European Journal of Echocardiography 2006 7(3):247-249; doi:10.1016/j.euje.2005.04.013
Copyright © 2005, The European Society of Cardiology
Echocardiographic images in mitral valve repair by "edge to edge" technique
U. Da Col,
G. Bardelli,
I. Di Bella*,
G. Minniti and
T. Ragni
Divisione di Cardiochirurgia, Ospedale Silvestrini, S. Andrea delle Fratte, Perugia 06100, Italy
Received 24 September 2004; received in revised form 14 April 2005; accepted after revision 20 April 2005.
* Corresponding author. Tel.: +39 75 5782300; fax: +39 75 5782214. isidorodibella{at}yahoo.it
 |
Abstract
|
|---|
The "edge to edge" or "double orifice" technique is a new surgical
option of mitral repair when functional valve insufficiency
is present, due to ischemic or dilated cardiomyopathy. This
technique is not frequently used and radically changes mitral
anatomy and hemodynamic. Therefore, echocardiographic examination
is completely different and implies good experience to evaluate
postoperative valve function. For these reasons we present a
case report of a patient who underwent this repair and was evaluated
in the follow up by standard transthoracic echocardiography:
the anatomical and functional assessment that was satisfactory
compared with transesophageal examination is documented.
Keywords: Mitral insufficiency; Mitral valve repair; Echocardiography
|
Introduction
|
|---|
Functional mitral insufficiency due to ischemic heart disease
or dilated cardiomyopathy is an increasingly important cause
of mitral regurgitation with poor long term prognosis. An effective
but non-frequent surgical correction is the "edge to edge" or
"double orifice" technique described by Alfieri and colleagues
1,2 and the intraoperative evaluation is
done by transesophageal
echocardiography. Nevertheless, postoperative and follow up
assessment of these patients is very important and in this case
report we evaluated the effectiveness of transthoracic approach.
|
Case report
|
|---|
A 78-year-old man with a history of
non-Q wave inferior myocardial
infarction followed by moderate dyspnea on exertion is presented.
The symptoms had been present for one year and recently worsened.
The physical examination revealed a moderate systolic murmur
on the apex which radiated to the left axilla. Transthoracic
echocardiography showed good global left ventricular function
with impaired inferior wall motion. The mitral valve showed
normal leaflets and severe regurgitation with the jet directed
towards the atrial septum. Transesophageal echocardiography
showed a moderately dilated mitral annulus (35mm antero-posterior
diameter), posterior leaflet prolapse and severe regurgitation.
3 Coronary angiography revealed a subocclusive lesion on the posterolateral
branch of the circumflex
coronary artery. He underwent surgical
mitral repair connecting the midportion of the anterior and
posterior leaflets ("edge to edge") and stabilizing the annulus
with a complete flexible annuloplasty ring Sovering N° 30
(Sorin Biomedica, Saluggia, Italy). The postoperative course
was uneventful and the patient was discharged on day 7.
Transthoracic echocardiography was performed before discharge. In parasternal short axis and apical four chamber view the double mitral valve orifices was seen as an "eight shaped" image during diastole (Figs. 1–3
) with two separate antegrade flows. We consider a good result of the "edge to edge" technique when the residual mitral regurgitation is not more than 1+/4+ and the residual total mitral area is greater than 2.5cm2. Therefore, it is important to obtain the mitral area by the planimetry of the two orifices (Fig. 4). This area must be similar to the area of the two orifices calculated by Doppler technique. The posteromedial orifice mean velocity was 1.30m/s, mean gradient 7.6mmHg, PHT 155ms and the functional area 1.42cm2. The anterolateral orifice mean velocity was 1.25m/s, mean gradient 6.9mmHg, PHT 186ms and functional area 1.18cm2. In this patient the total functional area was 2.6cm2 which can be considered trivial mitral stenosis. In the same view, the annuloplasty ring appears as a hyperechogenic structure along the annular circumference. In the different projections the point of systolic leaflets coaptation is in the same plane as the valve annulus.
|
Discussion
|
|---|
Similar to
more commonly used mitral repair procedures, the
"edge to edge" or "double orifice" procedure allows a good and
stable leaflets coaptation even in ischemic mitral regurgitation.
Since functional regurgitation appears to result from an imbalance
between the opening and closing forces acting on the mitral
leaflets, suturing the two leaflets together to ensure coaptation
is a simple solution to a complex problem. The annuloplasty
increases and stabilizes the surface of coaptation of the leaflets
while the Alfieri technique prevents the possible development
of leaflet tethering and repair failure in the follow up of
these ischemic patients.
4 For this reason, and for the presence
of leaflet prolapse, both procedures were used. Postoperative
assessment of the patients after standard
repair techniques
can be performed by transthoracic echocardiography and transesophageal
echocardiography should be limited to selected cases. The "edge
to edge" mitral repair is a recently introduced surgical option,
used in selected cases and that completely changes the anatomy
and hemodynamic of the valve.
5 Echocardiographic experience
for postoperative assessment remains limited.
6 This case shows
that transthoracic echocardiography is an effective technique
for assessing the anatomical and functional results in early
and long term follow up.
|
References
|
|---|
- Maisano F., Schreuder J.J., Oppizzi M., Fiorani B., Fino C., Alfieri O. The double-orifice technique as a standardized approach to treat mitral regurgitation due to severe myxomatous disease: surgical technique. Eur J Cardiothorac Surg (2000) 17:201–205.[Abstract/Free Full Text]
- Alfieri O., Maisano F., De Bonis M., Stefano P.L., Torracca L., Oppizzi M., et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J Thorac Cardiovasc Surg (2001) 122:674–681.[Abstract/Free Full Text]
- Jouan J., Tapia M., Cook R.C., Lansac E., Acar C. Ischemic mitral valve prolapse: mechanisms and implications for valve repair. Eur J Cardiothorac Surg (2004) 26:1112–1117.[Abstract/Free Full Text]
- Matsunaga A., Tahta S.A., Duran C.M.G. Failure of reduction annuloplasty for functional ischemic mitral regurgitation. J Heart Valve Dis (2004) 13(3):390–397.[Web of Science][Medline]
- Maisano F., Redaelli A., Pennati G., Fumero R., Torraca L., Alfieri O. The hemodynamic effects of double orifice valve repair for mitral regurgitation: a 3D computational model. Eur J Cardiothorac Surg (1999) 15:419–425.[Abstract/Free Full Text]
- Kinnaird T.D., Bradley L.M., Ignaszewski A.P., Abel J.G., Thompson C.R. Edge-to-edge repair for functional mitral regurgitation: an echocardiographic study of hemodynamic consequences. J Heart Valve Dis (2003) 12:280–286.[Web of Science][Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
Top
Abstract
Introduction
