title: Echocardiographic evaluation of mitral inflow hemodynamics after asymmetric double-orifice repair.
abstract: BACKGROUND
  A comprehensive transesophageal echocardiographic (TEE) examination is essential for the evaluation of a mitral valve (MV) repair. The edge-to-edge MV repair (i.e., Alfieri stitch) can pose a unique challenge in assessing iatrogenic mitral stenosis, especially when an asymmetric double-orifice is created. The reliability of the simplified Bernoulli equation for evaluating transvalvular pressure gradients across an asymmetric Alfieri MV repair remains controversial. We sought to evaluate the reliability of this principle further by comparing TEE-acquired pressure gradients across each orifice in patients undergoing asymmetric, double-orifice repair.
  
  
  METHODS
  Routinely collected intraoperative, 2-dimensional and 3-dimensional TEE datasets acquired from 15 patients undergoing double-orifice MV repair were retrospectively reviewed and analyzed. Planimetered anterior lateral (AL) and posterior medial (PM) orifice areas were acquired from 3-dimensional TEE full volume datasets, by cropping the image to develop a short-axis view at the narrowest diastolic orifice cross-sectional area at the MV leaflet tips. Transmitral Doppler flow velocity values were measured through the AL and PM orifices. Peak and mean pressure gradients were calculated from the simplified Bernoulli equation at both orifices and were compared to each respective orifice for each patient.
  
  
  RESULTS
  The mean difference between the AL and PM orifice areas for each patient was statistically significant (0.72 ± 0.40 cm(2), P < 0.0001). The mean differences between the AL and PM parameters were also significant for peak velocity: 0.15 m/s, SD: 0.08, P < 0.0001; peak pressure gradients: 1.76 mm Hg, SD: 1.42, P < 0.0001; and mean pressure gradient: 1.04 mm Hg, SD: 0.93, P < 0.0001.
  
  
  CONCLUSIONS
  The echocardiographic assessment of MV dysfunction after an Alfieri repair is important. Although the differences that we demonstrated between orifice areas and maximum velocities across the asymmetric orifices after a double-orifice MV repair are statistically significant, the corresponding difference in mean transorifice pressure gradient is not clinically relevant. Thus, either orifice can be interrogated with Doppler echocardiography for the determination of pressure gradients after double-orifice MV repair.
authors.affiliation: From the *Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; †Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; and ‡Missoula Anesthesiology, Missoula, Montana; and §International Heart Institute of Montana, Missoula, Montana.
authors.forename: Agnieszka
authors.initials: A
authors.lastname: Trzcinka
authors.forename: John A
authors.initials: JA
authors.lastname: Fox
authors.forename: Douglas C
authors.initials: DC
authors.lastname: Shook
authors.forename: Jan N
authors.initials: JN
authors.lastname: Hilberath
authors.forename: Gregg
authors.initials: G
authors.lastname: Hartman
authors.forename: Bruce
authors.initials: B
authors.lastname: Bollen
authors.forename: Xiaoxia
authors.initials: X
authors.lastname: Liu
authors.forename: Andrea
authors.initials: A
authors.lastname: Worthington
authors.forename: Stanton K
authors.initials: SK
authors.lastname: Shernan
mesh_terms: D000368:Aged; D015150:Echocardiography, Doppler; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D058386:Mitral Valve Annuloplasty / Q000009:adverse effects; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D008946:Mitral Valve Stenosis / Q000000981:diagnostic imaging / Q000209:etiology / Q000503:physiopathology; D008955:Models, Cardiovascular; D011237:Predictive Value of Tests; D011312:Pressure; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013536:Suture Techniques / Q000009:adverse effects; D016896:Treatment Outcome