INTRAOPERATIVE EVALUATION OF VALVULAR FUNCTION USING TRANSESOPHAGEAL AND EPICARDIAL ECHOCARDIOGRAPHY

Objectives and Background. Intraoperative transesophageal echocardiogr aphy (TEE) and epicardial echocardiography (ECE) offer the opportunity to assess valvular function before and after cardiopulmonary bypass. Valve reconstruction offers many advantages over prosthetic valve repl acement. The purpose of this study was to assess the utility of TEE an d ECE during the surgical treatment of mitral, aortic, and tricuspid v alve diseases. Methods. Intraoperative echocardiography was performed in 50 patients undergoing surgery for valvular heart disease. In 21 re cent patients, concurrent TEE with Doppler color flow mapping was perf ormed. The severity of mitral stenosis (MS) was assessed by the intrao perative echocardiographic mitral valve area (MVA) and morphologic fin dings of the mitral apparatus. The severity of mitral regurgitation (M R) was visually graded on a semiquantitative scale of 0-4+ according t o the ratio of the maximal regurgitant jet area to the left atrial are a (JA/LAA) indicated by transesophageal and epicardial Doppler color f low mapping. The severity of aortic regurgitation (AR) was similarly g raded on a scale of 0-4+ according to the ratio of the maximal regurgi tant jet area to the left ventricular area (JA/LVA) in end diastole. T he severity of tricuspid regurgitation (TR) was similarly graded on a scale of 0-4+ according to the ratio of the maximal regurgitant jet ar ea to the right atrial area (JA/RAA). These criteria for the severity of valvular regurgitation were compared with conventional nonsimultane ous angiographic criteria and operative criteria according to fluid in jection into the flaccid ventricles. Tricuspid annulus diameter during systole was measured before and after tricuspid annuloplasty. Results . There was a good correlation (r = 0.78, P < 0.001) between intraoper ative two-dimensional. echocardiographic MVA and operative MVA by dire ct measurement. Epicardial two-dimensional MVA and transthoracic MVA m easured by mitral pressure half time method were similar (r = 0.88, P < 0.005). Mitral commissurotomy was performed in 4 (27%) of 15 patient s with MS. Comparison of mitral JA/LAA measurements as assessed by epi cardial and transesophageal color flow mapping revealed an excellent c orrelation between the techniques (r = 0.94, P < 0.001). Intraoperativ e TEE and ECE assessment of the severity of MR showed good agreement w ith preoperative angiographic gradings and with operative gradings. Mi tral valve repair was performed in 10 (48%) of 21 patients with MR. Po strepair intraoperative Doppler studies showed satisfactory surgical r esults in all. No significant residual MR (grade greater than or equal to 2+) was identified in this series. Comparison of aortic JA/LVA mea surements as assessed by epicardial and transesophageal color flow map ping showed an excellent correlation between the techniques (r = 0.96, P < 0.001). Intraoperative echocardiographic assessment of the severi ty of AR showed good correlation with preoperative angiographic assess ment. Aortic valve repair was performed in 1 (11%) of 9 patients with AR. There was a good correlation (r = 0.77, P < 0.005) between tricusp id JA/RAA ratios as assessed by epicardial color flow mapping and oper ative gradings for TR. Tricuspid annulus diameter during systole measu red by epicardial technique was significantly (P < 0.001) decreased af ter tricuspid annuloplasty. Conclusions. Both intraoperative TEE and E CE are useful for the evaluation of valvular function in the mitral, a ortic, and tricuspid positions. Doppler color flow mapping is a reliab le method of assessing valve regurgitation. Combined intraoperative us e of transesophageal and epicardial techniques is recommended.