Echocardiographic predictors of left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve after mitral valve reconstruction for myxomatous valve disease

Intraoperative TEE Assessment During Mitral Valve Repair for Degenerative and Ischemic Mitral Valve Regurgitation

Intraoperative assessment of the mitral valve (MV) in patients undergoing repair for MV regurgitation is a valuable support for the cardiac surgical team; results can be favored by adequate assessment tailored to the main condition affecting the MV. This article will review current available data for assessment of the MV in degenerative and ischemic mitral regurgitation.

Frequency and mechanism of persistent systolic anterior motion and mitral regurgitation after septal ablation in obstructive hypertrophic cardiomyopathy

Relief of obstruction using ventricular septal ablation (VSA) may not eliminate systolic anterior motion (SAM) of the mitral valve and mitral regurgitation (MR) in patients with obstructive hypertrophic cardiomyopathy. The hypothesis was that persistent SAM after VSA was secondary to anterior papillary muscle displacement and malcoaptation of mitral valve leaflets and that these findings could predict persistence of SAM. Echocardiograms were examined from 37 patients with obstructive hypertrophic cardiomyopathy before and 12+/-3 months after VSA. Anterior leaflet malposition (anterior-to-posterior leaflet coaptation position ratio), papillary muscle malposition (septal-to-lateral/left ventricular internal diameter ratio), and anterior position of coaptation relative to the septum (coaptation-to-septal distance) were assessed. MR proximal jet width was also measured. Of 37 patients, 30 underwent successful VSA (left ventricular outflow tract gradient reduction>50%); 22 of 30 and 7 of 7 with <50% reduction (total 29 of 37; 78%) showed persistent SAM at 12+/-3 months. These patients had more anterior malposition of the mitral valve and less MR reduction than those without SAM: anterior-to-posterior leaflet coaptation position ratio 0.42+/-0.06 versus 0.56+/-0.09, septal-to-lateral/left ventricular internal diameter ratio 0.39+/-0.12 versus 0.55+/-0.12, coaptation-to-septal distance 1.8+/-0.42 versus 2.8+/-0.30 cm, and MR reduction by 29+/-22% versus 71+/-12% (p<0.0001). Gradients, both at rest and provokable, were higher (27+/-33 vs 4+/-5 mm Hg, p=0.0004; >45 mm Hg in 9 vs 0, p=0.03, respectively) in patients with persistent SAM. Anterior malposition was present before VSA, with anterior-to-posterior leaflet coaptation position ratio<0.5 predicting SAM after VSA (p<0.0001). In conclusion, SAM and MR were often not eliminated using VSA. Mitral valve malposition was a strong predictor of SAM and MR reduction after VSA and may need to be considered in optimizing results of this procedure.

Perioperative transesophageal echocardiographic evaluation of the native mitral valve

During the past few decades, the effect of intraoperative transesophageal echocardiography's (TEE) influence on perioperative cardiac surgical decision making has become increasingly more appreciated. To date, there are no prospective, large-scale, randomized trials that have specifically identified a consistent, independent advantage for intraoperative TEE. However, data from several clinical investigations have consistently implicated an important, clinically significant, and cost-effective role for TEE as a safe and valuable hemodynamic monitor in identifying high-risk patients, in assisting in the determination of the definitive surgical approach, and in providing a timely post-cardiopulmonary bypass evaluation of the procedure, thereby allowing for the opportunity to immediately re-intervene or to at least triage patients appropriately. In addition, intraoperative TEE has been instrumental in diagnosing cardiac and associated great vessel pathology and in identifying structural abnormalities, including the presence and extent of congenital abnormalities, aortic disease, intracardiac masses, and pericardial disease. Intraoperative TEE, however, has perhaps been most useful for the perioperative evaluation of cardiac valvular disease, especially during surgical procedures involving the mitral valve. This article will focus primarily on the role of intraoperative TEE in defining mitral valve anatomy, the pathogenesis and mechanism of mitral valve pathology, and its influence on perioperative clinical decision making in patients undergoing mitral valve surgery.

Acute myocardial ischemia associated with latent left ventricular outflow tract obstruction in the absence of left ventricular hypertrophy

Left ventricular outflow tract obstruction (LVOTO) is a recognized feature in hypertrophic cardiomyopathy, but can occur in other clinical scenarios such as acute myocardial ischemia. In some patients, LVOTO may only be detectable with provocation testing such as exercise stress. Accurate and timely diagnosis, therefore, relies on recognizing an echocardiographic substrate in which LVOTO may occur, such as ventricular hypertrophy. The investigators describe two cases of latent LVOTO, presenting with acute myocardial ischemia in the absence of obstructive coronary artery disease, in which the diagnosis was delayed because of the absence of hypertrophy, or other recognizable substrate, on the resting echocardiographic study, but became evident during exercise echocardiography.

Rest and Dobutamine stress echocardiography in the evaluation of mid-term results of mitral valve repair in Barlow's disease

Background

Surgical "anatomical" repair is the most frequent technique used to correct mitral regurgitation due to severe myxomatous valve disease. Debate, however, persists on the efficacy of this technique, as well as on the durability of the repaired valve, and on its functioning and hemodynamics under stress conditions. Thus, a basal and Dobutamine echocardiographic (DSE) study was carried out to evaluate these parameters at mid-term follow-up.

Methods and Results

Twenty patients selected for the study (12 men and 8 women, mean age 60 ± 9 years) underwent pre- and post-operative transthoracic echocardiography (TTE) and intra-operative transesophageal echocardiography (TEE). At mid-term follow-up (20 ± 5 months) all patients underwent rest TTE and DSE (3 min. dose increments up to 40 microg/Kg/min protocol). Pre-discharge and one-month TTE showed absence of MR in 11 pts., trivial or mild MR in 9 pts. and normal mitral valve area and gradients. Mid-term TTE showed decrease in left atrial and ventricular dimension, in pulmonary artery pressure (sPAP) and grade of MR. During DSE a significant increase in mitral valve area, maximum and mean gradients, sPAP, heart rate and cardiac output and a decrease in systolic annular diameter and left ventricular volume were found; in 6 pts. a transient left ventricular outflow tract obstruction was observed.

Conclusion

Basal and Dobutamine stress echocardiography proved to be valuable tools for evaluation of mid-term results of mitral valve repair. In our study population, the surgical technique employed had a favourable impact on several cardiac parameters, evaluated by these methods.

Noninvasive cardiac imaging in patients with hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiomyopathy and the most common cause of cardiac death in young athletes in the U.S. Noninvasive imaging plays an important role in detecting the disease, understanding its pathophysiology, and selecting as well as guiding appropriate therapy. In this review, we discuss the existing methodology with emphasis on current and emerging clinical applications in patients with HCM.

Systolic anterior motion of the mitral valve despite the sliding leaflet technique for repair of the mitral valve

We report a systolic anterior motion of the anterior mitral leaflet despite employing the sliding leaflet technique for repair of mitral valve regurgitation. A 65-year-old man with chronic, symptomatic mitral regurgitation due to ruptured chordae tendineae underwent mitral valve repair by quadrangular resection of the posterior leaflet and sliding leaflet technique with ring annuloplasty. After weaning from cardiopulmonary bypass, left ventricular outflow obstruction developed and transesophageal echocardiography demonstrated systolic anterior motion of the mitral valve and severe mitral regurgitation. Non-operative treatment resolved the outflow tract obstruction, systolic anterior motion and mitral regurgitation. We conclude that post-repair systolic anterior motion can still occur after the sliding plasty procedure and that medical treatment can successfully resolve systolic anterior motion and outflow tract obstruction in most patients.

Midterm Results of the Edge-to-Edge Technique for Complex Mitral Valve Repair

BACKGROUND

The edge-to-edge technique (E2E) has been advocated for the complex repair of myxomatous mitral valves. We compared outcomes of E2E performed in patients at risk for systolic anterior motion (SAM) versus outcomes in patients with residual mitral regurgitation (MR) after repair completion.

METHODS

A total of 1,612 patients had repair of myxomatous mitral valves between June 1997 and December 2003 at Brigham and Women's Hospital. The E2E was used in 72 (4.5%) patients. Fifty-two patients (52/72; group I) had E2E for persistent MR after complex repair. Twenty patients (20/72; group II) had E2E for high risk of post-repair SAM and left ventricular outflow tract obstruction. Mean age of the patients was 61 +/- 14 years; 47 were male, average New York Heart Association class at admission was 2.4 +/- 0.6, and mean left ventricular ejection fraction was 56 +/- 12%.

RESULTS

The operative mortality was zero. Immediate postoperative MR was significantly improved in all patients compared with the preoperative grade (p value < 0.0005). Mean follow-up was 388 days. In those in whom E2E was used for residual MR without SAM risk (group I), postoperative MR (> or = 2+) was detected in 15 of 52 patients at 6 months. In group II, SAM was completely eliminated and the mean MR grade in the immediate postoperative period was 0.5 +/- 0.7. There was no long-term recurrence of MR in group II.

CONCLUSIONS

This study suggests that E2E eliminates SAM and long-term MR in patients with pre-repair echocardiographic predictors of SAM. The E2E is not efficacious in preventing long-term recurrent MR if performed for residual MR after complex mitral repair.

Overreduction of the Posterior Annulus in Surgical Treatment of Degenerative Mitral Regurgitation

BACKGROUND

The concept of overreduction of the posterior annulus was applied in surgical treatment of degenerative mitral valve disease.

METHODS

From April 1993 to November 2004, 141 patients underwent overreduction of the posterior annulus of the mitral valve in mitral valve repair for degenerative disease. Mean scallop involvement per patient was 2.3 and increased to 3.0 in the last period. Correction of the prolapse of the posterior leaflet included resection with focal sliding (n = 100), or application of artificial chordae (n = 28), with (n = 11) or without (n = 17) plication of one or more scallops. The anterior leaflet prolapse was corrected with edge-to-edge technique (n = 20) or chordal replacement (n = 28). An overreducting ring, 40 (n = 81) or 50 (n = 60) mm long (autologous pericardium in 64 cases and Sovering Miniband [Sorin, Saluggia, Italy] in 77) was used in all the patients.

RESULTS

Three patients died in the early period (2.1%) and 3 (2.1%) were reoperated on from 3 to 24 months due to endocarditis (2 cases) and failure of repair (1 case). Ten-year freedom from death any cause was 91.6%, from reoperation 96.4%, from death any cause and reoperation 87.7%, from death any cause, reoperation, and New York Heart Association class III-IV 79.8%. Sixty-four patients out of 68 who survived more than 2 years (94.1%) at a mean follow up of 4.2 +/- 2.5 years had no or 1+ residual mitral regurgitation.

CONCLUSIONS

Although the complexity of mitral valve repair for degenerative disease increased, results of surgery remained stable. Apposition of a posterior overreductive ring was useful to cover any mistake performed during the correction.

Massive Posterior Mitral Annular Calcification Causing Dynamic Left Ventricular Outflow Tract Obstruction: Mechanism and Management Implications

We report a case of massive posterior mitral annular calcification causing severe systolic anterior motion of the anterior mitral leaflet and dynamic left ventricular outflow tract obstruction. Mechanism of genesis of systolic anterior motion by this unusual mechanism is illustrated. Importance of recognizing this mechanism and its implications for surgical therapy are discussed. Our patient also had liquefaction necrosis of mitral annular calcification causing its extension into left ventricular myocardium mimicking a tumor.

New locus for autosomal dominant mitral valve prolapse on chromosome 13: clinical insights from genetic studies

BACKGROUND

Mitral valve prolapse (MVP) is a common disorder associated with mitral regurgitation, endocarditis, heart failure, and sudden death. To date, 2 MVP loci have been described, but the defective genes have yet to be discovered. In the present study, we analyzed a large family segregating MVP, and identified a new locus, MMVP3. This study and others have enabled us to explore mitral valve morphological variations of currently uncertain clinical significance.

METHODS AND RESULTS

Echocardiograms and blood samples were obtained from 43 individuals who were classified by the extent and pattern of displacement. Genotypic analyses were performed with polymorphic microsatellite markers. Evidence of linkage was obtained on chromosome 13q31.3-q32.1, with a peak nonparametric linkage score of 18.41 (P<0.0007). Multipoint parametric analysis gave a logarithm of odds score of 3.17 at marker D13S132. Of the 6 related individuals with mitral valve morphologies not meeting diagnostic criteria but resembling fully developed forms, 5 carried all or part of the haplotype linked to MVP.

CONCLUSIONS

The mapping of a new MVP locus to chromosome 13 confirms the observed genetic heterogeneity and represents an important step toward gene identification. Furthermore, the genetic analysis provides clinical lessons with regard to previously nondiagnostic morphologies. In the familial context, these may represent early expression in gene carriers. Early recognition of gene carriers could potentially enhance the clinical evaluation of patients at risk of full expression, with the ultimate aim of developing interventions to reduce progression.

Prevention of Systolic Anterior Motion After Repair of the Severely Myxomatous Mitral Valve With an Anterior Leaflet Valvuloplasty

BACKGROUND

Systolic anterior motion after mitral valve repair of severely myxomatous valves is due to excess tissue or anterior displacement, or both, of the leaflet coaptation point. Our series of anterior leaflet valvuloplasty, an alternative to the sliding leaflet technique to prevent systolic anterior motion, is presented.

METHODS

Between January 1, 1996 and January 6, 2003, we performed elliptical excisions of the base of the anterior leaflet in 47 patients with a mean age of 66 years (range, 29 to 86). All patients had an anterior leaflet height of 3.0 cm or more and an annular diameter of 4.0 cm or more. Repairs included posterior leaflet (37; 80%), and anterior leaflet (28; 61%) resections, with occasional transposition flaps (9; 19%). All 47 (100%) had an annuloplasty ring (9, Physio; 37, Seguin). Four (8%) included tricuspid repair, 6 (13%) aortic valve replacement, and 9 (19%) coronary artery bypass. Follow-up was between 2 months and 8 years.

RESULTS

There was no systolic anterior motion or in-hospital (30-day) mortality. Postoperative echocardiography revealed an average anterior leaflet height of 2.2 +/- 0.3 cm, with an annular diameter of 3 +/- 0.2 cm. The anterior/posterior leaflet ratio decreased from 1.6 +/- 0.2 to 1.4 +/- 0.1 cm while the coaptation point-annular plane distance decreased from 1.2 +/- 0.2 to 0.9 +/- 0.1 cm. There were 4 late noncardiac deaths. Two patients have required mitral valve replacement owing to progressive disease and 6 patients were lost to follow-up. The 35 patients remaining have trace-mild mitral regurgitation.

CONCLUSIONS

Our anterior mitral valve leaflet valvuloplasty, regardless of the ring, results in a decrease in surface area and excursion of the anterior leaflet without systolic anterior motion.

Edge-to-Edge Technique to Treat Post-Mitral Valve Repair Systolic Anterior Motion and Left Ventricular Outflow Tract Obstruction

BACKGROUND

Systolic anterior motion of the mitral valve causing left ventricular outflow tract obstruction is an uncommon complication of mitral valve repair that may necessitate immediate additional surgical action. We prospectively evaluated the technique of the edge-to-edge suture on post-mitral repair systolic anterior motion, which persisted despite conservative treatment.

METHODS

From March 2002 to March 2004, 4 of 112 patients requiring mitral valve repair surgery for chronic degenerative mitral regurgitation had systolic anterior motion with severe left ventricular outflow tract obstruction and mitral regurgitation. All 4 patients (mean age, 50 years) had posterior leaflet prolapse with chordal rupture with a billowing anterior leaflet, but without chordal rupture. Repair was achieved through a quadrangular resection of the posterior leaflet, completed by plication of the annulus in 2 patients and leaflet sliding in the other 2. All patients had mitral annuloplasty; two patients had a complete CE Physio ring (Edwards Lifesciences, Irvine, CA) inserted, whereas the other 2 patients had an open CG Future band (Medtronic, Minneapolis, MN). Routine perioperative transesophageal echocardiography showed systolic anterior motion, severe left ventricular outflow tract obstruction (> 50 mm Hg), and mitral regurgitation. After resuming cardiopulmonary bypass, all patients had an edge-to-edge suture at the middle part of the free edge of the anterior and posterior leaflets.

RESULTS

The control transesophageal echocardiography showed in all cases disappearance of the systolic anterior motion, of the left ventricular outflow tract obstruction and of mitral regurgitation. Mean follow-up was 14 months (range, 6 to 28 months). All patients were in New York Heart Association's functional class I.

CONCLUSIONS

With the edge-to-edge repair, the early and 2-year results were satisfactory with total disappearance of the systolic anterior motion, of the left ventricular outflow tract obstruction and of the recurrent mitral regurgitation.

Posterior mitral annuloplasty using autologous pericardium in the repair of posterior leaflet prolapse

OBJECTIVE

Mitral valve repair is frequently performed now because it produces a favorable postoperative quality of life, as well as improved cardiac function. For the treatment of posterior leaflet prolapse, we perform a posterior mitral annuloplasty using an autologous pericardium. The present study assessed the efficacy of this operation.

METHODS

From April 1999 to October 2003, 42 patients underwent a posterior mitral annuloplasty using autologous pericardium for the treatment of posterior leaflet prolapse. There were 15 men and 27 women with an average age of 63.9 +/- 11.8 years. The length of the autologous pericardium matched the length of the posterior leaflet annulus as measured with Carpentier-Edwards ring sizer that was chosen based on the area of the anterior leaflet.

RESULTS

The average size of the Carpentier-Edwards ring sizer that was used to determine the length of the autologous pericardium was 27.7 +/- 13 mm, and the absolute length of the pericardium was 50.9 +/- 1.8 mm, and the average intraoperative jet area, as assessed by transesophageal echocardiography, was 0.36 +/- 0.47 cm2. The five-year freedom from reoperation was 97.1%, while the freedom from significant residual mitral regurgitation (> or = 3+/4+) was 92.0%. Two patients (4.8%) developed systolic anterior motion, and one patient (2.4%) had a cerebral infarction. None of the patients died after surgery, and no patients developed complications such as hemolysis or ring detachment.

CONCLUSIONS

Posterior mitral annuloplasty using an autologous pericardium was shown to be a superior technique because it allows a sufficient annular repair with no complications such as hemolysis or ring detachment.

An unusual cause of left ventricular outflow tract obstruction after mitral valve repair

Left ventricular outflow tract (LVOT) obstruction caused by systolic anterior motion is a cause of failed mitral valve repair. Intraoperative transesophageal echocardiography has been very helpful in diagnosing problems with mitral valve repairs intraoperatively, allowing immediate correction. We report an unusual cause of LVOT obstruction attributed to prolapse of the annuloplasty ring into the LVOT. Intraoperative hemodynamics were normal, and the diagnosis would not have been made before leaving the operative suite without the transesophageal echocardiography.

Anterior leaflet resection of the mitral valve

Triangular resection is a reconstructive option for treatment of anterior leaflet mitral disease with segmental prolapse. In our experience, it is a safe and reproducible technique, associated with low rates of recurrent MR or need for reoperation, as well as decreased likelihood for systolic anterior motion after mitral repair. We review our experience with this technique over a 25-year experience with mitral valve reconstruction.

SAM-systolic anterior motion of the anterior mitral valve leaflet post-surgical mitral valve repair

Systolic anterior motion (SAM) is a postoperative complication experienced by patients undergoing mitral valve repair. The incidence of SAM after mitral valve repair ranges from 5 to 10%. Early recognition of the signs and symptoms of SAM is imperative to the management of these patients. This article presents the pathophysiology of mitral valve dysfunction to give the practitioner a clear understanding of the dynamics of SAM. This article's main focus is the detection and management of SAM and the most current treatment modalities. A case study is used to illustrate the complex management necessary for the patient with SAM.

Mitral valve repair for degenerative disease: is pericardial posterior annuloplasty a durable option?

OBJECTIVE

Biological and prosthetic rings are available for supporting mitral valve repair (MVR). Contrasting data are reported on the durability of pericardial ring annuloplasty. This retrospective study was undertaken to assess the durability of MVR for degenerative regurgitation with posterior annuloplasty performed with glutaraldehyde-treated autologous pericardium.

METHODS

From August 1995 through December 2000, 133 patients underwent mitral repair for degenerative regurgitation (86 men, age 62.9+/-11.5 years). Thirty patients (22.6%) underwent combined coronary artery bypass graft and fourteen (10.5%) underwent tricuspid annuloplasty. Associated aortic disease, previous cardiac surgery and endocarditis were considered exclusion criteria.

RESULTS

Seventy-seven patients (57.9%) received a Carpentier-Edwards ring and 56 received (42.1%) an autologous pericardium ring. Thirty-day mortality was 3.8%. Mean follow-up, 98.3% complete, was of 35.6+/-18.7 months. Five-year freedom from reoperation and recurrence of mitral regurgitation> or =3+/4+ was significantly higher in the prosthetic ring group (90.1% - CL90%: 81.9-98.3%) compared with the pericardial ring group (62.6% - CL90%: 43.1-82.1%; P=0.027). Prosthetic ring implantation (P=0.004; RR=0.11) and preoperative New York Heart Association (NYHA) class< or =II (P=0.011; RR=0.16) were independently related to a lower risk of reoperation and recurrence of mitral regurgitation> or =3+/4+, by multivariate analysis. Five-year overall survival was 91.4% (CL90%: 87.9.7-95%). A higher preoperative left ventricular end-diastolic diameter (P=0.006; RR=1.17) and the severity of associated coronary artery disease (P=0.021; RR=2.00) were independent predictive factors for poor survival by multivariate analysis.

CONCLUSIONS

Posterior pericardial annuloplasty can jeopardize reproducibility and durability of MVR for degenerative regurgitation.

Detection of mechanisms of immediate failure by transesophageal echocardiography in quadrangular resection mitral valve repair technique for severe mitral regurgitation

Residual mitral regurgitation (MR) after repair is a risk factor for late reoperation. The use of intraoperative transesophageal echocardiography (IOTEE) decreases the incidence of immediate repair failure. This study identifies the mechanisms of immediate failure by IOTEE in the quadrangular resection technique, a well-standardized mitral valve repair procedure to guide further repair procedures. Two hundred five consecutive patients underwent quadrangular resection due to prolapse or flail posterior leaflet. Twenty-four patients (11%) had immediate failure. Immediate reinstitution of cardiopulmonary bypass ("second pump run") was needed in 21 patients (10%) for further repair. The identified mechanisms of failure were residual cleft provoking interscallop malcoaptation into the posterior leaflet in 8 patients, residual prolapse of the anterior or posterior leaflets in 1 and 4 patients, respectively, residual annular dilation in 3, left ventricular outflow obstruction in 2, suture dehiscence in 2, and other mechanisms in another 2 patients. In 20 patients (95%), IOTEE guided further repair with resolution of the residual MR, whereas 1 patient underwent valve replacement due to pharmacologically untreatable left ventricular outflow obstruction. In conclusion, even if this type of valve repair technique is well standardized, the incidence of immediate failure is not negligible. IOTEE identified the mechanisms of the immediate failure and guided further repair procedures, thus reducing the incidence of valve replacement (0.5%) without increasing perioperative mortality and morbility.

[Cardiogenic shock due to dynamic left ventricular outflow tract obstruction as a mechanical complication of acute myocardial infarction]

We report the clinical case of a 77-years-old woman with cardiogenic shock caused by dynamic left ventricular outflow tract (LVOT) obstruction that appeared after anterior acute myocardial infarction. Dynamic LVOT obstruction has been reported in various circumstances aside from hypertrophic obstructive cardiomyopathy, such as acute myocardial infarction. In a patient with cardiogenic shock and a heart murmur after acute myocardial infarction, an acute mechanical complication, ventricular septal defect, and acute mitral regurgitation must be ruled out because the treatment of these conditions differs completely. We describe the diagnostic and therapeutic measures used in the diagnosis and treatment of this complication.

Echocardiographic evaluation of mitral regurgitation

Accurate evaluation of mitral regurgitation (MR) severity remains a challenging task in clinical cardiology. The importance of proper quantification of regurgitation cannot be underestimated because a delayed decision to replace or repair a defective valve may lead to worsening ventricular function and increased perioperative and long-term mortality. In this review we discuss both recent developments in the quantification of MR as well as new insights into the pathophysiology and progression of this lesion.

Pitfalls in surgical decision-making during mitral valve repair

Mitral valve repair has become the mainstay of surgical treatment for mitral valvular regurgitation. Surgeons in North America were relatively slow to adopt the various repair techniques, perhaps because rheumatic heart disease was less common, and the initial experiences with large numbers of repairs in Europe dealt largely with rheumatic disease. Subsequent experience, however, has clearly shown that patients with degenerative mitral valve disease can expect very durable repairs, and that most such patients have relatively simple pathologic conditions. The potential for repair, with a lack of need for long-term anticoagulation, has led to earlier surgical intervention. Still, mitral valve repair is far more complex than mitral valve replacement and must be accompanied by careful intraoperative decision making. Pitfalls exist that are different from those that accompany replacement. In this article, we examine some of the more common problems, their identification, and, hopefully, ways to avoid them.

Transesophageal echocardiographic (TEE) evaluation of the aortic valve, left ventricular outflow tract, and pulmonic valve

The most important role of TEE in aortic valve disease is in the diagnosis of endocarditis and its complications. Examination of the annulus and subvalvular region is essential in any patient with possible aortic valve endocarditis. Assessment of the severity of aortic stenosis is a useful application of TEE when other data are either inconsistent or unavailable. TEE can provide a diagnosis of the origin of acute severe aortic insufficiency; this information may play a critical role in surgical planning. The diagnosis of a variety of aortic valve diseases can be made when TEE is performed to find an embolic source or to rule out dissection. In the case of mass lesions, such as papillary fibroelastomas and Libman-Sacks vegetations, the results of TEE carry major therapeutic implications. TEE offers generally excellent quality images of the LVOT and images of the RVOT and pulmonic valve that are superior to transthoracic echocardiography. The major clinical usefulness of TEE stems from its ability to identify pulmonic valve mass lesions and the causes of left and right ventricular outflow obstruction. TEE is also an important adjunct in the surgical management of left ventricular outflow obstruction.