Authors: Kumar R et al.
Source: Anesthesia & Analgesia, 142(1):85–92, January 2026,
This retrospective study evaluates a three-dimensional echocardiographic method for assessing mitral valve area (MVA) after transcatheter edge-to-edge repair (TEER), addressing a persistent challenge in intraprocedural imaging. Iatrogenic mitral stenosis is a recognized risk following TEER, particularly when multiple clips are required, but accurately quantifying MVA during the procedure is difficult. Conventional flow-based methods such as pressure half-time (PHT) are highly sensitive to hemodynamic conditions, which are substantially altered by general anesthesia, rendering intraprocedural measurements unreliable predictors of postprocedural valve function.
The authors introduce and test a three-dimensional orifice area (3DOA) technique using intraprocedural transesophageal echocardiography (TEE) to directly measure MVA under general anesthesia. MVAs obtained with TEE 3DOA were compared with MVAs derived from transthoracic echocardiography (TTE) PHT performed postprocedure in awake patients, which served as the reference standard. For comparison, conventional TEE PHT measurements obtained under general anesthesia were also analyzed.
In a cohort of 20 adult patients undergoing TEER with MitraClip for severe mitral regurgitation, TEE 3DOA measurements demonstrated excellent agreement with postprocedural TTE PHT measurements in awake patients. Bland–Altman analysis showed narrow limits of agreement, and concordance correlation was high, indicating strong alignment between intraprocedural 3DOA measurements and physiologic, awake-state MVA assessment. In contrast, TEE PHT-derived MVAs under general anesthesia correlated poorly with postprocedural awake measurements, with wide limits of agreement and weak concordance.
These findings highlight the limitations of flow-dependent echocardiographic measurements during TEER under general anesthesia and support the use of direct anatomic assessment with three-dimensional imaging. By minimizing the influence of anesthesia-related hemodynamic variability, the 3DOA technique offers a more reliable approach for intraprocedural evaluation of mitral valve area and early detection of clinically significant mitral stenosis before the procedure is completed.
Key Points
• Accurate intraprocedural assessment of mitral valve area after TEER is challenging due to anesthesia-induced hemodynamic variability.
• Three-dimensional orifice area measurement using TEE shows excellent agreement with postprocedural awake TTE measurements.
• Conventional pressure half-time measurements obtained under general anesthesia correlate poorly with awake-state valve area.
• A 3D echocardiographic approach may improve real-time decision-making and reduce the risk of iatrogenic mitral stenosis during TEER.
Thank you to Anesthesia & Analgesia for allowing us to summarize and discuss this important study.