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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

You can change the size and the format of the image or video loops by using the links below the image or video loop.
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Loop Text Key  
Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Stop Your Billowing
Case#: 8
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits
72 yo male with hx of CABG 18 years ago now with SVG to OM 100%, SVG to RCA 100%, LIMA to LAD patent, and RIMA to RCA patent with new onset systolic murmur, atrial fibrillation, and SOB/PND. He has a history of sleep apnea but refuses CPAP. The ECG shows SR, mutiple PVCs, and RBBB. His LVEF is 55%. He is on a beta blocker, lipid therapy, and his plavix was stopped 14 days ago and his coumadin was stopped 7 days ago.

Please discuss the pathology of the disease, the type of repair that can be performed and the results of each repair. Which repair method would you recommend for this patient?


Case Discussion/CME Questions
This case is an example of Barlow's syndrome. Barlow's syndrome was named after JB Barlow who describe a "click-murmur" syndrome in 1966 and later became known as mitral valve prolapse (MVP). Barlow's syndrome can progress to involve both leaflets where both leaflets prolapse and a mitral valve regurgitation is present. The leaflets are redundant and thickened. Up to 40% of theses patients have a dysautonomia where there is a flight or flight response to emotional triggers.

Barlow valves can be repaired or replaced. When compared to fibroelastic disease, Barlow valves have a higher incidence of recurence rate of reoperation for mitral regurgitation (6% versus 2.6%). If chordal shortening, an annuloplasty ring, and a sliding annuloplasty were utilized in the Barlow valves, the recurrence rate was the same for reoperation for mitral regurgitation.

One study showed that a quadrangular resection of the posterior middle scallop and a triangular resection of the anterior scallop, a sliding valvuloplasty and a fold valvuloplasty of the lateral scallops had excellent results where there were no reoperations for mitral regurgitation after about 2 years of follow up.

However, other physicians from CTSNet feel that Barlows disease can only be successfully treated with gortex sutures (or similar) rather than resection. Their results have claimed a 2% reoperation rate for mitral regurgitation.

Another option is to perform an Edge-to-Edge repair on the Barlow valve. Reults of the Edge-to-Edge repair show a 9% reoperation rate for mitral regurgitation.

As far as the echo is concerned, the TEE shows a Barlow's valve (anterior and posterior prolapse with a P3 flail scallop. In some of the views, the amount of prolapse is obvious, but, in the 3D view, the amount of anterior prolapse is certianly less than the posterior prolapse.
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