The document discusses the perioperative transesophageal echocardiography (TEE) for mitral valve repair, emphasizing its importance before and after cardiopulmonary bypass, including valve evaluation and identifying defects. It outlines methods for quantifying mitral regurgitation and assessing ventricular function, alongside classifications and standards for various mitral valve anomalies. Key recommendations include the necessity of exact localization of defects and monitoring potential complications like systolic anterior motion (SAM) during the repair process.

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. 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. MITRAL VALVE
APPARATUS
• ANNULUS
• AML,PML
• CHORDAL TENDONS
• PAPILLARY MUSCLES
• LV MYOCARDIUM

6. 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

7. • T
SURGEON’S VIEW TEE VIEW
TRANSTHORASIC VIEW

8. PROLAPSE AND BILLOWING

9. CARPENTIER’S CLASSIFICATION
Normal
Ringdilatation
Perforation
Cleft
Excessive
Chordal-rupture,-elongation
Papillary muscle-rupture,-
elongation
Ventricle dilatation (DCM)
Postischemic
Thickening calcification
Leaflets
Chords
Restrictive

10. 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

11. Transgastric View
Transgastric LV 2 Chamber
Transgastric LVSAX
LV
LA
90 Degrees
LVRV
0 Derees

12. 1. A1/P1
2. SAMA1
P1
ME 5 Chamber View

13. ME 4 Chamber
View
A2/A3 P2/P3

14. ME COMMISURAL View
A2
P1P3

15. AMLPML
LAA
Apex
LA
AW
IW
LV
ME 2CH 90 DEGREE VIEW

16. AML
PML
FW
Apex
LA
LV
PW
ASW
LVOT
ME 3CH LONG AXIS 120-150 DEGREE VIEW

17. TG LVSAX - Basal View
Anterolateral
Commissure
Posteromedial
Commissure
Anterior Mitral Leaflet
Posterior Mitral Leaflet

18. European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644

19. European Heart Journal – Cardiovascular Imaging (2013) 14, 611–644
What is a repairable Mitral Valve?

20. • 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

21. Perioperative TEE
• Before Weaning CPB:
– De-airing
– Ventricular function
– Regional Wall Motion Abnormalities
– Circumflex Artery
– Normal function of Aortic Valve

22. 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

23. 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,

24. • 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]

25. GRADING OF SAM
• Easy to revert ( volume, ionotrop)
• Difficult to revert ( beta blocker, afterload)
• Persistent
Ann Card Anesth 2011;14:85-90

26. MV PERFORATION

27. VENA CONTRACTA LINE OFCOAPTATION

28. A1-P1 PREBYPASS

29. POSTBYPSASS

30. PREBYPASS
A2 PROLAPSE

31. ANNULUS & PML HEIGHT
AML HEIGHT

32. NEO CHORDAE
POSTBYPASS
POST REPAIR

33. PREBYPASS TEE SHOWS FLAIL P1

34. POSTBYPASS

35. FLAIL PML PRE AND POST BYPASS

37. VEGETATION ON MITRAL VALVE

40. SAM AFTER MV REPAIR

41. POST TREATMENT

42. COLOUR M-MODE

43. SEVERE AR WITH MR

44. CIURCUMFLEX VISUALISATION

45. Foster et al
Ann Thorac Surg 1998;65:1025–31

46. Lambert et al
Anesth Analg 1999;88:1205–12

47. Bollen et al.
Journal of Cardiothoracic and
Vascular Anesthesia, Vo114, No 3
(June), 2000: pp 330-338
Duran nomenclature

48. JASE. 2003; 16: 61 – 66

49. 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

50. 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

51. Journal of Cardiothoracic and Vascular Anesthesia, Vol 26, No 5 (October), 2012: pp 777-784

52. European Heart Journal – Cardiovascular Imaging (2012) 13, 605–611

61. 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 }

62. 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.

65. a At heart rates between 60 and 80 bpm and in sinus rhythm.
Journal of the American Society of Echocardiography January 2009

67. THANK YOU