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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).

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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
Redo Redux
Case#: 29
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
74 yo female with a history of a CABG and mitral valve repair 10 months ago who was doing fine until 2 month ago when she had a subacute onset of shortness of breath and dyspnea on exertion. She has a history of COPD and 80 pack year history. She also had a history of hepatitis B, renal insufficiency, and depression. Cath showed a patent SVG to the LAD but the LIMA to the Diagonal had 90% stenosis.

The first 6 loops are echo loops of her CABG/MV Repair 10 months ago.

Please assess the etiology of the valve lesion(s).
Please calculate the ERO of the valve lesion(s).
Please indicate the severity of the valve lesions.
What is your assessment of the etiology of her SOB and DOE?
What is your assessment of the IntraopPostop looops?
(IntraopPostop loops are loops after the patient is weaned from ECC)

Case Discussion/CME Questions
From the outset the first noticeable change from the preoperative echo loops is the enlargement of the right ventricle and the severe tricuspid regurgitation. While she had some mitral regurgitation after her mitral valve repair 10 months ago, the mitral regurgitation is worse and barely meets the criteria for severe mitral regurgitation. However, her left atrium is not enlarged and the pulmonary veins do not show impedence to forward flow during systole. Therefore, her SOB and DOE are due to right sided heart failure.

The left ventricle is not enlarged compared to the preoperative echo loops and regional wall motion abnormalities are not present. While her left ventricle was hyperdynamic in the preoperative echo loops, her left ventricle has a more normal ejection fraction despite more mitral regurgiation. The 2D echo loops point to a restricted P2/3 (Type IIIb lesion) and the 3D clearly shows a P2/3 restriction indicating ischemic mitral regurgitation. Her tricuspid regurgitation is due to the right ventricular dilation.

The MR Jet area is 5.74 cm2 but another jet was not included so the total MR jet area should be around 6 cm2. The TR jet area is 11.2 cm2 which is severe TR. The hepatic vein Doppler shows systolic reversal. There is ascites surrounding the liver. The RV is dilated and hypokinetic.

The calculations are as follows:
MV PISA Radius = 0.833 cm, Va = 57 cm/sec
MR VTI = 148 cm
MR Vmax = 4.17 m/s
PISA Angle = 180 degrees

MR ERO = 0.59 cm2 (0.40 is the threshold for severe)
MR RV = 88 mls ( 60 mls is the threshold for severe)

TV PISA Radius = 0.848 cm, Va 57
TV VTI = 59.6 cm
TR Vmax = 2.24 m/s
TR Angle = 180 degrees

TR ERO = 1.15 cm2 (0.40 cm2 is the threshold for severe)
TR RV = 68.5 mls (40 mls is the threshold for severe)

Other items to note is the E Vmax of the TV is 92 cm/sec where a E Vmax > 78 cm/sec indicates severe TR. Similarly, the E Vmax of the MV was 148 cm/sec which indicates severe MR (E Vmax > 120 cm/sec is consistent with severe MR).

The PV SV is 74 mls and the TV SV is 290 mls for a RV of 215 mls.
The AV SV is 78 mls and the MV SV is 260 mls for a RV of 182 mls.
The LVEF by Teicholz is 56% with a SV of 55 mls.

After the patient was weaned from the ECC, the initial assessment is that the RV is dilated and hypokinetic and the left ventricle is not filling. The MV appears to be restricted. The PISA of the MV is 0.892 cm and the Vmax is 2.54 cm with a VTI of 72 cm with a mean gradient of 16 mmHg. The MVA calculated to 0.80 cm2 which indicated that severe mitral stenosis was present (threshold for severe MS is 0.9 cm2). After the valve was re-repaired the mean gradient dropped to 5 mmHg and the Vmax dropped to 1.51 cm/sec.

While this patient didn't follow the classic ischemic MR (history of myocardial infarction with posterior papillary muscle displacement) they didn't follow the classic functional MR (left ventricular dilation with A2-P2 loss of coaptation due to  distal displacment of the papillary muscles) either. The P2/P3 and even a commisural restriction indicates an ischemic etiology. Ischemic MR has a poor prognosis even for patients with minor MR due to ischemia. The ROA of ischemic MR is dynamic where it is maximal at the beginning and end of systole and minimal during the middle of systole (where we usually do our measurements).

Recurrent MR after mitral valve repair is more likely if a less than echo-perfect mitral valve repair was performed on the first operation. Recurrent MR after a mitral valve repair can be due to procedural techniques (30%) or progression of the valve disease (57%).

Tricuspid regurgitation can occur from left ventricular dilation from mitral regurgitation in the absence of pulmonary hypertension. The dilation of the left ventricle can lead to right ventricluar papillary muscle displacement from the septal wall dilating or septal wall motion abnormalities. The tricuspid annulus diameter has been used as a guide for an indication for repair at the time of mitral valve repair. An annulus greater than 40 mm is an indication for tricuspid valve repair in the face of mild or less tricuspid regurgitaiton. Moderate tricuspid regurgitation frequently progresses after mitral valve reapir. Columbo repaired all tricuspid valves with an annular diameter greater than 21 mm even though severe TR was not present. A dilated annulus is present if the diameter is greater than 35 mm but, even normal sized diameters may represent a dilated annulus is some patients. In this patient, the tricuspid regurgitation was mild or trace during the first mitral valve repair and the annulus was around 25 mm. In retrospect, a tricuspid ring was indicated in a patient with a normal sized tricuspid annulus and trivial TR.

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