TEE

[Robotic Wis-Hipple]

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This thread is awesome. Lots of great info on the finer points of MR and it’s medical vs surgical management. Clearly we have two sides making their cases by much smarter and more experienced pros than I.

I have but one mental exercise question;

If this Pt had flail MR clearly seen on TTE with the rest of her presentation being the same what’s her next step?

I think clearly medical management would be a continuum in reality and it’s not some board question of medically manage or surgically repair without doing anything medical. So, volume optimization, inotropic, and myocardial O2 support would occur but it’s a difference of booking her for repair tomorrow or not. I think the TEE does this, and so I think I’d have done it.

I will say no to mitraclip though 😉

 

[dchz]

What is the point of even replying to that guy. Claims to be a great ICU doc but doesnt do ICU and lets leave aside he said he hasnt looked after covid pt. Now he wants to tell everyone how to do cardiac anesthesia & surgery. Give me a break. Dude doesnt know 1 single thing about the mitral valve

What did he say, you cant diagnose primary MR until all causes of secondary are outruled? WTF? a P2 flapping in the wind can 100% be diagnosed and even coexist with secondary MR but still be repairable

hahaha, I respond to him because I still respect him.

There is always room for a contrarian, it keeps us grounded. I adamantly disagree with his medical opinion though. I respond because if he's talking past all the details I entailed, someone else reading this also might be confused. So there is also the altruistic component of responding to the masses as well. This instance I think he was slightly over zealous. After I said all there needs to be said to make my points as clear as I can be. I respectfully stopped replying 🙂

 

[dchz]

If this Pt had flail MR clearly seen on TTE with the rest of her presentation being the same what’s her next step?

If she's pretty symptomatic I think we can safely assume severe MR 2/2 primary defect. I would take her to OR and confirm on TEE before we cut.

If you don't see the clear defect on TTE and you see severe secondary MR, you have a discussion with cardiologist and surgeon.

I don't understand how the anecdote about fluoro negates its utility since (in my amateur opinion) it seems that it's gotta be a significant volume of blood refluxing retrograde during an LV gram to be able to pick up angiographic pulmonary vein blush. Regardless though, the hallmark of holosystolic pulmonary vein flow reversal isn't that it's sensitive- it's that it's a pretty specific marker of severe mitral regurgitation.

View attachment 307967

I mean just exactly that is highlighted. It's not sensitive. So if you use it to rule out MR you get burned, but I've seen several people say "no S wave reversal so therefore no severe MR." That's not a true statement.

I will say no to mitraclip though 😉

20 years ago people said the same to TAVR.

If you can throw an Alfieri stitch without open procedure and it buys the pt 10 years, why not?

 

[vector2]

I mean just exactly that is highlighted. It's not sensitive. So if you use it to rule out MR you get burned, but I've seen several people say "no S wave reversal so therefore no severe MR." That's not a true statement.

Yeah, if anyone has been using PV S-wave as a sensitivity marker then that is obviously wrong and has been for a long time. In my original post, I said that that is one of the things I use as supporting information (aka to make the diagnosis by adding specificity). I consider PW S-wave reversal with its high specificity to be the specificity yang to the E<A-wave sensitivity ying (Grade I diastolic inflow pattern or E clearly < A rules out severe MR with near 100% sensitivity).

Say for instance a pt has MR with an obvious coaptation defect with color off, a jet area with color on that that looks severe (the eyeball tests) and a 2d VC of 0.7 cm. All those things are relatively insensitive (in comparison to say 3d echo or magnetic resonance) for severe MR. Now, say in this same patient I sample the PV and there is dense contour holosystolic reversal of flow with PW. Would you not feel comfortable stating that the likelihood of severe MR is very high with just that information alone?

 

[vector2]

If this Pt had flail MR clearly seen on TTE with the rest of her presentation being the same what’s her next step?

Again, there is no question whatsoever as to what to do if her main problem is acute symptomatic severe non-ischemic primary MR. She is going for surgery. That much is made very clear by ACC/AHA and ESC/EACTS guidelines. Obviously medical stabilization is going on here during the period where the patient is getting admitted to ICU, diagnoses made, consults placed etc, but that medical stabilization should solely be in the furtherance of getting her to surgery as quickly as possible. I agree with dchz that you should just take her to the OR to do a TEE exam


"Urgent surgery is indicated in patients with acute severe mitral regurgitation. In the case of papillary muscle rupture as the underlying disease, valve replacement is in general required. "

2017 ESC/EACTS Guidelines for the management of valvular heart disease

The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery

academic.oup.com

"The principal intervention for primary MR is surgery; transcatheter mitral valve repair using an edge-to-edge clip plays a very limited role. In contrast, surgical treatment for secondary MR should be considered only after appropriate medical and device therapies have been instituted. Whenever feasible, mitral valve repair is strongly preferred over mitral valve replacement for primary MR. "

2017 ACC Expert Consensus Decision Pathway for Mitral Regurgitation - American College of Cardiology

David S. Bach, MD, FACC

www.acc.org

 

[deleted171991]

If she's pretty symptomatic I think we can safely assume severe MR 2/2 primary defect. I would take her to OR and confirm on TEE before we cut.

Read that again. What have you done to dchz, the logical thinker? Oh, wait, you put him through a knee jerk cardiac anesthesia fellowship. How about severe MR due to fluid overload and coronary ischemia?

The difference between you and me is that I've already seen a number of wrong diagnoses in unoptimized patients, even in only a few years of ICU. I've even seen Ivy League-trained attendings fall into that trap. Then I waltz in during my ICU week, optimize the patient, and suddenly the "ARDS" or the "atypical" pneumonia, or the "probable stroke" just disappear. And it's usually some very common-sense intervention, such as intensive diuresis, or eliminating some medications. I swear to you, the greatest pathological mechanism in America is iatrogenesis.

In the rush to automatically do what they have been taught, people forget about First Do No Harm, and about the possibility that they are dealing with the results of other doctors' mistakes; I usually start exactly from those (goes well with my cynicism and opinion of the world).

The fact that I was so right in this case (about what was going on here), should make you wonder whether I may be somewhat right about those two rules, too. Or I may just be very lucky. As in "severe primary luck". I am betting on the secondary causes. 🙂

 

[Robotic Wis-Hipple]

Again, there is no question whatsoever as to what to do if her main problem is acute symptomatic severe non-ischemic primary MR. She is going for surgery. That much is made very clear by ACC/AHA and ESC/EACTS guidelines. Obviously medical stabilization is going on here during the period where the patient is getting admitted to ICU, diagnoses made, consults placed etc, but that medical stabilization should solely be in the furtherance of getting her to surgery as quickly as possible. I agree with dchz that you should just take her to the OR to do a TEE exam


"Urgent surgery is indicated in patients with acute severe mitral regurgitation. In the case of papillary muscle rupture as the underlying disease, valve replacement is in general required. "

2017 ESC/EACTS Guidelines for the management of valvular heart disease

The Task Force for the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery

academic.oup.com

"The principal intervention for primary MR is surgery; transcatheter mitral valve repair using an edge-to-edge clip plays a very limited role. In contrast, surgical treatment for secondary MR should be considered only after appropriate medical and device therapies have been instituted. Whenever feasible, mitral valve repair is strongly preferred over mitral valve replacement for primary MR. "

2017 ACC Expert Consensus Decision Pathway for Mitral Regurgitation - American College of Cardiology

David S. Bach, MD, FACC

www.acc.org

This is literally my point. That’s my reason for the thought experiment.

If on day 7 of this patient’s presentation that TTE shows a flail leaflet it’s do what you can to optimize volume status and perfusion while figuring out which OR block she goes to.

So, in the setting of a decompensated regurgitant lesion and pulmonary edema if you have a test that answers that question I think you do it. I mean if it’s negative you keep doing what you’ve been doing, but if positive you take corrective action. If anything the fact this patient has been being medically managed for 6-7 days without significant change (I may argue worsening based on reported EF and implied primary pathology of the mitral valve as well as failure to improve on conservative therapy) increases my desire to rule out primary pathology not corrected by staying the course.

My entire point was that you got the TTE to do this rule in/out and it failed. You did it for the reason of proving the need or lack of need for surgical correction, so follow that same line of thought in the utility of getting the TEE.

 

[MoMoGesiologist]

Read that again. What have you done to dchz, the logical thinker? Oh, wait, you put him through a knee jerk cardiac anesthesia fellowship. How about severe MR due to fluid overload and coronary ischemia?

The difference between you and me is that I've already seen a number of wrong diagnoses in unoptimized patients, even in my less than 5 years of ICU. I've even seen Ivy League-trained attendings fall into that trap. Then I waltz in during my ICU week, optimize the patient, and suddenly the "ARDS" or the "atypical" pneumonia, or the "probable stroke" just disappear. And it's usually some very common-sense intervention, such as intensive diuresis, or eliminating some medications. I swear to you, the greatest pathological mechanism in America is iatrogenesis.

In the rush to automatically do what they have been taught, people forget about First Do No Harm, and about the possibility that they are dealing with the results of other doctors' mistakes; I usually start exactly from those (goes well with my cynicism and opinion of the world).

The fact that I was so right in this case (about what was going on here), should make you wonder whether I may be somewhat right about those two rules, too. Or I may just be very lucky. As in "severe primary luck". 🙂

And yet here we are, people adamantly arguing this patient needs a TEE and balloon pump and valve replacement, despite the fact patient got better on diuresis alone...

 

[Hork Bajir]

Some of the egos on this thread are over the top. I look at this case as an example of how complex medical decision making can be in 2020, and as more evidence that even the smartest and best educated of us can only guess at the correct course of action. Inevitably we’ll all be wrong some portion of the time (even you @FFP).

 

[deleted171991]

Some of the egos on this thread are over the top. I look at this case as an example of how complex medical decision making can be in 2020, and as more evidence that even the smartest and best educated of us can only guess at the correct course of action. Inevitably we’ll all be wrong some portion of the time (even you @FFP).

The only person who always thinks he's right is the pathological kind. You know, Trump.