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Mitral valve tee2013(dr dharmesh)

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there is detailed analysis of mitral valve segments by 2d transesophageal echo cardiography. There is a review on this and simplified approach how one can identify the pathological segment with great accuracy using two dimensional tee.

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Mitral valve tee2013(dr dharmesh)

  1. 1. TEE & MITRAL VALVE DR. DHARMESH R. AGRAWAL M.D., P.D.C.C., Adv PTEE(NBE,USA), IACTA TEE FELLOWSHIP, IACTA HONORARY TEE FELLOWSHIP CONSULTANT ANESTHESIOLOGIST FORTIS HOSPITAL BANGLORE, INDIA
  2. 2. 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
  3. 3. MITRAL VALVE APPARATUS • ANNULUS • AML,PML • CHORDAL TENDONS • PAPILLARY MUSCLES • LV MYOCARDIUM
  4. 4. Mitral Valve Cusp Nomenclature L R N P1 P2 P3 A1 A2 A3 Carpentier Duran L R N P1 PM P2 A1 A2 C1 C2 Anterior Posterior Anterior Posterior
  5. 5. • T SURGEON’S VIEW TEE VIEW TRANSTHORASIC VIEW
  6. 6. PROLAPSE AND BILLOWING
  7. 7. CARPENTIER’S CLASSIFICATION Normal Ringdilatation Perforation Cleft Excessive Chordal-rupture,-elongation Papillary muscle-rupture,- elongation Ventricle dilatation (DCM) Postischemic Thickening calcification Leaflets Chords Restrictive
  8. 8. ME MITRAL VALVE VIEWS Midesophageal Long Axis 130-150 degrees LV Ao RV LV LA RV RA 4 Chamber 0 degrees Midesophageal Mitral Commissure 60 degrees 2 Chamber LAA View 90 degrees LA LA LA LAA LV LV
  9. 9. Transgastric View Transgastric LV 2 Chamber Transgastric LVSAX LV LA 90 Degrees LVRV 0 Derees
  10. 10. 1. A1/P1 2. SAMA1 P1 ME 5 Chamber View
  11. 11. ME 4 Chamber View A2/A3 P2/P3
  12. 12. ME COMMISURAL View A2 P1P3
  13. 13. AMLPML LAA Apex LA AW IW LV ME 2CH 90 DEGREE VIEW
  14. 14. AML PML FW Apex LA LV PW ASW LVOT ME 3CH LONG AXIS 120-150 DEGREE VIEW
  15. 15. TG LVSAX - Basal View Anterolateral Commissure Posteromedial Commissure Anterior Mitral Leaflet Posterior Mitral Leaflet
  16. 16. European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644
  17. 17. European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644 What is a repairable Mitral Valve?
  18. 18. • 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
  19. 19. Perioperative TEE • Before Weaning CPB: – De-airing – Ventricular function – Regional Wall Motion Abnormalities – Circumflex Artery – Normal function of Aortic Valve
  20. 20. 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
  21. 21. 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,
  22. 22. • 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]
  23. 23. GRADING OF SAM • Easy to revert ( volume, ionotrop) • Difficult to revert ( beta blocker, afterload) • Persistent Ann Card Anesth 2011;14:85-90
  24. 24. MV PERFORATION
  25. 25. VENA CONTRACTA LINE OFCOAPTATION
  26. 26. A1-P1 PREBYPASS
  27. 27. POSTBYPSASS
  28. 28. PREBYPASS A2 PROLAPSE
  29. 29. ANNULUS & PML HEIGHT AML HEIGHT
  30. 30. NEO CHORDAE POSTBYPASS POST REPAIR
  31. 31. PREBYPASS TEE SHOWS FLAIL P1
  32. 32. POSTBYPASS
  33. 33. FLAIL PML PRE AND POST BYPASS
  34. 34. VEGETATION ON MITRAL VALVE
  35. 35. SAM AFTER MV REPAIR
  36. 36. POST TREATMENT
  37. 37. COLOUR M-MODE
  38. 38. SEVERE AR WITH MR
  39. 39. CIURCUMFLEX VISUALISATION
  40. 40. Foster et al Ann Thorac Surg 1998;65:1025–31
  41. 41. Lambert et al Anesth Analg 1999;88:1205–12
  42. 42. Bollen et al. Journal of Cardiothoracic and Vascular Anesthesia, Vo114, No 3 (June), 2000: pp 330-338 Duran nomenclature
  43. 43. JASE. 2003; 16: 61 – 66
  44. 44. 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 jetJASE. 2003; 16: 61 – 66
  45. 45. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644
  46. 46. Journal of Cardiothoracic and Vascular Anesthesia, Vol 26, No 5 (October), 2012: pp 777-784
  47. 47. European Heart Journal – Cardiovascular Imaging (2012) 13, 605–611
  48. 48. 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 }
  49. 49. 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.
  50. 50. a At heart rates between 60 and 80 bpm and in sinus rhythm. Journal of the American Society of Echocardiography January 2009
  51. 51. THANK YOU

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