Intraoperative transesophageal echocardiography following mitral valve repair: a systematic review

Abstract

Objective: We aimed to examine the recent evidence and search for novel assessments on intraoperative TEE following mitral valve repair that can impact short and long-term outcomes.

Methods: The Ovid MEDLINE, PubMed, and EMBASE databases were searched from January 1, 2008, until January 27, 2021, for studies on patients with severe Mitral Valve Regurgitation (MR) undergoing Mitral Valve (MV) repair surgery with intraoperative Transesophageal Echocardiography (TEE) performed after the repair. Additional searches were conducted using Google search engine, Web of Science, and Cochrane Library.

Results: After reviewing 302 records, 8 retrospective and 22 prospective studies were included (n = 30). Due to clinical and methodological diversity, these studies are noncomparable and data were not amenable to quantitative synthesis.

Conclusion: Although technological advances allowed the objective assessment of geometric and dynamic alterations of the MV, the impact of the use of these technologies on short- or long-term outcomes was not studied. There is uncertainty and conflicting evidence on the ideal method and metrics to evaluate MV patency post-repair. Few isolated studies validated methods to assess coaptation surface and LV function post-repair.

Keywords: Intraoperative transesophageal echocardiography; Mitral valve; Mitral valve repair; Systematic review; TEE.

Figure 1

PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.

Figure 2

Flowchart representing an intraoperative stepwise approach to assess the Mitral Valve (MV) immediately after repair. Transesophageal Echocardiography (TEE) is used to guide the separation from Cardiopulmonary Bypass (CPB) and assure that the heart has no residual air; after hemodynamic optimization, a systematic examination of the MV using 2D TEE is used to identify if there is any residual mechanism of Mitral Valve Regurgitation (MR), and if this is not present, Color Flow Doppler (CFD) will confirm if there is residual MR. Any MR less or equal to mild is acceptable and further interrogation with Continuous Wave Doppler (CWD) calculating the Mean Pressure Gradient (MPG) will exclude significant Mitral Valve Stenosis (MS) post-repair. Residual MV pathology, any residual MR greater than mild and high MPG should undergo an integrated approach by the surgeon to decide if the repair is acceptable or not. If not acceptable, CPB is resumed, and further repair or replacement is performed. Once the outcome is acceptable, a comprehensive TEE examination is performed, including assessment of biventricular function, new Left Ventricle (LV) Regional Wall Motion Abnormalities (RWMA), new or worsening Aortic Valve Insufficiency, Systolic Anterior Motion of the MV and measurement of the MV Coaptation Height (CH).