Let's do some echo:

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Replacement is likely the better choice. Surgeon skill has a lot to do with short and long term outcomes. There was a good paper on this 3-4 years ago.
 
@sevoflurane very nice- that is exactly the paper I was referring to. This patient had a basal inferior aneurysm, which I tried to demonstrate in the third image. From the paper: “Our previous analysis did not corroborate these observations and identified only the presence of a basal aneurysm or dyskinesis as an independent predictor of recurrent mitral regurgitation.”

With respect to the thing beneath the mitral valve... Not a clot. Would it change anything if I told you that this surgeon uses a chordal sparing technique for MVR?

Also @anbuitachi no worries dude, there’s a reason you need an extra year of training to do cardiac. If you asked me to discuss spinal cord stims or take care of a sick neonate, I’d be lost
 
Hork Bajir said:
@sevoflurane very nice- that is exactly the paper I was referring to. This patient had a basal inferior aneurysm, which I tried to demonstrate in the third image. From the paper: “Our previous analysis did not corroborate these observations and identified only the presence of a basal aneurysm or dyskinesis as an independent predictor of recurrent mitral regurgitation.”

With respect to the thing beneath the mitral valve... Not a clot. Would it change anything if I told you that this surgeon uses a chordal sparing technique for MVR?

Also @anbuitachi no worries dude, there’s a reason you need an extra year of training to do cardiac. If you asked me to discuss spinal cord stims or take care of a sick neonate, I’d be lost
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neochord?
 
When this surgeon does MV replacement, he tries to preserve as much of the subvalvular apparatus as possible (I believe there are some benefits in terms of LV geometry and function). He does this by “tucking” the remaining chordal tissue up underneath the ring of the valve. In this case there was a small piece of the head of the anterolateral pap muscles which was part of that chordal tissue, which must have came loose during the process of tying down the valve. It was flopping around in the LV near the LVOT. We showed the surgeon who assured us that it wasn’t going to go anywhere or cause any problems, and we left it alone. I did make it a point to take lots of pictures and comment on it in the echo report so that subsequent echocardiographers don’t see it and freak out, thinking it’s a veg or thrombus.

Anyway, that’s all the cases I’ve got for now- someone else’s turn! 😎
 
Hork Bajir said:
When this surgeon does MV replacement, he tries to preserve as much of the subvalvular apparatus as possible (I believe there are some benefits in terms of LV geometry and function). He does this by “tucking” the remaining chordal tissue up underneath the ring of the valve. In this case there was a small piece of the head of the anterolateral pap muscles which was part of that chordal tissue, which must have came loose during the process of tying down the valve. It was flopping around in the LV near the LVOT. We showed the surgeon who assured us that it wasn’t going to go anywhere or cause any problems, and we left it alone. I did make it a point to take lots of pictures and comment on it in the echo report so that subsequent echocardiographers don’t see it and freak out, thinking it’s a veg or thrombus.

Anyway, that’s all the cases I’ve got for now- someone else’s turn! 😎
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Nice. Cool case. I’ll be the first to admit that those clips looked like “we’re going back on for replacement”. I would be worried that all that flopping would turn into thrombus down the line.
 
vector2 said:
Looks like a papillary fibroelastoma but it's a bit irregular that it'd be on the atrial side
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So I guess really it depends on valve function what the next step would be. I’m not sure of the chances of embolism but if the valve functions ok then stick with the TAVR
 
If you do a TAVI with that on the mitral, risk of causing it to embolize?
 
I’m surprised that there’s not more MR, based on the 2D it looked like there was malcoaptation - either due to AL leaflet flail or PL restriction. Also appears to be a fair amount of annular calcification, which isn’t surprising... The thought of a mobile chunk of calcium crossed my mind, but I don’t see enough shadowing under the mobile echo density for that the be the case.

Differential otherwise includes papillary elastoma, thrombus, or vegetation. LA myxomata can also very rarely be found on the MV too, if I’m not mistaken. However I think it becomes a bit of a moot point, since whatever it is, the mobility and size seem to suggest that it needs to come out (stroke risk otherwise too high for a 72 yo, assuming he or she is robust enough to tolerate a pump run). I would argue that if you’re going on CPB anyway, don’t dick around with the TAVR and just do the SAVR on bypass.

If you wanted to do the TAVR for whatever reason (let’s say we decided not to go after the thing on the MV), I don’t see how the risk of embolization would be crazy. Granted it’s not nothing, but generally no wires or catheters end up in the LA during a TAVR. Only risk I can think of for causing the thing to flick off during a TAVR would be rapid pacing, or if wires/catheters tug on subvalvular apparatus and cause unusual leaflet motion. Wonder if a Sentinel device would help catch it when it flies off...

Great case
 
Hork Bajir said:
I’m surprised that there’s not more MR, based on the 2D it looked like there was malcoaptation - either due to AL leaflet flail or PL restriction. Also appears to be a fair amount of annular calcification, which isn’t surprising... The thought of a mobile chunk of calcium crossed my mind, but I don’t see enough shadowing under the mobile echo density for that the be the case.

Differential otherwise includes papillary elastoma, thrombus, or vegetation. LA myxomata can also very rarely be found on the MV too, if I’m not mistaken. However I think it becomes a bit of a moot point, since whatever it is, the mobility and size seem to suggest that it needs to come out (stroke risk otherwise too high for a 72 yo, assuming he or she is robust enough to tolerate a pump run). I would argue that if you’re going on CPB anyway, don’t dick around with the TAVR and just do the SAVR on bypass.

If you wanted to do the TAVR for whatever reason (let’s say we decided not to go after the thing on the MV), I don’t see how the risk of embolization would be crazy. Granted it’s not nothing, but generally no wires or catheters end up in the LA during a TAVR. Only risk I can think of for causing the thing to flick off during a TAVR would be rapid pacing, or if wires/catheters tug on subvalvular apparatus and cause unusual leaflet motion. Wonder if a Sentinel device would help catch it when it flies off...

Great case
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Nice synopsis and differential @Hork Bajir . The big question of the case is to cancel or to proceed right? Everyone here is super smart and I get the feeling that nobody thinks that this mass is neither a vegetation or a thrombus which would lead us down the pathway of cancelling the case.

CFD was certainly non-impressive and reassuring as others mentioned above. Took an en face 3D clip to help in decision making. I feel that this is a rare presentation of a large calcium deposit near the posteromedial commissure and you make a valid point with the lack of shadowing. Although mobile (bad sign), I think the only reason it is mobile is because it is attached to A3 which you can clearly see in the 2d x-plane clip/3d en face. Finally, since we are doing a TAVR, we are not doing a transeptal puncture which would give me some reservation.

We decided to proceed and landed a nominal 29 mm Sapien 3 w/o any issues.
Documented a final 3D clip at the end of the case to show it did not embolize.

Nice job everyone.
 
Well, TAVRs are done from the Aortic Side, so I imaging the risk of embolization is not as high as it would be for say a LAA Occlusion Device. Second, I agree with the sentiment that the MR is not as bad as I thought it would be on the 2D, but regardless, one could argue that after the TAVR the MR should improve a little (LVESP should be much lower, DId the MR improve? @sevoflurane) and if he wasn't a candidate for SAVR, I imagine he is not really a candidate for repair/replacement, unless the TAVR was done so he could get the MVR.
 
Yup this patient was getting a TAVR or nothing. Surgical risk for SAVR too high.

MR didn’t really improve significantly, but it was pretty mild MR to begin with.
 
Hork Bajir said:
@sevoflurane just curious, what made you think that this was mobile calcium as opposed to myxoma/elastoma/etc?
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Density of the mass, the way it moves and location. Also... common things being common. Truth of the matter is that you don’t know until you get path back. But this looked like a calcium deposit to me.

Here is an example of a myxoma that came in this past year. Density and appearance are very different than what I presented.
 
Anyone tried out the new “3D glass” rendering option that comes with Philips’ valve package? It’s the next step in the evolution of their “true view” mode. I find it makes some really beautiful images- below is a still frame of a fenestrated secundum ASD from the POV of the RA. I’ll try to add some color clips later, which is where the 3D glass really shines (very nice for mapping PVLs since you can adjust the transparency of the tissue, allowing you to see the jet on both sides of the valve)

F6C846FE-EF0B-4208-B3A1-A0C592EB7766.jpeg
 
sevoflurane said:
Nice synopsis and differential @Hork Bajir . The big question of the case is to cancel or to proceed right? Everyone here is super smart and I get the feeling that nobody thinks that this mass is neither a vegetation or a thrombus which would lead us down the pathway of cancelling the case.

CFD was certainly non-impressive and reassuring as others mentioned above. Took an en face 3D clip to help in decision making. I feel that this is a rare presentation of a large calcium deposit near the posteromedial commissure and you make a valid point with the lack of shadowing. Although mobile (bad sign), I think the only reason it is mobile is because it is attached to A3 which you can clearly see in the 2d x-plane clip/3d en face. Finally, since we are doing a TAVR, we are not doing a transeptal puncture which would give me some reservation.

We decided to proceed and landed a nominal 29 mm Sapien 3 w/o any issues.
Documented a final 3D clip at the end of the case to show it did not embolize.

Nice job everyone.
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I may have missed this (didn't read the whole thread), but did anyone consider using a Sentinel device during the discussion?
 
Terrible and dilated RV, some sort of drainage cannula in the RA. Suggestion of significant TR but not well shown. Protek? Vortex? Arguably there is a McConnel’s sign with sparing of the RV apex
 
another case. all images post-CPB s/p AVR after pt was told TAVR was not feasible based on TAVR protocol CTA findings.

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vector2 said:
another case. all images post-CPB s/p AVR after pt was told TAVR was not feasible based on TAVR protocol CTA findings.

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9xtQVtU.gif

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So it seems they fixed the paravalvular leak but now that MR needs to be addressed. It seems to be a chronic problem because the LA looks dilated with high LA pressure. I'm curious about the mitral pre-bypass although maybe its secondary to that poor LV function.
 
Hork Bajir said:
Terrible and dilated RV, some sort of drainage cannula in the RA. Suggestion of significant TR but not well shown. Protek? Vortex? Arguably there is a McConnel’s sign with sparing of the RV apex
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Proteks are placed R IJ like a swan. This device is seen appearing from the IVC...
 
Hork Bajir said:
Terrible and dilated RV, some sort of drainage cannula in the RA. Suggestion of significant TR but not well shown. Protek? Vortex? Arguably there is a McConnel’s sign with sparing of the RV apex
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Twiggidy said:
ECMO venous cannula?
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This is an impella RP with inflow at the IVC/RA junction and outflow in the PA. Little bit tricky in the bicaval because you can't see the cannula continuing into the TV. This pt had severe post-op RV dysfunction coming off pump after AVR/CABG and required MCS. Impella was able to d/c'ed after 3 days and dobutamine continued.
 
Oh interesting, I haven’t seen any RPellas in person. They were using them at my current institution briefly, but stopped shortly before I begin fellowship because the mortality was upwards of 80%. Now it’s Protek, ECMO, or surgical Centrimag RVAD. What do you look for on echo to confirm proper positioning?
 
Hork Bajir said:
Oh interesting, I haven’t seen any RPellas in person. They were using them at my current institution briefly, but stopped shortly before I begin fellowship because the mortality was upwards of 80%. Now it’s Protek, ECMO, or surgical Centrimag RVAD. What do you look for on echo to confirm proper positioning?
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Yeah that is pretty interesting. I know an LV impella is 3.5-4 centimeters past the AV annulus so I wonder if that's the same distance past the triscuspid annulus?
 
Hork Bajir said:
Oh interesting, I haven’t seen any RPellas in person. They were using them at my current institution briefly, but stopped shortly before I begin fellowship because the mortality was upwards of 80%. Now it’s Protek, ECMO, or surgical Centrimag RVAD. What do you look for on echo to confirm proper positioning?
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Twiggidy said:
Yeah that is pretty interesting. I know an LV impella is 3.5-4 centimeters past the AV annulus so I wonder if that's the same distance past the triscuspid annulus?
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It's gotta be placed using fluoro w/wo TEE imo. Some folks you can pick up a really good ME Asc Ao SAX showing the main and R PA and some you can't. This lady didn't have great windows or else I would've included a shot of the impella pigtail at distal main PA or very proximal R or L PA which is where it should be terminating.
 
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Also I'd add that institutional mortality numbers for short term MCS can be a bit misleading regardless of which device you're talking about. More and more (as suspected) we're learning that you don't delay MCS, especially right heart support, until the the pt is maxed on inotropes and iNO and totally decompensating. We brought this lady back to ICU on some moderate dose epi and milrinone and pulled the trigger within hours to bring her back to the cathlab for impella when it looked like her CO/CI wasn't going to go in the right direction. I think early escalation and early RV rest (caveat being RA to PA MCS still creates significant afterload compared to direct ventricular unloading) really contributed to a good outcome.
 
vector2 said:
It's gotta be placed using fluoro w/wo TEE imo. Some folks you can pick up a really good ME AV SAX showing the main and R PA and some you can't. This lady didn't have great windows or else I would've included a shot of the impella pigtail at distal main PA or very proximal R or L PA which is where it should be terminating.
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oh ok....distal to the pulmonic valve. brain spasm. that makes 100% more sense
 
Twiggidy said:
Yeah that is pretty interesting. I know an LV impella is 3.5-4 centimeters past the AV annulus so I wonder if that's the same distance past the triscuspid annulus?
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I think for L sided impella, it depends on the type. For the CP and 5.0, both of which I believe have a pigtail, optimal distance is ~3.5cm past the AV. For the 5.5, sans pigtail, manufacturers recommend 5-6cm beyond the valve
 
sevoflurane said:
RV is of paramount importance. If you can't get blood to the LV (via RV ejection), then the LVAD will not work. When you start adding 1-2 l/m to the systemic circulation, that is 1-2 l/m extra flow that the RV suddenly is confronted with. It doesn't have a lot of time to accommodate for such a change in hemodynamics. Therefore, inhaled vasodilators and RV augmentation with volume and inotropes may be necessary. If these maneuvers don't work this may cause the RV to go into failure. One thing to keep in mind is that the RCA (supplies the RV) is anterior. Air tends to go down the RCA when coming off bypass. Furthermore, CPB doesn't protect the RV nearly as well as the LV. This only adds insult to injury when dealing with LVAD placement. Many of the the RVADS that are placed in practice are actually due to an LVAD that overwhelmed the RV leading to RV failure.


The "suckdown" phenomena is usually due to an underfiled LV causing the interventricular septum to get pulled towards the LV free wall. Doing this alters the geometry of the RV. Augmenting the geometry of the RV may equate to poor systolic performance AND tricuspid annulus dilatation leading to acute tricuspid regurgitation.


Here is a modified bicaval view showing this:

IMG_7335_zps10a137f9.jpg



If you see this coming off bypass you need to think: oh... oh... what can we do to make this better. :nurse:

The answer...? As weird as it sounds, reduce your flow rates on your LVAD and augment volume status. These maneuvers will return the RV to it's regular shape and hopefully increase RV unloading to the LV.

In addition to causing the suckdown phenomena, the inflow canulas can become obstructed. Check for this by using color Doppler and seeing laminar flow. You can also use CWD. Flows should be less than 2.5 m/s. Similarly, the outflow cannula (ascending aorta) should show slightly lower flows. 1-2 m/s.

AI is bad... LVAD worsens AI and therefore you may not achieve increased organ perfusion. You can create a partial closed loop from the ascending aorta back into the LV causing a volume overload problem. You need a competent valve. What are the choices?

1) Repair the valve.
2) Replace the valve and deal with higher morbidity/mortality. Never use mechanical valves. Always bioprosthetic ones.
3) Sounds crazy... but if it's destination therapy or bridge to transplant, you can surgically sew the aortic valve shut so that it doesn't open at all! 😱


Good stuff.
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Just saw this, but I want to emphasize how important it is to keep the RV happy. Surgeon have gone down two paths (that I’m aware of) with this regard. There are data from off-pump cabgs that show that staying off-pump can reduce risk of RV dysfunction. The are other data that shows that maintaining RV geometry also keeps it happy (so avoidance of full sternotomy/pericardiotomy.) Some surgeons even have tried combining both techniques.

Ive heard the analogy that the LV is like a dog, even if you insult it it’s gonna come back to you eventually. But, the RV is like a cat, if you insult it, you can’t be sure if it’ll ever come back.
 
vector2 said:
Lol I excitedly clicked on this bumped thread hoping you would
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A few good Mitral Clip cases earlier this week. I might dig ‘em up and post them.

Here is today’s case. Nothing crazy.

Anyone want to guess what is happening here?

 
Long story short, 40 y/o male with no significant past medical history admitted for weakness, fever/chills, and shortness of breath. TTE performed found a Mitral vegetation. TEE performed with some images below. Surgeon wants to know what he has to do and if he can do the case at a community hospital that does about 150-200 hearts per year, but no ECMO or other advanced capabilities available.

 
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