It is clear that severe complications such as persistent severe mitral regurgitation after repair or large paravalvular leaks after valve replacement can be readily detected by intraoperative echo and treated while the chest is still open. It is less clear where the threshold for a second pump run lies in the presence of mild-to-moderate post-repair regurgitation.
Data from the Cleveland Clinic2 indicate that in the presence of 1+ to 2+ regurgitation post-repair there is a trend towards more frequent late reoperations in such patients. Comparing 76 patients with 1+ or 2+ post-repair regurgitation to matched patients with no post-repair regurgitation, this study found a higher rate of re-operations over the next four years in the "less than echo-perfect" group (Fig.4).
In a recent large retrospective analysis of 1072 patients undergoing mitral valve repair for degenerative disease at the same institution17, the use of intraoperative echo was found to be a significant predictor for freedom from reoperation in subsequent years in a multivariate model of risk factors for reoperation (Fig.5).
Figure 1: Images of a patient developing postoperative systolic anterior motion (SAM) of the mitral valve after repair. Top: preoperative image. No SAM is present. Middle: pronounced SAM with septal contact. Bottom; resolution of SAM after discontinuation of catecholamines, administration of volume, vasopressors and a beta-blocker (esmolol). Reproduced with permission from Maslow AD et al, Echocardiographic predictors of left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve after mitral valve reconstruction for myxomatous valve disease. J Am Coll
Figure 2: Schematic drawing indicating linear measurements important in the prediction of postoperative SAM. C coaptation point, AML anterior leaflet length, PML posterior leaflet length, SEP-C distance from coaptation point to
Figure 3: Intraoperative, post-pump images of a mitral bioprosthesis in the transverse (0 plane before (left) and after (right) protamine reversal oj anticoagulation. The number oj regurgitant jets decreases from three to one. Reproduced with permission from Morehead et al., Intraoperative echocardiographic detection of regurgitant ¡ets after valve replacement, Ann Thorac Surg 2000:69:135-9.
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