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. 2021 Jan 1;32(1):9-19.
doi: 10.1093/icvts/ivaa230.

Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality

Shyamal R Asher  1 , Gregory W Malzberg  2 , Chin Siang Ong  3 , Raymond J Malapero  2 , Huan Wang  2 , Prem Shekar  4 , Tsuyoshi Kaneko  4 , Marc P Pelletier  4 , Hari Mallidi  4 , Mahyar Heydarpour  5 , Douglas C Shook  2 , Stanton K Shernan  2 , John A Fox  2 , J Daniel Muehlschlegel  2 , Xinling Xu  6 , Thy B Nguyen  6 , Thoralf M Sundt  3 , Simon C Body  7
Affiliations

Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality

Shyamal R Asher et al. Interact Cardiovasc Thorac Surg. .

Abstract

Objectives: Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P.

Methods: Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics.

Results: In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)].

Conclusions: In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.

Keywords: Intraoperative transoesophageal echocardiographic; Mitral regurgitation; Preoperative transthoracic echocardiographic.

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Figures

None
Graphical abstract
Figure 1:
Figure 1:
CONSORT diagram. Representation of the inclusion and exclusion criteria upon the study population is shown. Individuals can have 2 or more concurrent exclusion criteria. AVR: aortic valve replacement; CABG: coronary artery bypass grafting; MR: mitral regurgitation.
Figure 2:
Figure 2:
Kaplan–Meier plot of survival after aortic valve replacement surgery on 2522 patients (A), coronary artery bypass grafting surgery on 2858 patients (B) and combined aortic valve replacement-coronary artery bypass grafting surgery on 1404 patients (C), stratified by the most severe observed grade of mitral regurgitation observed by preoperative TTE or intraoperative TOE for each patient.
Figure 3:
Figure 3:
Meta-analysis of multivariable mortality models for the effect of the severity of mitral regurgitation grade measured by preoperative transthoracic echocardiography (A) or intraoperative transoesophageal echocardiography (B) and the most severe observed grade of observed mitral regurgitation from either preoperative transthoracic echocardiographic or intraoperative transoesophageal echocardiography (C) for patients undergoing AVR, CABG surgery or both surgeries. AVR: aortic valve replacement; CABG: coronary artery bypass grafting; CI: confidence interval; HR: hazard ratio.
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