Dr.GÖKHAN KAHVECİ Istanbul 01 Oct 2013

1. PreoperativeEchocardiographicCluesForRepair of Degenerative Mitral Valveand IntraoperativeDecisionMaking Dr.GÖKHAN KAHVECİIstanbul01 Oct 2013

2. Nationalrepairratesgenerallyapproximate less than 60% of operated patients (degenerative mitral regurgitation), despiteguidelinerecommendations-USA İn Turkey?

3. The Echocardiographer’s Role in Mitral Surgery • Prereferralechocardiographic assessment plays a pivotal role in directingpatients Carefulechocardiographicassessment “road map for the repairstrategy” appropriate matching of surgical expertisetodegenerativevalvecomplexity ExperiencedSurgeon Mitral Super-specialists

4. The Echocardiographer’s Role in Mitral Surgery

5. 2013

6. Carpentier’sFunctionalClassification Type I LeafletPerforation/AnnularDilation Type II ExcessiveLeafletMobility-DMR TypeIIIaRestrictiveLeafletMotion-Systole/Diastole-RMR TypeIIIbRestrictiveLeafletMotion-Systole-FMR

7. Degenerative Mitral ValveDisease • Degenerative mitral valve disease is the most commonetiology of MR • Affectsrelativelyhealthyindividuals • Naturalhistory is insidious • Repair(not replacement) is the surgical treatment ofchoice • The restoration of life expectancy can be expected

8. Degenerative Mitral ValveDisease Morphologicchanges in theconnective tissue of the mitral valve StructuralLesions (chordalelongation, chordalrupture, leaflet tissue expansion, annulardilation) LeafletProlapseMR

9. Degenerative Mitral ValveDisease FED Barlow

10. Barlow’sandFibroelasticDeficiency AnnulusSeverelydilatedNear normal size 32 mm Anyanyu AC, Semin ThoracCardiovascSurg, 2007

11. Fibroelastic Deficiency-P2 chordal rupture

12. Barlow’s Disease

13. Echocardiography • Precisemorphologicassessmentis necessary to predict the rates of successful reconstructivevalvesurgery • Preop TTE-TEE • Periop TEE • 3D imaging • Quantification of mitral regurgitationseverity • PAP, LV size, LV function

14. Echocardiography Theechocardiographicreportshouldprovideclues on thelikelihood of thevalverepair

15. Echocardiography ACC-AHA-2006 ESC-2012 Experiencedsurgicalcenters!! Proper differentiation of the degenerative disease!! (critical step)

16. Echocardiography StudyingthePreoperativeEchocardiogram/ClinicalSenario (experiencedsurgeonandcardiologist) (speaking common language) EtiologyandLesions Mental Plan (Surgeon) Incisiontype? Technique? Cross-clamp time?

17. Echocardiography “road map for the repairstrategy” Barlow’s disease with bileaflet multi-segmentalprolapseandannularcalcification (complex) Mediansternotomy/larger lateral thoracotomy-posterior leaflet resection, sliding leaflet plasty, annulardecalcification, chordal transfer/substitution, papillarymuscle sliding, and large-ring annuloplasty Simple P2 prolapse Minimallyinvasiveapproache-posteriorleafletresection, ring annuloplasty

18. Quantification of MR ColorFlow Jet Area Lancellotti p.

19. Quantification of MR EAE Recommendation 2010

20. Quantification of MR

21. Quantification of MR Lancellotti P-EJE 2010

22. Vena ContractaWidth-2D(TTE-TEE)

23. Vena ContractaWidth-2D(TTE-TEE) Intermediate vena contractavalues (3-7 mm) needconfirmationby a morequantitivemethod!!

24. Vena ContractaArea-3D (TTE-TEE)

25. Vena ContractaArea-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 Prognosticvalue?

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

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

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

30. Mitral Inflow and Aortic Outflow Stroke Volume Measurement

31. EROA and RV-3D (TTE-TEE)PISA NeedValidation

32. Quantification of MR AccurateEstimation of MR Traditional2D- VC/ EROA / RV-RF Formultipleorcomplicatedjets- 3D Fordifficultsurfaceimaging- MRI (esp RV)

33. Left VentricularDimensions ESD>40 mm or ESD> 22 mm/m²

34. Left Ventricular Function Chronic MR PreloadAfterload N or LV EF maystill be in normal rangedespitethe presence of significantmuscledysfunction !!!!!!

35. PreoperativeLeft Ventricular Function Repair MVR Enriquez-Sarano M,Circulation 1994

36. Subclinical LV dysfunction • An inability to increase the left ventricular ejectionfraction or reduce the end-systolic volume withstress reflects the presence of an impaired contractilereserve.

37. Subclinical LV Dysfunction Predictors of Subclinical LV dysfunction in asymptomatic MR: • LateralannulussystolictissueDopplervelocity <10.5 cm/s • LongitudinalStrain rate <1.07/s (avarage of basalandmid 12 segments) • Global LongitudinalStrain(STE) <18.1%

38. LeftAtrial Size LA volume >40 mL/m²

39. LeftAtrial Size LA >55 mm

40. PulmonaryArteryPressure PASP >50 mm Hg Medikal Postoperative

41. Asymptomatic Severe MR ERO ≥ 0.4 cm² and/or RV ≥ 60 mL EF >60% and ESD <40 mm Watchfulwaiting? EarlySurgery? Echocardiographicpredictors of postop LV dysfunction?

42. Risk Factorsfor Post-op LV Dysfunction in AsymptomaticOrganic MR • Chordalrupture • Massive MR (RVol >100 mL and ERO >0.5 cm²) • ESD 37-39 mm, or >22 mm/m² in smallpatients • Age >55 • AF/PulmonaryHypertension • BNP >105 pg/mL • Unfavourableexerciseechocardiographyfindings ??? Michelena HI, RevEspCardiol. 2010

43. ExerciseEchocardiography in DMR Magne J, et al

44. ExerciseEchocardiography in AsymptomaticOrganic MR Lancellotti P, CurrOpinCardiol 2012

45. 3D-TEE • Three-dimensional TEE was more accurate (92%–100%) than 2D TEE (80%–96%) in identifyingprolapsedsegments¹. • Three-dimensional TEE was more accurate (96.5%) than 2D TEE (70%) in identifying >1 segmentorcommissuralprolapsus². 1.Biaggi P, JASE, 2012 2.Canna LG,AJC,2011

46. 3D-TEE Biaggi P, JASE, 2012

47. Real-Time 3D- Morphologic Analysis of Mitral ValveandAnnulus

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

49. 3D-TEE Canna LG,AJC,2011

50. 3D-TEE Canna LG,AJC,2011