12.09.2013

TEE after Repair:Success or Failure ?

Frank LangerDepartment of Thoracic & Cardiovascular Surgery

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Careful TEEassessmentrequired !!!

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Evaluation of Mechanisms

AV-morphology ?Cusp configuration ?Calcification ?

ME SAX view, ME LAX view

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Evaluation of Mechanisms

AV-diameterSinus diameterSTJ-diameterAA-diameter

ME LAX view

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Evaluation of Mechanism

ME LAX view, ME SAX view

Grade of AR ? (jet width, VC)Jet direction ? (eccentric vs. central)Jet origin ?

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Critical 6 stepsof assessmentrequired !!!

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Residual Aortic Regurgitation

Step 1

Immediately afterremoval of X-clamp:LV-distension ???

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Residual Aortic Regurgitation

Step 2

Immediately afterremoval of X-clamp:LV ejection without volume loading is suggestive of significant AR

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Residual Aortic Regurgitation

Step 3

Immediately afterremoval of X-clamp:Confirm AV-morphology (ME LAX)

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Residual Aortic Regurgitation

Step 4

Immediately afterremoval of X-clamp:Evaluate residual AR (ME LAX, SAX):

degree (VC < 4mm) ?residual prolapse ?

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Residual Aortic Regurgitation

Step 5

Weaning from CPB:Wide amplitude of arterial pressurewith low diastole suggests significant AR

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Residual Aortic Regurgitation

Step 6

Weaning from CPB:AR I: Accept !AR II: Comorbidities ? Alternatives ? EH ?

AR III, IV: Optimize ? Replace ?

Edwards Workshop 12.09.2013

Frank Langer: TEE after Repair: Success or Failure

Conclusions

• Careful analysis of mechanisms is an essential step for successful repair.

• Standardized evaluation steps allow correct assessment of repair results.