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      Intraoperative Evaluation of Transmitral Pressure Gradients after Edge-to-Edge Mitral Valve Repair

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          Abstract

          Objective

          Edge-to-edge repair of the mitral valve (MV) has been described as a viable option used for the surgical management of mitral regurgitation (MR). Based on the significant changes in MV geometry associated with this technique, we hypothesized that edge-to-edge MV repairs are associated with higher intraoperative transmitral pressure gradients (TMPG) compared to conventional methods.

          Methods

          Patient records and intraoperative transesophageal echocardiography (TEE) examinations of 552 consecutive patients undergoing MV repair at a single institution over a three year period were assessed. After separation from cardiopulmonary bypass (CPB), peak and mean TMPG were recorded for each patient and subsequently analyzed.

          Results

          84 patients (15%) underwent edge-to-edge MV repair. Peak and mean TMPG were significantly higher compared to gradients in patients undergoing conventional repairs: 10.7±0.5 mmHg vs 7.1±0.2 mmHg; P<0.0001 and 4.3±0.2 mmHg vs 2.8±0.1 mmHg; P<0.0001. Only patients with mean TMPG ≥7 mmHg (n = 9) required prompt reoperation for iatrogenic mitral stenosis (MS). No differences in peak and mean TMPG were observed among edge-to-edge repairs performed in isolation, compared to those performed in combination with annuloplasty: 11.0±0.7 mmHg vs 10.3±0.6 mmHg and 4.4±0.3 mmHg vs 4.3±0.3 mmHg. There were no differences in TMPG between various types of annuloplasty techniques used in combination with the edge-to-edge repairs.

          Conclusions

          Edge-to-edge MV repairs are associated with higher intraoperative peak and mean TMPG after separation from CPB compared to conventional repair techniques. Unless gradients are severely elevated, these findings are not necessarily suggestive of iatrogenic MS. Thus, in the immediate postoperative period mildly elevated TMPG can be expected and tolerated after edge-to-edge mitral repairs.

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          Most cited references34

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          Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice.

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            2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

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              Safety of transesophageal echocardiography.

              Since its introduction into the operating room in the early 1980s, transesophageal echocardiography (TEE) has gained widespread use during cardiac, major vascular, and transplantation surgery, as well as in emergency and intensive care medicine. Moreover, TEE has become an invaluable diagnostic tool for the management of patients with cardiovascular disease in a nonoperative setting. In comparison with other diagnostic modalities, TEE is relatively safe and noninvasive. However, the insertion and manipulation of the ultrasound probe can cause oropharyngeal, esophageal, or gastric trauma. Here, the authors review the safety profile of TEE by identifying complications and propose a set of relative and absolute contraindications to probe placement. In addition, alternative echocardiographic modalities (e.g., epicardial echocardiography) that may be considered when TEE probe placement is contraindicated or not feasible are discussed. Copyright © 2010 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, USA )
                1932-6203
                2013
                2 September 2013
                : 8
                : 9
                : e73617
                Affiliations
                [1 ]Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
                [2 ]Department of Anesthesiology, University of Colorado Denver, Denver, Colorado, United States of America
                [3 ]Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
                [4 ]Department of Anesthesiology and Intensive Care Medicine, Tübingen, Germany
                University of Colorado Denver, United States of America
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: JNH HKE SKS MN-M. Performed the experiments: JNH HKE SKS AHW. Analyzed the data: JNH HKE SKS AHW. Wrote the paper: JNH SKS SFA MN-M.

                Article
                PONE-D-13-27178
                10.1371/journal.pone.0073617
                3759443
                24023891
                e4b6d9bf-d8bd-4b85-bfb4-312ff688a938
                Copyright @ 2013

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 27 June 2013
                : 23 July 2013
                Page count
                Pages: 6
                Funding
                This work received departmental funding from Brigham and Women's Hospital, Boston, Massachusetts. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine
                Anatomy and Physiology
                Cardiovascular System
                Anesthesiology
                Anesthesiology Monitoring
                Cardiovascular
                Valvular Disease
                Critical Care and Emergency Medicine
                Surgery
                Anesthesia
                Cardiothoracic Surgery
                Cardiovascular Surgery
                Minimally Invasive Surgery

                Uncategorized
                Uncategorized

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