Value of Systolic Pulmonary Venous Flow Reversal and Color Doppler Jet Measurements Assessed With Transesophageal Echocardiography in Recognizing Severe Pure Mitral Regurgitation

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Abstract

We evaluated the value of color and pulsed Doppler transesophageal echocardiographic parameters and of V waves in estimating the severity of mitral regurgitation (MR) in 62 consecutive patients (38 men and 24 women, aged 39 to 80 years) with angiographically proven chronic pure MR (15 grade I/II, 47 grade III/IV). Twenty patients were examined before cardiac surgery under general anesthesia. Sensitivity, specificity, and positive and negative predictive values of systolic pulmonary venous flow reversal for the presence of grade III/IV MR were 87%, 93%, 98%, and 64%, respectively; these were for jet areas ≥8.0 cm2—66%, 100%, 100%, and 48%, for jet lengths ≥50 mm—70%, 87%, 94%, and 48%, for enlarged V waves—86%, 38%, 83%, and 43%, and for either flow reversal or a jet area ≥8.0 cm2—96%, 93%, 98%, and 88%. We conclude that a combination of measurements improved the negative predictive value considerably, which is of importance in a population with a high pretest probability of severe MR. Enlarged V waves are not reliable in predicting severe MR. The optimal cutoff value for jet area and jet length was lower in anesthesized patients than in conscious patients; in anesthesized patients, sensitivity, specificity, and positive and negative predictive values of jet area ≥5.0 cm2 for grade III/IV MR were 67%, 100%, 100%, and 50%, respectively; these were 87%, 100%, 100%, and 71% for flow reversal. Because the results of mitral repair are often evaluated with transesophageal echocardiography during surgery, our findings have clinical implications for evaluation of severe MR in anesthesized patients: pulmonary venous flow direction is the first-choice measure; jet area can be used when a low cutoff point is chosen. (Am J Cardiol 1996;78:444–450)

Section snippets

METHODS

The study group consisted of 62 consecutive patients (38 men and 24 women, aged 38 to 80 years, mean 61) with angiographically proven chronic MR, accepted for mitral valve surgery (n = 32), aortic valve surgery (n = 7), or coronary artery bypass surgery (n = 23) during a 10-month period, and who underwent preoperative TEE for (concomitant) mitral valve surgery because of MR. The interval between angiography and echocardiography was <2 months. Informed consent was obtained from all patients and

RESULTS

Cineangiography: Three patients had grade I, 12 grade II, 26 grade III, and 21 grade IV MR. Because distinguishing between mild/moderate and severe MR is of clinical importance, we concentrated our analysis on 2 groups: 15 patients with grade I/II MR and 47 patients with grade III/IV MR.

Pulmonary venous flow pattern: Systolic pulmonary venous flow reversal was not found in grade I patients, in 1 grade II patient (8%), in 21 grade III patients (81%), and in 20 grade IV patients (95%), and was

DISCUSSION

Pulmonary venous flow: The present study underlines the value of flow reversal in identifying patients with severe MR. This is in agreement with previous studies.1, 2, 3, 4 Flow reversal was very capable of distinguishing grade I/II from grade III/IV MR, but not of distinguishing grade III from grade IV MR. This contradicts the results of Klein et al[2] but is in agreement with the study of Lai et al.[4] Neither Klein nor Lai differentiated between pansystolic and late systolic flow reversal.

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