Journal of the American Society of Echocardiography 3 7 4 A b s t r a c t s May lunc 1996

IO1A

Abstract Poster Session 101 Intraoperative Echocardiography

DOES PREP UMP INTRAOPERAT1VE E C H O C A R D I O G R A P H Y C H A N G E O P E R A T I V E PLANS IN M I T R A L V A L V E REPAIR? Maria-Anna Secknus MD, Allan L Klein MD, Nicholas G Smedira MD, Delos M Cosgrove MD, William J Stewart MD. The Cleveland Clinic Foundation, Cleveland, OH.

Postpump iutraoperative TEE (IOE) provides a safety net to assure successful cardiac surgery, especially useful in valve repair. Prepump IOE is done routinely, providing an immediate picture of the pt's individual anatomy defining the mechanism of valve dysfunction. However, in this era of cost containment, considerable time and expense could be saved if part of the IOE could be omitted. We sought to determine if the prepump IOE has a significant impact on operative management that can not be replaced by the preop transthoracic echo (TTE). Of 660 consecutive pts having IOE over a 6 month period, 121 had _> moderate mitral regurgi ta t ion (MR) on their preop TTE (average 10.5 days preop), no concomitant disease except CAD requiring CABG, and a prepump IOE performed to reassess MR and the need for mitral (MV) repair.

Results: On the basis of the prepump IOE, in 6 (5.0%) of 121 cases the operative plan was changed with cancellation of MV repair previously proposed, because the MR (at baseline or during phenylephrine challenge) was less (by 1+ or more) than the preop TTE showed. Of the remaining 115 prepump IOE's, all had MV repair and/or CABG performed according to preoperatively defined plans, including 24 pts with less MR, 1 with more MR, and 90 with identical MR as the preop TIE.

P o s t p u m g IOE detected unsat isfactory results requiring immediate second pump run in 8 pts (6.6% of 121) : 4 for further MV repair, 3 for MV replacement, and i for CABG).

C o n c l u s i o n s : The degree of MR on prepump IOE was reduced by one degree or more compared to the preop T I E in 25% of the pts (30 of 121), leading to cancellation of the planned MV repair in 5% (6 of 121). A second pump run was required in 6.6% (8 of 121). Both prepump and postpump IOE are important in the operative management of MR.

101C W i t h d r a w n b y a u t h o r s ' r e q u e s t

IOID In t raopera t ive Traasgast r ic CW Doppler A s s e s s m e n t During LVOT Surgery: A Rel iab le Predic tor of Residual Obst ruct ion

Peter C. Frommelt, David A. Lewis, Andrew N. Pe!ech Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI

Standard TEE views otthe LVOT are limited by poor Doppler beam alignment with the peak velocity of flow. Transgastric imaging allows well-aligned CW Doppler interrogation of the LVOT and was attempted daring intraoperative TEE in all children undergoing LVOT surgery at Children's Hospital of Wisconsin From 12/91 to 12195, 37 patients, ranging in age from 2 days to 18 years (median 5.2 yrs) and in weight from 2.9 to 100 kg (median 16.7 kg), had TEE during surgery to resect membranous or fibromuscular subaortic obstruction (n=20), valvuloplasty for aortic stenosis/insuffJcien cy (n-13)~ aortoplasty for supravalvar stenesis (n='l), or aortic valve replacement (n=3) in 4 patients, transgastric images of the LVOT could not be obtained. Intraoperative Doppler gradients identified several residual obstruction (mean 69 mmHg) after surgery in 5 pts; 4 of these underwent immediate reoperation with subsequent adequate relief, and 1 pt required later aortoventriculoplasty. All other pts had successful LVOT reconstruction with intraoperative Doppler gradients ranging from 0-46 mmHg, and none required early reoperation. Good correlation between the intraoperative transgastric gradient (mean 25.3 mmHg) and the early postoperative transthsracic echo gradient (mean 21.8 mmHg)was found:

_ i : i - .......... i I

~oj .-" , • y=.~,+1o.~ I Pearson corlelation r=0845 • ~-005 ! . . . . i

Post op TTE G~di~t We conclude th at transgastric Doppler assessment of the LVOT is a critical component of intraeperative monitoring during LVOT st[ rgery and is a reliable predictor of residual obstruction

101B INTRAOPERATIVE TRANSESOPHAGEAL ECHO DETERMINATION OF THE SEVERITY OF MITRAL REGURGITATION USING PROXIMAL ISOVELOCITY SURFACE AREA: CORRELATION WITH DOUBLE SAMPLING DYE CURVE Robin A. Horn MD, Jae K. Oh MD, Roger L. Click MD, Hartzell V. Schaff MD, Martin D. Abel MD, Maurice E. Sarano MD, Fletcher A. Miller MD, James B. Seward MD; Mayo Clinic and Mayo Foundation, Rochester, MN

Evaluation of mitral regurgitation is the most common indication for intraoperative TEE. MR severity is usually based on color flow imaging, but a more quantitative method of determining MR severity has been recently validated by TTE using the proximal isovelocity surface area(PISA) method. To assess the feasibility and reliability of TEE PISA method for the intraoperative quantitation of MR severity, radius(R) of PISA, radius squared(R2), flow rate, and effective regurgitant orifice (ERO) were correlated with double sampling dye curve measurements of MR severity. Twenty-three measurements were made in nineteen pts (19 pre-op and 4 post-op) who had intra-op TEE. PISA was measured using a relatively fixed aliasing velocity (mean 30cm/sec;range 2/-38cm/sec) from at least two planes and the average radius was used in each pt. ERO was calculated as flow rate(6.28xR2 x aliasing velocity)/MR peak velocity. For double sampling dye curves, indocyanine green dye was injected into the LV and was sampled in the aorta and LA. The proportion of area under the LA dye curve in reference to the area under aortic dye curve was expressed as a regurgitant fraction. Results: The correlation(r) between double sampling dye curve and PISA variables were r=0.79 for Radius, p<.01; r=0.74 for Rz, p<.01;r=0.74 for flow rate, p<.01 and z~-0.61 for ERO, p<.01. However, because of the potential limitations of quantifying MR in pts with eccentric jets(15/23 jets), the correlation was repeated in patients with central jets(7/23 jets) and was improved 0.84, 0.87, 0.91,and 0.94 respectively. For eccentric jets the correlations were weaker as compared to central jets: R(0.76), R2(0.69) flow rate(0.68), ERO(0.26). Conclusions: During TEE 1) PISA can be used to assess the severity of MR, 2) ERO appears to be of good value in patients with central jets, and 3) the radius of PISA appears to be a simple and useful measure of MR severity.

101E DISCREPANCY BETWEEN DOPPLER AND CATHETER GRADIENTS IN PATIENTS WITH ST. JUDE PROSTHETIC VALVES Irvin F. Goldenberg, MD; Jeanne D. Goldenberg, RDMS; John Novicki; Orn Arnar, MD; Terrence Longe, MD; Minneapolis Heart Institute & Abbott Northwestern Hospital, Minneapolis, MN

In vitro studies have demonstrated discrepancies between simultaneous Doppler (DOP)- and catheter (CATH)- obtained gradients (GRAD) for the prosthetic St. Jude aortic valve. However published in vivo studies (simultaneous DOP and CATH data in patients with this valve) to confirm this discrepancy in gradients are not available. In fact the only published data (Circulation 1989;80(3):504-14) on simultaneous DOP and CATH gradients in the St. Jude aortic valve (~-2) showed no difference between DOP and CATH gradients. To further evaluate the relationship between simultaneous DOP and CATH gradients, we obtained these measurements in ten patients with St. Jude aortic prosthetic valves. The peak instantaneous and mean valve GRAD were significantly higher by DOP measurements (peak valve GRAD, mean±SD, 38±14 vs. 23~14 mmHg, p<0.01; mesa GRAD 19+8 vs. 14±10 mmHg, p<0.02; DOP vs. CATH GRAD). Peak DOP GRAD exceeded peak CATH GRAD by 105% (0 to 340%; 0 to 28 mmHg). Mean DOP GRAD exceeded mean CATH GRAD by 53% (0 to 120%; 0 to 13 mmHg). Conclusion: In rive DOP measurements of transvallallar GRAD often overestimate catheter measurements. In vitro studies suggest that the higher DOP GRAD are due to DOP measuring a localized maximum velocity through the central orifice of the St. Jude valve, which does not reflect the average velocity or pressure across the valve, while CATH GRAD often measures the recovered pressure distal to the valve.