Significant residual MR after a cardiac operation may portend a less favorable survival after operation. Patients presenting for MV surgery may have MR due to many causes. The surgeon may elect to repair or replace the valve dependent on the pathology of the valve, some disease states being more amendable to repair than others. The anesthesiologist's contributions start with the identification of the type of valvular disease process (annular dilatation, restriction of leaflets, perforated leaflets, prolapsed leaflets, vegetations, etc.). These pathologies may arise from disease states such as myxomatous disease, rheumatic disease, torn chordae tendonae, ischemic cardiomyopathy, infectious processes and papillary muscle infarction.. It is next important to identify the severity of the MR under appropriate loading conditions as well as to identify the specific location of the MR jet.

The same considerations apply to the patient who presents for CABG surgery with incidental mitral regurgitation. Significant MR after a revascularization procedure can also contribute to a less favorable outcome. Patients with greater amounts of MR should have a survival benefit of repairing or replacing the mitral valve at operation for CABG. It therefore becomes important to identify the MR before cardiopulmonary bypass, assess its severity and recognize the type of disease process. This will aid the surgeon in the decision to repair or replace a diseased MV.

Lambert et al have set forth to educate us in how to perform such an analysis in a logical and consistent manner which facilitates communication with the surgeon. They start with a methodical anatomical examination of the MV, identifying the various portions of the MV, using the same nomenclature that the surgeons do. They proposed a consistent exam and then applied their approach in the OR in a prospective manner in patients presenting with moderately severe or severe MR. The diagnosis by TEE was compared to the intraoperative findings by the surgeon.

Lambert et al compared their prospective results using this system to a retrospective group of patients having similar surgery and being cared for by the same group of experienced anesthesiologists. They found that their methodical approach to MV analysis led to fewer and less serious errors in diagnosis of the pathology of the MR at surgery. Some limitations of this study are that a retrospective groups of tapes were used as a control group, that the study number is low and that the two groups of patients were not identical with respect to the types of procedures done. However, the results appear convincing and logical.

Drs. Savage and Cosgrove (cardiac anesthesiologist and surgeon at the Cleveland Clinic) wrote an editorial, which accompanies this article. They reinforce the need for a unified approach to the TEE examination of the mitral valve citing the necessity of accurate use of terminology about the MV between anesthesiologist and surgeon.

This excellent study both expands our knowledge of how to diagnose MV disorders and enhances our communication skills and interactions with our surgical colleagues as they come to be more dependent on our skills in TEE.