**2.7.4 Postpump examination**

In most cases, with an experienced surgeon, mitral valve repair leads to a competent mitral valve with mild or no residual mitral regurgitation. However, there are potential complications of mitral valve repair that are readily recognized by postpump intraoperative echocardiography. Many of these complications may not be apparent clinically or may take longer to accurately diagnose without echocardiography. If left untreated, these complications may interfere with the long-term success of the procedure and require early re-operation (Otto, 2003). In fact, the trust-based relationship between the echocardiographer and the surgeon is tested when a second run pump is needed. In case of debatable "moderate" mitral regurgitation, the team has to focus on the mitral coaptation (and geometry) rather than on the Colour Doppler analyses. Remember to avoid the hypovolemic status.

Transesophageal echocardiography is practically the only method used immediately after weaning from the cardiopulmonary bypass in order to assess the result of the mitral repair. It must rapidly answer some essential questions about the repaired valve. The most important task of the transesophageal echocardiography is to analyze the postoperative mitral valve geometry and function, focusing on leaflet coaptation.

 It may occur that immediately after weaning the patient off the cardiopulmonary by-pass, the echocardiographer declares the success of the repair after analyzing only some of the available views, usually the mid-esophageal 0° or distal-esophageal 135°, where only scallops A2 and P2 are evaluated. The postoperative transesophageal examination has to be performed using the same algorithm that was used during the preoperative evaluation. One has to bear in mind that the triangle of coaptation remains the goal of a typically functioning reconstructed valve. It should be taken into consideration that the reconstruction of the coaptation triangle is not always possible. When present, the echocardiographer has to search for it in all the segments of the valve: from the anterior commissure and corresponding scallops A1/P1, P2/A2 and of course the medial scallops A3/P3 and the posterior commissure.

leaflet mobility became cornerstone principles that guide the mitral repair in our centre. The classical techniques of repair included the quadrangular resection of the posterior mitral leaflet and ring annuloplasty, which inevitably led to a rigid posterior leaflet (Verma, NYJM 2009). Lately, many surgeons have chosen to perform the triangular resection (instead of quadrangular) in order to guarantee a higher mobility of the posterior leaflet and thus an increased anatomical and functional leaflet reserve, convinced that this will subsequently

In conclusion, we may assume that the importance of the preoperative transesophageal examination is given by the accuracy in identifying the mechanism of mitral regurgitation and valve anatomy (flail, prolapse, loss of coaptation, perforation and so on), and by describing the geometry of the mitral apparatus. There is a close correlation between valve geometry and function. The Colour Doppler mapping might underestimate the entity of the regurgitant flow; thus, the prepump echocardiographic evaluation needs to rely more on

In most cases, with an experienced surgeon, mitral valve repair leads to a competent mitral valve with mild or no residual mitral regurgitation. However, there are potential complications of mitral valve repair that are readily recognized by postpump intraoperative echocardiography. Many of these complications may not be apparent clinically or may take longer to accurately diagnose without echocardiography. If left untreated, these complications may interfere with the long-term success of the procedure and require early re-operation (Otto, 2003). In fact, the trust-based relationship between the echocardiographer and the surgeon is tested when a second run pump is needed. In case of debatable "moderate" mitral regurgitation, the team has to focus on the mitral coaptation (and geometry) rather than on the Colour Doppler analyses. Remember to avoid the

Transesophageal echocardiography is practically the only method used immediately after weaning from the cardiopulmonary bypass in order to assess the result of the mitral repair. It must rapidly answer some essential questions about the repaired valve. The most important task of the transesophageal echocardiography is to analyze the postoperative

 It may occur that immediately after weaning the patient off the cardiopulmonary by-pass, the echocardiographer declares the success of the repair after analyzing only some of the available views, usually the mid-esophageal 0° or distal-esophageal 135°, where only scallops A2 and P2 are evaluated. The postoperative transesophageal examination has to be performed using the same algorithm that was used during the preoperative evaluation. One has to bear in mind that the triangle of coaptation remains the goal of a typically functioning reconstructed valve. It should be taken into consideration that the reconstruction of the coaptation triangle is not always possible. When present, the echocardiographer has to search for it in all the segments of the valve: from the anterior commissure and corresponding scallops A1/P1, P2/A2 and of course the medial scallops A3/P3 and the

mitral valve geometry and function, focusing on leaflet coaptation.

valve geometry and regurgitant mechanism, and less on the Colour flow Doppler.

achieve a better and longer lasting coaptation.

**2.7.4 Postpump examination** 

hypovolemic status.

posterior commissure.

After surgical repair, the essential issue is that the coaptation point must be dragged within the left ventricle, underneath the mitral annular plane (Figure 15). In the normal mitral valve, this type of coaptation expresses the physiological equilibrium between the collagen and elastic fibres, which confers the right balance between the elasticity and resistance of the valve. Same should be true about the repaired mitral valves, which will most probably remain elastic and long-lasting when their geometry satisfies the mentioned criteria.

Fig. 16. TEE postoperative aspect of complex mitral valve repair. Notice the rebuilding of the triangle of coaptation (arrows) and the classical 'smile' aspect of the mitral valve on the intraoperative photo (middle). LA = left atrium.

Even if already stated, it should be underlined that the triangle of coaptation and the coaptation length need to be carefully assessed in all the regions of the mitral valve before expressing the final judgement on the real immediate outcome of the repair. Keep in mind possible traps. The surgeon's "hurry" to know the results of repair; do not express any conclusions before appropriate ventricular loading conditions are achieved. Do not start the post-operative assessment by Colour Doppler. The most important thing is to assess the length of coaptation and valve geometry.

In order to correctly assess the valve geometry, the loading conditions should be optimal: hypovolemia should be avoided as it may underestimate a potential residual mitral regurgitation or label as 'prolapsing' an otherwise normal valve leaflet. We have stated about the prepump exam that the importance of the Doppler techniques for the evaluation of the severity of the mitral regurgitation was lower than the importance of the geometrical analysis. This does not mean that Color Doppler mapping shouldn't be performed but it should integrate the geometrical analysis and not replace it. These details are essential to the surgeon. The outcome depends on that. This statement is also true about the post-pump examination. Geometry is more important than colour (meaning Colour Doppler mapping).

Whenever the result of the repair is suboptimal and there is residual mitral regurgitation, the echocardiographer must be able to rapidly identify the true mechanism of mitral regurgitation. The problem may vary from residual prolapse or restriction of one or more valve sectors - presumably due to incorrect neo-cordal length, residual marginal prolapse if left untreated, oversized annuloplasty ring, persistence of pseudo-commissures, etc. In these cases further surgery with a second run pump might be needed. Rarely, the mitral valve problem may be a consequence of a ventricular dysfunction when a post-pump contractility

The Degenerative Mitral Valve Regurgitation:

**4. Acknowledgements** 

to the manuscript.

**5. References** 

57-66

1158-1161

Circulation. 1997; 95:636-642).

From Geometrical Echocardiographic Concepts to Successful Surgical Repair 23

coaptation height as geometric echocardiographic concepts aiming to restore the mitral valve shape and coaptation, is a crucial point to improve the surgical planning and results.

We acknowledge BENEA Diana MD and IONESCU Georgiana MD, for helpful contribution

Bargiggia, GS.; Tronconi, L.; Sahn, DJ.; Recusani, F.; Raisaro, A. & De Servi, S. A new

Baumgartner, H.; Schima, H. & Kuhn, P.; Value and limitations of proximal jet dimensions

Benea, D.; Cerin, G.; Diena, M. & Tesler, UF. Pharmacologic Resolution of Functional Out

Bonow, R. (2011). Valvular heart disease: Patient needs and practice guidelines. *Aswan Heart Center Science & Practice Series*, Vol 1 (April 2011), pp. 20-29, ISSN 2220-2730 Brickner ME, Willet DL, Irani WN-Assesement of Mitral RegurgitationSeverity by Doppler Color Flow Mapping of the Vena Contracta. Circulation 1997;95:636-642 G Cerin, M Diena, G Lanzillo, S Casalino, A Zito, D Benea, U Filippo Tesler. Degenerative

Romanian Journal of Cardiovascular Surgery, 5 (3), pp. 131-39, 2006. Cerin, G.; Popa, BA.; Benea, D.; Lanzillo, G.; Karazanishvili, L.; Casati, V.; Popa, A.; Novelli,

4 (October 1991); pp. 1481-9, ISSN 1524-4539.

32, No 4. (October 2005), pp. 563–566, ISSN 0730-2347

*Cardiology Scientific Sessions,* Beijing, China (June 2010)

7, (December 1999), pp. 2096-2104, ISSN 0735-1097

*European Heart Journal* 2007, 28, 1358-1365

method for quantitation of mitral regurgitation based on color flow Doppler imaging of flow convergence proximal to regurgitant orifice. *Circulation.* Vol 84. No

for the quantitation of valvular regurgitation: an in vitro study using Doppler flow imaging. *Journal of the American Society of Echocardiography*, Vol 4, (Jan-Feb 1991), pp.

flow Tract Obstruction after Mitral Valve Repair. *Texas Heart Institute Journal*, Vol

mitral regurgitation - surgical and echocardiographic consideration for repair.

E.; Renzi, L. & Diena, M. The triangle of coaptation: a new concept to enhance mitral valve repair through reshaping the native geometry. *World Congress of* 

& Grossi E. (April 2011). Analysis of the mitral coaptation zone in normal and functional regurgitant valves. *The Annals of Thoracic Surgery*, Vol 89, Issue 4, pp.

Regurgitation Severity by Doppler Color Flow Mapping of the Vena Contracta.

Echocardiographic predictors of left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve after mitral valve reconstruction for myxomatous valve disease. *Journal of the American College of Cardiology*, Vol 37, No

symptomatic mitral regurgitation: greater compliance with guidelines is needed

Gogoladze, G.; Dellis, SL.; Donnino, R.; Ribakove, G.; Greenhouse, DG.; Galloway, A.

Hall SA, Brickner ME, Willett DL, Irani WN, Afridi I, Grayburn PA – Assessment of Mitral

Maslow, DA.; Regan, MM.; Haering, MJ.; Johnson, RG. & Levine RA(1999).

Mirabel, M; Iung,B, Baron, G; Messika-Zeitoun, D & Détaint, D. Surgical referral in

issue may appear. This should also be clearly pointed out by the post-pump echocardiographic examination. In this case, further surgery for the mitral valve might not be needed, but only ventricular assistance.

The main problem with residual mitral regurgitation arises in patients with moderate insufficiency. In loose teams, the surgeon tends to underestimates the importance of the mitral regurgitation. Because the echocardiography is a semi quantitative method, in every day practice the surgeon will go easier to the second run pump only if the echocardiographer was able to 100% accurately identify the preoperative lesions, compared to the intraoperative findings. Therefore, an excellent preoperative assessment will bond the team, creating a trustful relationship between the surgeon and the echocardiographer.

The evaluation of the outcome after mitral repair has been done mainly using the Colour Doppler mapping. When the residual regurgitation is absent or of mild degree, the result is judged as adequate. Generally, superior degrees of residual regurgitation, naturally correlated with the coaptation and geometrical analysis, indicate the need for a second pump run. In selected cases (e.g. old patients or significant comorbidities), moderate or more than moderate residual regurgitation might be accepted when the risk of a second pump run to correct the valvular problem exceeds the potential benefit for the patient.

The annuloplasty ring is used in almost all operated patients. From an echocardiographic technical perspective this might determine difficulties in the postoperative evaluation of the repaired mitral valve when performing the distal esophageal long axis views. Usually, the presence of the annuloplasty ring might 'hide' the mitral valve leaflets by posterior shadowing immediately after surgery. To overcome this problem a valid solution could be the evaluation from the deep transgastric short-axis and long axis views.
