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Abstract
The aim of this work was to study the value of intraoperative transoesophageal echocardiography in assessment of tricuspid valve annuloplasty as a guide for the adequacy of tricuspid valve repair by adjustable annuloplasty technique before chest closure.
This study was conducted on 60 patients having rheumatic heart disease with mitral valve affection or mitral and aortic valve affection (stenosis or regurgitation or both) associated with functional moderate to severe tricuspid regurgitation.
The patients were divided into two matched groups and all patients were subjected to:
i) Preoperative assessment: Including clinical evaluation, laboratory investigation, twelve leads ECG, chest x-ray and transthoracic echocardiography.
ii) Intraoperative assessment:
- Group I: Intraoperative TEE was used for adjustment of tricuspid valve annuloplasty while the patients on bypass.
- Group II: Digital pulpation was used to confirm the adequacy of valve repair and TEE for evaluation of the repair after the patients were off bypass.
iii) Postoperative assessment: All the patient were followed twice over a period of three months using transthoracic echocardiography.
All the patients had significant improvement of their NYHA functional classification and there was no mortality in both groups.
? Group I: Included 30 patients who underwent mitral or double valve replacement (mitral and aortic) with adjustable tricuspid annuloplasty. Their mean age was 28.7 ± 5.4 years. 19 patients had MVR and 11 patients had DVR. The results showed a significant decrease in the regurgitant jet area (preoperatively it was 22.0 ± 11.9 cm2 and reduced to 1.2 ± 1.0 cm2 after repair) and the ratio of the jet area to right atrial area (preoperatively it was 47.6 ± 20.2 % and reduced to 2.8 ± 1.9 % after repair). This results were obtained when the suture was adjusted under echocardiographic guidance, the peak inflow velocity and the gradient across the tricuspid valve did not show significant changes during the procedures.
? Group II: Included 30 patients who underwent mitral or double valve replacement with standard De Vega’s annuloplasty. Their mean age was 28.6 ± 5.2 years. 18 patients had MVR and 12 patients had DVR. The results showed a decrease in the TR grade, regurgitant jet area and the ratio of the jet area to right atrial area but less than the results achieved in group I. One patient had moderate TR intraoperatively after repair during TEE evaluation and required further surgery with Carpentier ring implantation.
Comparing the results of both groups revealed that TEE was more accurate in the adjustment of tricuspid valve annuloplasty with less TR jet area in group I than in group II (P value < 0.01) and no patients necessitated further surgery.
A significant decrease in the semiquantitative grade of TR, of regurgitant jet area of the ratio jet area/right atrial area was obtained when the suture was adjusted under echocardiographic guidance. The peak inflow velocity and the gradient across the tricuspid valve did not show significant changes throughout the procedures. The results showed that the tricuspid suture annuloplasty guided by TEE enables a substantial reduction in residual TR without creating valve stenosis.
Intraoperative echocardiography has long been recognized as a useful tool in patients undergoing cardiac operations, with the introduction of the transoesophageal approach for echocardiographic imaging, the development of combined two dimensional and color Doppler flow capabilities and the growing willingness of the surgeon to undertake complex intracardiac operations increase the interest in intraoperative transoesophageal echocardiography which is useful in formulating the surgical plan, assessing immediate operative results and identifying patients with unsatisfactory results who are at risk for postoperative complications.