Ann Thorac Surg 2005;80:59
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Invited commentary
Richard Mainwaring, MD
Pediatric Cardiovascular Surgery, 5301 F St, Suite 111, Sacramento, CA 95819
(Email: mainwar{at}sutterhealth.org).
The authors report their experience with intraoperative transesophageal echocardiography (TEE) as a predictive tool in assessing A-V valve regurgitation in complete atrioventricular septal defects (C-AVSD). Follow-up transthoracic echocardiography (TTE) was performed at a mean interval of 19 months following surgery. Thirty-three of the 35 patients in this study had grade I left-sided A-V valve regurgitation by intraoperative TEE, and of these 23 maintained the same grade while 10 patients had an increase to grade II regurgitation. Two patients had grade II regurgitation by intraoperative TEE, and both of these patients had improvement to grade I on follow-up TTE. This discrepancy between the intraoperative TEE and postoperative TTE is consistent with previous publications on this subject. Lee and colleagues [1] found that 47% of their patients had a change in grade of mitral regurgitation (MR) at follow-up TTE. At first pass, these data would suggest a certain futility to performing an intraoperative TEE. However, the fact that some patients change the grade of their MR from TEE to TTE (but don’t require re-operation) is of secondary consequence.
It is of note that none of the patients in this series have required re-operation for left-sided A-V valve regurgitation, which is quite commendable. Most published series do have a significant incidence of patients progressing to severe MR and requiring re-operation. For example, in a recent article by Harkel and colleagues [2], 15 of 157 patients required re-operation for this reason. In their series, the most important risk factor for developing severe MR "late" was severe MR preoperatively. Thus, there does appear to be some important predictive value in this echocardiographic information.
The most important aspect of intraoperative TEE is identifying patients with significant hemodynamic abnormalities in the operating room and addressing these issues at that time. To emphasize this point, 4 of 35 patients in this series had re-initiation of bypass and revision of the repair. All four were successfully managed, and their data attests that they did not require later re-operations. While this was not the specific point of this paper, it would be of interest to know how the authors managed these revisions, particularly with respect to the two patients who had significant MR and tricuspid regurgitation, as this can be a difficult situation. It would also be of interest to know what the mechanism is underlying the progression of MR in the 10 patients described in this series. Is it through a residual (partially re-approximated) cleft? Is it through a commissure, related to annular dilatation, or is it central? This information might provide some insight as to whether the progression of MR on follow-up TTE is preventable by modifying a specific aspect of the surgical repair technique.
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References
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- Lee HR, Montenegro LM, Nicolson SC, Gaynor JW, Spray TL, Rychik J. Usefulness of intraoperative transesophageal echocardiography in predicting the degree of mitral regurgitation secondary to atrioventricular defect in children Am J Cardiol 1999;83:750-753.[Medline]
- Harkel ADJT, Cromme-Dijkhuis AH, Heinerman BCC, Hop WC, Bogers AJJC. Development of left atrioventricular valve regurgitation after correction of atrioventricular septal defect Ann Thorac Surg 2005;79:607-612.[Abstract/Free Full Text]
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