DK2985_C000 1..28 - AlSharqia Echo Club

392 Transesophageal Echocardiography(A)(B)LARALVVEGETATIONRV(C)(D)VEGETATIONFigure 17.12 A 64-year-old man is scheduled for mitral valve replacement. (A–C) Eccentric mitral regurgitation is due to endocarditisshown in this mid-esophageal four-chamber view: a vegetation with a mobility score of 4 is present on the tip of A2 segment. (D)Intraoperative findings show a vegetation attached to the anterior leaflet at the junction of A1 and A2 (LA, left atrium; LV, left ventricle;RA, right atrium; RV, right ventricle). (Photo D courtesy of Dr. Michel Pellerin.)Two diagnostic pitfalls were mentioned by these authors:first, when a large P2 scallop prolapse extends on mostof the posteromedial commissural area, the adjacent P3is also, erroneously, identified as prolapsing. As the midesophagealfour- and two-chamber views often transsectthe middle and lateral scallops close to P2, P2 may be mistakenfor either P1 or P3. This could be avoided by usingthe commissural and the long-axis view instead. The otherfrequent misdiagnosis is failing to diagnose the prolapseof a scallop or a segment opposite to a more obviouslyprolapsing one.1. Complexity of Lesion and Relationship to RepairNonrheumatic posterior leaflet prolapse due to degenerativemitral valve disease or ruptured chordae tendinae ismost often amenable to surgical repair. However, this ismore difficult with involvement of the anterior leaflet,presence of rheumatic or ischemic disease as well as calcificationsof the leaflets or annulus. In a report of 286patients with MR, the feasibility of repair was found tobe dependent on the mechanism, being higher in the posteriorleaflet disease or flail group (88%) than the anteriorleaflet disease or flail group (59%) or the severe bileafletchordal rupture group (29%) (25). Calcifications of theannulus significantly complicate mitral repair. Theyappear as echo-dense structures with acoustic shadowing,most commonly located in the posterior atrioventriculargroove with a typical C-shape distribution between 10and 2 o’clock in the transgastric short-axis view.D. Ischemic Mitral Valvular DiseaseIschemic mitral regurgitation (IMR) can be simply definedas the occurrence of MR in a clinical context of myocardialischemia. It accounts for 13–30% of MV surgery.Four clinical settings are generally recognized: papillarymuscle rupture, regurgitation in the setting of acute myocardialinfarction, regurgitation due to reversible ischemiawith preserved overall left ventricular systolic function,and regurgitation associated with end-stage ischemic