betweenthe head of the papillary muscle and mitralannulus.



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Annulus MV Coaptation distance


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Coaptation distance

Tenting AreaPosterolateral angle



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Ivan Iglesias

Semin Cardiothorac Vasc Anesth 2007;11:301victor j nababan-jess


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Predictor for SAM

Excessive length of PML (> 15 mm)

Excessive length of AML (> 35 mm)

Length AML + PML exceeds diameter of mitral annulus > 15 mm

Distance of coaptation point of mitral leaflets to septum < 15 mm (c-

septal)

Ivan Iglesias

Semin Cardiothorac Vasc Anesth 2007;11:301victor j nababan-jess


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Systolic Anterior Motion post MV repair

significant LVOT gradient and significant residual MR



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Conclusion

Imaging studies are becoming increasingly important in

the management of patients with MR, particularly giventhe trend for early interventions in patients with severeasymptomatic MR.

Precise follow-up of changes in geometry and volume ispossible and this facilitates establishing surgical

indications for patients with a tendency towardsventricular dysfunction before ejection fraction declines.

Three-dimensionalechocardiography gives a perfectsurgeons-eye view of the MV, nenabling preoperative

identification of complex lesions that require referral to aspecialized center.

The incessant training of future generations of specialistsis clearly crucial in avoiding unnecessary replacements.



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Thank You

Mitral TEE What is the Surgeon Need

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