New echocardiography-based classification of mitral valve pathology: relevance to surgical valve repair.

A new echocardiography-based classification of mitral valve pathology is proposed, the adoption of which may provide a uniform approach to the assessment of individual cases by the cardiologist, cardiac anesthesiologist, and surgeon. This type of approach may facilitate the planning and execution of valve repair techniques, with higher rates of success than are currently reported.

Tricuspid valve disease.

The normal tricuspid valve anatomy and function have several dissimilarities to the corresponding mitral valve in the left heart, in part, based on lower pressures in the right heart chambers. The functional abnormalities resulting from tricuspid valve disease are classified as primary and secondary. Primary valve disease is any associated intrinsic valve pathology. The list of responsible conditions includes congenital, rheumatic, infective endocarditis, carcinoid heart disease, toxic effects of chemicals, tumors, blunt trauma, and myxomatous degeneration. The secondary tricuspid valve disease does not involve intrinsic anatomic abnormalities of the valve apparatus, aside from tricuspid annular dilation secondary to right ventricular dilation and dysfunction. The most common cause of tricuspid valve disease is secondary to left heart disease, either myocardial, valvular, or mixed. Although bedside diagnosis of advanced tricuspid valve disease is feasible, echocardiography provides valuable clues to the presence and severity of tricuspid valve stenosis and/or regurgitation with considerable accuracy. The tricuspid regurgitation signal using Doppler techniques is utilized for estimation of right ventricular systolic pressure, which, in the absence of right ventricular outflow obstruction, corresponds to pulmonary arterial systolic pressure. This is clinically useful since nearly 80 to 90% of patients exhibit some degree of tricuspid regurgitation. The treatment of tricuspid valve disease is guided by underlying etiology and pathology. Tricuspid valve repair is increasingly advocated for patients with advanced tricuspid regurgitation, especially when combined with surgery on the left heart pathology. Primary tricuspid valve disease is often treated by surgical approach specific to the underlying pathology.

Impact of intraoperative echocardiography/surgery team on successful mitral valve repair: a community hospital experience.

BACKGROUND AND AIM OF THE STUDY: Mitral valve (MV) repair is generally accepted as the preferred treatment of mitral regurgitation (MR) with MV prolapse secondary to myxomatous mitral valve disease (MMVD). However, the incidence of successful valve repair is variable between hospitals and among different surgeons at one hospital, and often results in needless MV replacement. The study aim was to measure the impact of a dedicated echocardiography/surgery team on MV repair at a community hospital. METHODS: The outcome was analyzed of a group of 116 consecutive patients with severe MR secondary to MMVD who underwent surgery by the same surgeon over a six-year period. A dedicated team approach, comprising one echocardiographer and one surgeon was established in January 1999. The results of MV repair between 1996 and 1998 (group I; n = 37) were compared to results obtained between 1999 and 2001 (group II; n = 79). RESULTS: In group I, MV repair was attempted in 25 patients (67.6%) and was successful in 21 (56.8%). In group II, MV repair was attempted in 68 patients (86.1%) and was successful in 67 (84.8%). The success rate between groups was significantly (p = 0.001) different. The rate of successful MV repair in patients with a diffusely redundant prolapsing valve involving both leaflets and multiple segments with chordae elongation was significantly higher in group II (14/20; 70%) than in group I (1/6; 14.3%) (p = 0.011). CONCLUSION: A greater incidence of successful MV repair, even with more diffuse pathology of MMVD, was realized following the institution of dedicated echocardiography/surgery team at a community hospital. It is proposed that a combination of dedicated intraoperative echocardiography and surgical expertise is required for optimal results in MV repair.

Cerebrovascular events associated with infusion through arterially malpositioned triple-lumen catheter: report of three cases and review of literature.

Analysis of 10 adult patients treated from January 1998 to November 2004 for arterial misplacement of triple-lumen catheter (TLC) during internal jugular vein cannulation was performed. Three cases that developed neurologic symptoms occurring in the context of infusion through a TLC that was arterially malpositioned are presented, along with the review of literature. In 7 patients, the diagnosis of arterial misplacement was suspected by the color or flow characteristics of blood and confirmed by a combination of blood gas analysis, connecting catheter to transducer, and/or chest film. In the remaining 3 patients, intraarterial misplacement was not suspected. In these patients, the initial review of chest films by qualified physicians prior to starting infusion failed to detect malposition of the catheter. Retrospectively, subtle clues suggestive of arterially placed TLCs were found. All 3 patients developed neurologic symptoms. Initiation of neurologic workup delayed a correct diagnosis by 6 to >48 hours. A volumetric pump was used for infusion in all patients. Of the 3 patients with neurologic symptoms, 1 recovered completely, 1 became comatose, and 1 partially improved. Based on our observations and review of literature, we conclude that cursory examination of chest films to verify proper positioning of central venous catheter attempted through the internal jugular vein may fail to detect arterial malposition. Infusion by volumetric pump precludes backflow of blood in the intravenous tubing as an indicator. Neurologic symptoms concurrent with the infusion of fluids and medication should raise suspicion of accidental arterial infusion.

Arterial misplacement of large-caliber cannulas during jugular vein catheterization: case for surgical management.

BACKGROUND: Accidental placement of a large sheath or catheter in an artery during central venous cannulation, though rare, is a potentially devastating complication. The present study reviews our 14-year experience with this complication to determine appropriate role of surgical management. STUDY DESIGN: Review was conducted of all cases involving patients treated by the vascular surgery service from July 1989 to June 2003 for accidental placement of a large-caliber cannula (>or= 7 F) in an artery during catheterization of the jugular vein. Two management techniques were used during this period: removal of cannula followed by application of local pressure; and surgical exploration, removal of cannula under direct vision, and repair of artery. RESULTS: Eleven patients (5 men, 6 women) aged 35 to 73 years (mean age 56 years) were treated for cannulas placed accidentally in an artery. In nine patients, the cannula entered the carotid artery, and in two patients it entered the subclavian artery. Three patients had undergone placement of 8.5-F sheaths for monitoring cardiac hemodynamics, and 8 patients had triple-lumen catheters for fluid infusion or parenteral nutrition. Eight patients (three sheath, five catheter) were asymptomatic at the time of cannula removal. In three patients, the correct diagnosis was missed initially and infusion was started. All three developed neurologic symptoms. In two patients, the cannula (sheath) was pulled and pressure applied. One of them developed a stroke and the other developed a pseudoaneurysm that was treated surgically. Nine patients in whom the sheath or catheter was removed by surgical exploration had no new complications related to surgery. CONCLUSIONS: Surgical management seems to be the most effective and safe treatment of arterial misplacement of cannulas during jugular vein catheterization. Further study is needed to determine the optimum management of this potentially devastating complication.

Three-Dimensional Echocardiographic Reconstruction of the Left Ventricle by a Transesophageal Tomographic Technique: In Vitro and In Vivo Validation of its Volume Measurement.

Accurate determination of left ventricular (LV) volume has important therapeutic and prognostic implications in patients with cardiac disease. Volume estimations by two-dimensional techniques are not very accurate due to geometric assumptions. OBJECTIVES: To validate LV volume determinations by a new transesophageal three-dimensional echocardiographic technique. We performed three-dimensional reconstruction of the LV using an echo-computed tomographic (CT) technique based on serial pullback parallel slice imaging technique in both in vitro and in vivo settings. Fourteen latex balloons with various sizes (30-235 mL) and shapes (conical, pear shaped, round, elliptical, and aneurysms in various locations) filled with known volumes of water were imaged in a water bath. From the static three-dimensional image, the LV long axis was defined and the LV was sectioned perpendicular to this axis into 2-mm slices. The volume of each slice was calculated with the observer blinded to the actual volume as the product of the slice thickness and the manually traced perimeter of the slice and the LV volume as the sum of the volumes of the slices (Simpson's method). The calculated LV volume closely correlated with the actual volume (r = 0.99, P < 0.0001, calculated volume = 1.06x - 11.3, Deltavolume = -5.7 +/- 10.0 cc). Using the same system, transesophageal echocardiographic (TEE) images of the LV were obtained in 15 patients gated to respiration and ECG. Satisfactory dynamic three-dimensional reconstruction of the LV was possible in ten patients. The three-dimensional LV volumes (systolic and diastolic) using Simpson's method correlated well with those obtained from biplane or multiplane TEE images using the area length method (r = 0.89, p < 0.0001, y = 12.7 + 0.84x, Deltavolume = 1.3 +/- 18.1 cc). The LV major-axis diameters by the two methods showed very close correlations as well (r = 0.86, P < 0.0001, y = 19 + 0.74x, Deltadiameter = 1.0 +/- 7.2 mm). We conclude that three-dimensional LV volume calculation by the echo-CT technique is intrinsically sound, is independent of LV geometry, and with some limitations, is applicable in vivo. (ECHOCARDIOGRAPHY, Volume 13, November 1996)

Current concepts in mitral valve prolapse--diagnosis and management.

Although mitral valve prolapse as a disease entity has been recognized for over 50 years, its precise definition has been elusive. Initial reports based the diagnosis on auscultatory findings (late systolic click - murmur), with left ventricular angiography as a confirmative test. Echocardiography, first the M-mode, and subsequently the two-dimensional, became the dominant diagnostic modality. However, the early reports did not distinguish between billowing valve and flail valve. The advent of surgical repair techniques provided a different perspective; the surgical definition of mitral valve prolapse is often different from that of cardiologists. Intraoperative echocardiography gained wide acceptance necessitating a common language to describe precise terminology of the leaflet anatomy and definition of valve prolapse. The present report proposes a terminology and definitions of valve prolapse with relevance to surgical mitral valve repair. The addition of real-time 3D transesophageal echocardiography now provides highly accurate localization of lesions and the multi segment assessment of valve pathology. The etiologic considerations and surgical repair techniques with the role of echo - surgery team in improved patient outcome are described.

Tricuspid and pulmonary valve disease evaluation and management.

The clinical detection and quantification of tricuspid valve disease, although important, is not entirely accurate. Diagnostic evaluation is based on echocardiography, and color flow Doppler is useful for quantifying tricuspid regurgitation. Echocardiography provides information on heart chamber dimensions, right ventricular function, and the degree of pulmonary hypertension. In addition, tricuspid stenosis can be accurately assessed using mean and end-diastolic pressure gradient measurements. The treatment options for tricuspid stenosis include balloon valvuloplasty and surgical valve repair. Functional tricuspid regurgitation associated with left heart disease may require surgical attention during an operation to treat the left heart disease. Severe tricuspid regurgitation usually requires surgery to be performed in association with mitral valve surgery. Mild-to-moderate tricuspid regurgitation requires surgery when annular dilatation or severe pulmonary hypertension is present. The surgical options include tricuspid valve repair, with or without an annuloplasty ring. In patients with a primary anatomic deformity of the tricuspid valve, replacement of the valve with a bioprosthesis or mechanical valve may be considered. Intermediate and long-term results favor annuloplasty valve repair over valve replacement. Pulmonary valve disease is predominantly congenital, and generally takes the form of pulmonary stenosis. Pulmonary regurgitation often results from surgical or balloon valvuloplasty and is associated with deleterious long-term sequelae. The recent development of percutaneous valve replacement was a major advance.