title: Intraoperative evaluation of transmitral pressure gradients after edge-to-edge mitral valve repair.
abstract: OBJECTIVE
  Edge-to-edge repair of the mitral valve (MV) has been described as a viable option used for the surgical management of mitral regurgitation (MR). Based on the significant changes in MV geometry associated with this technique, we hypothesized that edge-to-edge MV repairs are associated with higher intraoperative transmitral pressure gradients (TMPG) compared to conventional methods.
  
  
  METHODS
  Patient records and intraoperative transesophageal echocardiography (TEE) examinations of 552 consecutive patients undergoing MV repair at a single institution over a three year period were assessed. After separation from cardiopulmonary bypass (CPB), peak and mean TMPG were recorded for each patient and subsequently analyzed.
  
  
  RESULTS
  84 patients (15%) underwent edge-to-edge MV repair. Peak and mean TMPG were significantly higher compared to gradients in patients undergoing conventional repairs: 10.7 ± 0.5 mmHg vs 7.1 ± 0.2 mmHg; P<0.0001 and 4.3 ± 0.2 mmHg vs 2.8 ± 0.1 mmHg; P<0.0001. Only patients with mean TMPG ≥ 7 mmHg (n = 9) required prompt reoperation for iatrogenic mitral stenosis (MS). No differences in peak and mean TMPG were observed among edge-to-edge repairs performed in isolation, compared to those performed in combination with annuloplasty: 11.0 ± 0.7 mmHg vs 10.3 ± 0.6 mmHg and 4.4 ± 0.3 mmHg vs 4.3 ± 0.3 mmHg. There were no differences in TMPG between various types of annuloplasty techniques used in combination with the edge-to-edge repairs.
  
  
  CONCLUSIONS
  Edge-to-edge MV repairs are associated with higher intraoperative peak and mean TMPG after separation from CPB compared to conventional repair techniques. Unless gradients are severely elevated, these findings are not necessarily suggestive of iatrogenic MS. Thus, in the immediate postoperative period mildly elevated TMPG can be expected and tolerated after edge-to-edge mitral repairs.
authors.affiliation: Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Jan N
authors.initials: JN
authors.lastname: Hilberath
authors.forename: Holger K
authors.initials: HK
authors.lastname: Eltzschig
authors.forename: Stanton K
authors.initials: SK
authors.lastname: Shernan
authors.forename: Andrea H
authors.initials: AH
authors.lastname: Worthington
authors.forename: Sary F
authors.initials: SF
authors.lastname: Aranki
authors.forename: Martina
authors.initials: M
authors.lastname: Nowak-Machen
mesh_terms: D001794:Blood Pressure; D003657:Decision Making; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000503:physiopathology* / Q000601:surgery*; D008946:Mitral Valve Stenosis / Q000503:physiopathology / Q000601:surgery; D013903:Thoracic Surgery / Q000379:methods*
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