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Ann Thorac Surg 2006;82:2240-2246
© 2006 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Discrepancy Between Intraoperative Transesophageal Echocardiography and Postoperative Transthoracic Echocardiography in Assessing Congenital Valve Surgery

^a Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan
^b Cardiac Care Unit, Okayama University Graduate School of Medicine and Dentistry, Okayama, Japan

Accepted for publication June 19, 2006.

^_* Address correspondence to Dr Sano, Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine and Dentistry, 2-5-1 Shikata-cho, Okayama City, 700-8558, Japan (Email: s_sano{at}cc.okayama-u.ac.jp).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
BACKGROUND: The purpose of this study was to investigate the discrepancy between intraoperative transesophageal and postoperative transthoracic echocardiography in assessing residual regurgitation in children undergoing valve repair.

METHODS: Forty-two consecutive children (median age, 5.1 years) who underwent valve repair for valvar regurgitation from 2001 to 2004 were retrospectively analyzed. The patients were divided into two groups: atrioventricular valve group (n = 33) and aortic valve group (n = 9). Regurgitation grade, fractional shortening, and atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography were compared with those obtained by transthoracic echocardiography at discharge (median, 11 days) and at follow-up (median, 8 months).

RESULTS: Intraoperative transesophageal echocardiography revealed specific residual lesions in 4 patients, leading to successful re-repair. Fractional shortening obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the atrioventricular valve group, the regurgitation grade obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (0.7 ± 0.8 versus 1.4 ± 0.9; p < 0.01), and agreement between the two examinations was found in 12 patients (38%). Peak atrioventricular inflow velocity obtained by intraoperative transesophageal echocardiography was lower than that obtained by predischarge transthoracic echocardiography (p < 0.01). In the aortic valve group, there was no significant difference between the regurgitation grades in the two examinations (0.8 ± 0.8 versus 1.1 ± 0.9), and complete agreement in regurgitation grade was found in 5 (56%) of 9 patients.

CONCLUSIONS: There were considerable discrepancies between the examinations in evaluation of residual atrioventricular valve regurgitation and potential atrioventricular valve stenosis: most of the residual regurgitations were underestimated by intraoperative transesophageal echocardiography. In contrast, reasonable agreement was found between the two examinations in evaluation of aortic valve regurgitation.

	Introduction

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Various reconstructive approaches for congenital valvar regurgitation in infants and children have been developed in the past two decades [1–3]. As surgical techniques have been refined, indication of surgery has been expanded to include complex valvar regurgitant lesions with a wide spectrum of morphologic abnormalities [1–3]. An accurate and detailed diagnosis of an affected valve is of great importance to design a surgical plan when repairing such complex valvar lesions. Furthermore, a credible intraoperative evaluation to determine the adequacy of surgical procedures is essential to achieve effective valve repair. A fluid-filling test has been used to evaluate the adequacy of surgical procedures; however, it is sometimes inaccurate because of the striking difference between spatial arrangement of valve apparatus in an arrested heart and that in a contracting heart [4, 5]. Epicardial echocardiography has also been one of the options [5, 6]; however, placing a transducer directly on a heart might lead to arrhythmia and hemodynamic instability, which might make accurate assessment difficult [7, 8].

Intraoperative transesophageal echocardiography (ITEE) is currently an essential method for assessing cardiac structure and function in pediatric patients undergoing open-heart surgery [7–9]. Intraoperative transesophageal echocardiography plays an important role in valve repair, not only for evaluation of preoperative valvar disease and function but also for assessment of the adequacy of surgical procedures [7, 10–12]. However, we have often experienced a significant discrepancy between evaluation of postoperative residual regurgitations using ITEE and that using postoperative transthoracic echocardiography (TTE). A discrepancy has been found in previous studies on evaluation of residual regurgitation in patients with complete atrioventricular defect (AVSD) [10, 13]. Because determination of the adequacy of surgical procedures at surgery crucially depends on ITEE findings, it is important to investigate the discrepancy between the two examinations to attain sufficient surgical results. The purpose of this study was to compare ITEE and postoperative TTE in assessment of residual regurgitations and to investigate the discrepancy of the two examinations in children with congenital valvar regurgitant lesions undergoing valve repair.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Patient Population
We conducted a retrospective study of children who underwent atrioventricular valve (AVV) or aortic valve (AoV) repairs for valvular regurgitation from January 2001 to December 2004 at Okayama University Hospital. The Institutional Review Board approved this retrospective study, and patient consent was waived for the study. Forty-two consecutive children (27 males and 15 females) were enrolled in this study. Patients who underwent primary repair for complete or partial AVSD were excluded. Patients with AVSD who had a left-sided AVV regurgitation late after repair were included. Age at operation ranged from 3 weeks to 23 years (median age, 5.1 years), with 12 (29%) patients being younger than 2 years of age. Weight at operation ranged from 2.9 to 59 kg (median weight, 13.5 kg). Thirty-three patients had a significant AVV regurgitation (AVV group), and 9 patients had a significant AoV regurgitation (AoV group). Preoperative diagnosis and affected valves are listed in Tables 1 and 2. Eighteen (42%) of the patients had undergone previous surgery, including three valve repairs.

Atrioventricular valve regurgitation was estimated by semiquantitative grading according to the maximum length and width of the abnormal jet relative to the atrium as follows: grade I if the regurgitant jet was less than one third of both the length and width of the atrium, grade II if the jet was one third to one half of the length and width of the atrium, grade III if the jet was one half to two thirds of the length and width of the atrium, and grade IV if the jet exceeded two thirds of the length and width of the atrium [15]. Aortic valve regurgitation was estimated according to the grading criteria described by Perry and colleagues [16] by measuring the height of the regurgitant color Doppler flow jet relative to the left ventricular outflow tract height: grade I for AoV regurgitation of 1% to 24%, grade II for 25% to 46%, grade III for 47% to 64%, and grade IV for greater than 65%. Predischarge and follow-up TTEs were performed using a 2.5- or 3.5-MHz probe transducer. Residual regurgitation assessed by ITEE was compared with those assessed by predischarge and follow-up TTE. Fractional shortening (FS) of the systemic ventricle of the entire cohort and peak AVV inflow velocity in the AVV group obtained by ITEE were compared with those obtained by predischarge TEE. Systolic blood pressure and heart rate measured at the time of ITEE were compared with those measured at the time of predischarge TTE.

Interobserver and Intraobserver Variability
Two investigators (O.H., Y.K) independently reviewed 123 videotapes on two occasions each. Each investigator was blinded to the patient’s name, diagnosis, and the initial echocardiographic reports. Videotapes were masked and were displayed in a random order. There was reasonable interobserver agreement (r = 0.952; p < 0.001) and intraobserver agreement (O.H: r = 0.966; p < 0.001; Y.K: r = 0.866; p < 0.001).

Statistical Methods
Data are presented as means ± standard deviations. The level of statistical significance was set at p equal to 0.05. Comparisons between ITEE and TTE data were performed by the paired Student’s t test. Agreement between ITEE and TTE was analyzed using linear regression by Spearman’s correlation.

	Results

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Residual regurgitations were successfully evaluated by ITEE in all but 1 of the patients. Insertion of the probe was abandoned in a 5-month-old boy with congenital isolated mitral regurgitation because of hemodynamic instability. Intraoperative transesophageal echocardiography revealed specific residual lesions that causing residual regurgitation of more than grade III in 4 patients (2 patients in the AVV group and 2 patients in the AoV group), which led to successful re-repair. None of the 41 patients left the operating room with grade IV residual regurgitation. Predischarge two-dimensional and color Doppler TTE was performed at the median period of 11 postoperative days (range, 6 to 18 days; mean, 9.8 days). In the entire cohort of 41 patients, FS of the systemic ventricle measured by ITEE was significantly lower than that measured by predischarge TTE (30% ± 4% versus 36% ± 9%; p < 0.01; Fig 1). Systolic blood pressure at the time of ITEE was significantly lower than that at the time of predischarge TTE (83 ± 12 mm Hg versus 95 ± 7 mm Hg; p < 0.001), and heart rate at the time of ITEE was significantly higher that that at the time of predischarge TTE (117 ± 20 beats/min versus 105 ± 15 beats/min; p < 0.001). Predischarge TTE did not reveal any evidence of dehiscence or failure of the repaired valves.

View larger version (28K): [in this window] [in a new window]   Fig 1. Fractional shortening of the systemic ventricle assessed by intraoperative transesophageal echocardiography (ITEE) and predischarge transthoracic echocardiography (TTE) in 41 patients; p < 0.01.

View larger version (19K): [in this window] [in a new window]   Fig 2. Agreement in atrioventricular valve (AVV) regurgitation grade between intraoperative transesophageal echocardiography (ITEE) and predischarge transthoracic echocardiography (TTE); r = 0.52; p < 0.01.

View larger version (25K): [in this window] [in a new window]   Fig 3. Peak atrioventricular valve (AVV) inflow velocity measured by intraoperative transesophageal echocardiography (ITEE) and predischarge transthoracic echocardiography (TTE); p < 0.01.

View larger version (19K): [in this window] [in a new window]   Fig 4. Agreement in aortic valve (AoV) regurgitation grade between intraoperative transesophageal echocardiography (ITEE) and predischarge transthoracic echocardiography (TTE); r = 0.683; p < 0.05.

In the AVV group, follow-up TTE showed that 23 (72%) of the 32 patients remained at the same regurgitation grade as that at the time of predischarge TTE (Fig 5). An increased regurgitation grade was found in 6 patients (18%), whereas 3 patients (9%) had an improved regurgitation grade. There was a positive correlation between grades of residual regurgitation obtained by predischarge TTE and follow-up TTE (r = 0.771; p < 0.001), but there was no correlation between residual regurgitation grades obtained by ITEE and follow-up TTE (not significant). There was no development of AVV stenosis during the follow-up period (1.32 ± 0.46 versus 1.34 ± 0.44 m/s; not significant). In the AoV group, seven (77%) of the 9 patients had the same regurgitation grade at follow-up (Fig 6). There was a positive correlation between the residual regurgitation grades obtained by predischarge TTE and follow-up TTE (r = 0.889; p < 0.001), but there was no correlation between the grades obtained by ITEE and follow-up TTE (not significant).

View larger version (47K): [in this window] [in a new window]   Fig 5. Atrioventricular valve regurgitation grade assessed by intraoperative transesophageal echocardiography (ITEE) and predischarge and follow-up transthoracic echocardiography (TTE). Each line represents 1 patient.

View larger version (27K): [in this window] [in a new window]   Fig 6. Aortic valve regurgitation grade assessed by intraoperative transesophageal echocardiography (ITEE) and predischarge and follow-up transthoracic echocardiography (TTE). Each line represents 1 patient.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

It is not surprising that there was a discrepancy in evaluation of residual AVV regurgitation by the two examinations. Previous studies showed the difficulty in accurate evaluation of AVV regurgitation after AVSD repair. Lee and coworkers [13] demonstrated that complete agreement in grade of residual left-sided AVV regurgitation was found only in 53% of patients undergoing AVSD repair. Likewise, Kim and associates [10] showed that complete agreement in regurgitation grade was found in 65% of the left-sided AVV and in 90% of the right-sided AVV. In those studies, regurgitation grade was underestimated by ITEE in the majority of patients. Our study also showed that AVV regurgitation grade was underestimated by ITEE in 90% of the patients who had a discrepancy in the grade and that the residual regurgitation in the tricuspid valve or right-sided AVV was evaluated more accurately than that of the mitral valve or left-sided AVV. Surgeons must keep in mind that regurgitation grade might be underestimated by ITEE in evaluation of AVV repair even if ITEE shows "perfect" valve repair in an operating room.

A number of factors contribute to the discrepancy in AVV regurgitation grade determined by ITEE and predischarge TTE. A heart shortly after reperfusion has systolic and diastolic dysfunction or a higher ventricular end-diastolic pressure mainly as a result of cardioplegic arrest followed by ischemia–reperfusion injury. Depressed ventricular function would affect the severity of residual regurgitation. Altered hemodynamics and preload and afterload would also affect the severity of residual regurgitation. In fact, our study showed significantly lower blood pressure and higher heart rate at the time of ITEE than those at the time of predischarge TTE. Furthermore, induction of general anesthesia and resultant changes in preload and afterload are associated with a decrease in severity of AVV regurgitation in the operating room [18–20]. Other possible factors include the use of inotropic agents and abnormalities in atrioventricular synchrony in the immediate postoperative period [10]. In addition, technical variability among investigators might account for some discrepancies in regurgitation grades. Of note, our study revealed significantly poor agreement in evaluation of residual regurgitation of the common AVV in patients with single ventricle morphology. In this series, most common AVV repairs were performed concomitantly with a staged single ventricle palliation, ie, bidirectional cavopulmonary shunt or Fontan operation. These surgical procedures would alter the intracardiac volume status dramatically and facilitate remodeling of ventricular, valvular, and subvalvular structures, which might cause the discrepancy in regurgitation grade in this particular subgroup.

An interesting finding of this study was that there was a considerable discrepancy in evaluation of peak AVV inflow velocity by ITEE and predischarge TTE. Although no patients showed symptoms of AVV stenosis or secondary pulmonary hypertension during the follow-up period, 3 patients had peak AVV inflow velocity greater than 2 m/s in predischarge TTE even though they had peak velocity less than 1.5 m/s at surgery. This discrepancy might be related to depressed cardiac output in the immediate postoperative period. Increased ventricular contractility and cardiac output in the late postoperative period may result in increased atrioventricular inflow velocity. In our series, annuloplasty was performed in the majority of cases, in which the diameter of the annulus was maintained at greater than 80% of the normal value (calculated according to the formula of Rowlatt and colleagues [21]). However, any patient has the potential to exhibit AVV stenosis because of its small annulus and complicated procedures required. Care should be taken in evaluating AVV inflow velocity because it might be considerably underestimated in the operating room.

There have been a few studies in which agreement between evaluation by ITEE and evaluation by postoperative TTE in pediatric patients with AoV regurgitation was investigated. Although it has been expected that AoV regurgitation could be underestimated by ITEE because of high ventricular end-diastolic pressure immediately after reperfusion, this study showed a relatively high rate of agreement between ITEE and predischarge TTE in evaluation of AoV regurgitation. Frommelt and associates [22] analyzed the agreement between evaluation by ITEE and evaluation by follow-up TTE in a series of children with left ventricular outflow tract surgery and found complete agreement in the assessment of postoperative AoV regurgitation in 23 (82%) of 28 patients. One possible reason for the good agreement is that the change in the loading condition and geometry of the systemic ventricle might have only a small effect on AoV regurgitation, whereas AVV regurgitation might be greatly affected by preload and afterload and intracardiac volume [19, 20]. Taken together, the results of this study and previous studies suggest that AoV regurgitation can be estimated more reliably than AVV regurgitation by ITEE.

Despite the discrepancy in regurgitation grade determined by ITEE and that determined by follow-up TTE, we still believe that ITEE is one of the most reliable modalities for evaluating the adequacy of valve repair in the pediatric population. Intraoperative transesophageal echocardiography can reveal specific residual lesions requiring re-repair. Moreover, the rate of agreement in regurgitation grade was approximately 70% in the AVV group patients who had residual regurgitation of more than grade II. These results indicate that ITEE enables identification of a critically incomplete repair, thus contributing to the avoidance of an early reoperation and to reduction in morbidity and mortality rates. In fact, there were no patients in this series who required a reoperation in the follow-up period. In addition, we found a weak positive correlation between AVV regurgitation grade determined by ITEE and that determined by predischarge TTE, indicating that regurgitation grade can be predicted to some extent because most patients who have a discrepancy in AVV regurgitation grade might have a one grade higher regurgitation in predischarge TTE.

Study Limitations
There are certain limitations in this study. First, the patient population was small and diagnoses of the patients were heterogeneous. Second, we compared semiquantitative regurgitation grade as a variable instead of regurgitant jet area, which is the most common way to quantitate regurgitation volume. The proximal isovelocity surface area method is another option for assessing AVV regurgitation [23]. Furthermore, there was no comparison between ITEE or postoperative TTE and other gold standards, and the possibility that regurgitation grade was overestimated by postoperative TTE in this study cannot be excluded. Although a reasonable agreement was found in a previous study between ITEE and TTE in assessing left ventricular dimensions and FS in a pediatric population [24], FS of a systemic right ventricle is not a widely accepted variable for assessing systolic right ventricular function. Combined measurement of FS with right ventricular end-diastolic area and percentage of systolic change in area [25] or myocardial performance index [26] would give more reliable values of systolic right ventricular function.

Conclusions
Intraoperative transesophageal echocardiography revealed specific residual lesions causing residual regurgitations in the operating room, thus enabling avoidance of early and late reoperation. Although there was reasonable agreement between ITEE and predischarge TTE in evaluating residual AVV regurgitation of more than grade II, there were considerable discrepancies in the evaluation of residual AVV regurgitation and potential AVV stenosis by the two examinations: most of the residual regurgitations were underestimated by ITEE. In contrast, reasonable agreement was found between the two examinations in evaluating AoV regurgitation. Physicians should be aware of the discrepancy between the two modalities for precise evaluation of the adequacy of valve repair in pediatric patients undergoing congenital valve surgery.

	Acknowledgments

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The authors thank Shin-ichi Ohtsuki, MD, Kohichi Kataoka, MD, and Yoshio Okamoto, MD, for providing precise follow-up echocardiographic images that allowed us to conduct this retrospective study.

	References

Top Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Osami Honjo Yasuhiro Kotani Kozo Ishino Shunji Sano Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Honjo, O. Articles by Sano, S. Search for Related Content PubMed PubMed Citation Articles by Honjo, O. Articles by Sano, S. Related Collections Congenital - acyanotic