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Table of Contents
Year : 2012  |  Volume : 15  |  Issue : 2  |  Page : 111-117
Pre-operative Tei Index does not predict left ventricular function immediately after mitral valve repair

1 Department of Anaesthesiology and Intensive Care Medicine II, Heartcentre, University Leipzig, Strümpelstraße 39, 04289 Leipzig, Germany
2 Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Germany
3 Hospital for Anaesthesiology and Intensive Care, University Leipzig, Germany

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Date of Web Publication16-Apr-2012


Echocardiographic assessment of systolic left ventricular (LV) function in patients with severe mitral regurgitation (MR) undergoing mitral valve (MV) repair can be challenging because the measurement of ejection fraction (EF) or fractional area change (FAC) in pathological states is of questionable value. The aim of our study was to evaluate the usefulness of the pre-operative Tei Index in predicting left ventricular EF or FAC immediately after MV repair. One hundred and thirty patients undergoing MV repair with sinus rhythm pre- and post-operatively were enrolled in this prospective study. Twenty-six patients were excluded due to absence of sinus rhythm post-operatively. Standard transesophageal examination(IE 33,Philips,Netherlands) was performed before and after cardiopulmonary bypass according to the guidelines of the ASE/SCA. FAC was determined in the transgastric midpapillary short-axis view. LV EF was measured in the midesophageal four- and two-chamber view. For calculation of the Tei Index, the deep transgastric and the midesophageal four-chamber view were used. Statistical analysis was performed with SPSS 17.0. values are expressed as mean with standard deviation. LV FAC and EF decreased significantly after MV repair (FAC: 56±12% vs. 50±14%, P<0.001; EF: 58±11 vs. 50±12Έ P<0.001). The Tei Index decreased from 0.66±0.23 before MV repair to 0.41±0.19 afterwards (P<0.001). No relationship between pre-operative Tei Index and post-operative FAC or post-operative EF were found (FAC: r=−0.061, P=0.554; EF: r=−0.29, P=0.771). Conclusion: Pre-operative Tei Index is not a good predictor for post-operative FAC and EF in patients undergoing MV repair.

Keywords: Doppler echocardiography, intraoperative transesophageal echocardiography, left ventricular function, mitral regurgitation, mitral valve repair, Tei Index

How to cite this article:
Mukherjee C, Groeger S, Hogan M, Scholz M, Kaisers UX, Ender J. Pre-operative Tei Index does not predict left ventricular function immediately after mitral valve repair. Ann Card Anaesth 2012;15:111-7

How to cite this URL:
Mukherjee C, Groeger S, Hogan M, Scholz M, Kaisers UX, Ender J. Pre-operative Tei Index does not predict left ventricular function immediately after mitral valve repair. Ann Card Anaesth [serial online] 2012 [cited 2022 Nov 29];15:111-7. Available from:

First and Second author had equally contributed for the development of this article

   Introduction Top

Surgical mitral valve (MV) repair is superior to conservative treatment in patients with significant mitral regurgitation (MR). [1],[2] Because of the reduced afterload and increased preload present in patients with MR, parameters such as ejection fraction (EF) and fractional area change (FAC) are prone to overestimate left ventricular (LV) systolic function. [3] The Tei Index or Myocardial Performance Index (MPI) with a mean value of 0.39±0.05 for the left ventricle is a simple Doppler-derived index combining systolic and diastolic ventricular function, and has been reported to have good correlation to invasive measurement of LV systolic and diastolic functions. [4],[5] Recent studies have questioned the proposed load independence of the Tei Index as an assessment of LV function. Two studies reported that Tei Index does not change in patients undergoing MV repair. [6],[7] They concluded that Tei Index is a good predictor for LV function after MV repair, whereas different clinical studies decisively assigned the dependence from changes in pre- and afterload. [8],[9] In our present study, we aimed to test the hypothesis that pre-operative Tei Index predicts post-operative FAC and EF in patients undergoing surgery with severe MR.

   Materials and Methods Top

After approval of the local ethics committee (registration number 007-09) and patients' written informed consent, 130 patients with sinus rhythm undergoing elective surgical MV repair were enrolled in this prospective study. Patients not in sinus rhythm at the end of the operation were subsequently excluded (n=26). After induction of anesthesia, a comprehensive TOE examination (iE 33 or Sonos 5500; Philips, Amsterdam, The Netherlands) was performed according to the ASE/SCA guidelines. [10] Post MV repair, another comprehensive TOE examination was performed after successful weaning from cardiopulmonary bypass. Both examinations were digitally stored and evaluated offline. MR was quantified by measurement of the vena contracta, [11] the FAC was calculated in the transgastric midpapillary short-axis view, the EF was measured according to modified Simpson's rule in the midesophageal four- (ME 4Ch) and two (ME 2Ch)-chamber view. The time interval from cessation of mitral inflow in one cardiac cycle to the onset of mitral inflow in the subsequent cardiac cycle was measured using Doppler examination of the transmitral inflow in the ME four-chamber view [Figure 1]a, "a". This includes isovolumetric contraction time (ICT), ejection time (ET) and isovolumetric relaxation time (IRT). ET was determined in the deep transgastric view [Figure 1]b, "b" using Doppler examination of the aortic flow. The mean value of three consecutive heart beats was calculated. The myocardial performance index (MPI) was then calculated according to the original equation of Tei et al.: a-b/b. [4] All measurements were performed before and after cardiopulmonary bypass. For statistical analysis, SPSS 17.0 software (SPSS Inc., Chicago, IL, USA) was used. All continuous variables were expressed as mean (SD). Comparison of paired variables was calculated by using the Students paired-samples t test. Correlation between independent variables was analyzed by calculating Pearsons correlation coefficient. For comparison of paired variables between different groups, "Analysis of variance between groups" (ANOVA) with Greenhouse-Geisser correction was performed. A P value of <0.05 was considered as statistically significant.
Figure 1: Measurement of Tei Index by pulsed Doppler of mitral and pulsed wave Doppler of aortic flow. Interval "a", from Doppler A to E wave, was measured in the midesophageal four-chamber view. Interval "b" was measured in deep transgastric view. Tei Index was then calculated by (a-b)/b

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   Results Top

Demographic data of the patients undergoing MV repair are listed in [Table 1]. The majority of the patients were classified either NHYA I or II. Intraoperative inotropic support was needed in 21 patients. Residual MR was detected in 16 patients. Pre- and post-operative echocardiographic findings of all patients are summarised in [Table 2]a. There was no difference between pre- and post-operative systolic and diastolic blood pressure. Heart rate was significantly higher after surgery (58±13 to 79±15 beats/min). Both parameters of LV systolic function significantly decreased after MV repair (FAC pre-operatively 58±11 to 50±12 after MV repair, P<0.001; EF pre-operatively 56±1 to 50±1 after MV repair, P<0.001). Tei Index was significantly lower after surgery (pre-operatively 0.66±0.23 to 0.41±0.19 after MV repair, P<0.001). There was no correlation between pre-operative Tei Index and post-operative FAC [Figure 2]a; r=−0.061, P=0.554] or post-operative EF [Figure 2]b; r=−0.29, P=0.771) in the whole study group.According to the recommendations for chamber quantification, we divided the patients into two subgroups depending on pre-operative EF (group I, EF≤55%, n=36; group II, EF>55%, n=68). T. [12] Time intervals in the subgroups did not differ from the whole study population [Table 3]. Tei Index and its correlation to post-operative FAC and EF are shown in the Table in [Figure 2]c-e. Similar to the entire study group, no correlations between Tei Index and FAC or EF were found in these groups [Figure 2]c-e.
Figure 2: Relationship between pre-operative Tei Index and post-operative fractional area change [Figure 2a] and post-operative ejection fraction (EF) [Figure 2b] in the total study population (n=104). Relationship between pre-operative Tei Index and post-operative fractional area change and to ejection fraction in group I (EF≤55, Figure 2c and 2d; n=36). Relationship between pre-operative Tei Index and post-operative fractional area change and post-operative ejection fraction in group II (EF≤55, Figure 2e and 2f; n=68). Inserted are the linear fit lines with the upper and lower 95% confidence limits. FAC- Fractional area change; EF- Ejection fraction

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Table 1: Demographic data (n=104)

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Table 2 a-c: Hemodynamics and echocardiographic findings in the total study population (Table 2a, n=104), concerning intraoperative inotropic [Table 2b] and concerning residual mitral regurgitation after mitral valve repair [Table 2c]

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Table 3: Time intervals and Tei Index in the subgroups selected from the total study population by pre-operative ejection fraction (EF)

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There was no influence of inotropic support on Tei Index in our patient population, as demonstrated in [Table 2]b. The decrease in Tei Index was not significantly different (0.25 without vs. 0.22 with inotropic support, P=0.576). In patients with residual MR, Tei Index decreased significantly after surgery [[Table 2]c, 0.63±0.27 vs. 0.46±0.21, P=0.04] without significant difference to the patients without residual MR (0.17 vs. 0.25, P=0.148).

   Discussion Top

In our study, no correlation could be found between pre-operative Tei Index and post-operative FAC or EF. All three parameters decreased significantly immediately after MV repair. The decrease of FAC and EF indicates a worsening of the LV function, whereas a decrease in Tei Index would indicate a better LV function. This is in contrast to previous published studies showing a correlation between pre-operative Tei Index and post-operative FAC and EF. [6],[7]

Loading conditions in patients with severe MR are markedly modified with an increase in preload and a decrease in afterload. These changes lead to a decrease in ET and an increase in Tei Index, whereas the sum of ICT and IRT remain unchanged or is even prolonged compared with healthy individuals. [13] Our study population had a pre-operative mean ET of 274 ms as compared with a mean ET of 292 ms in the study of Mabrouk et al. (patients n=25). [6] Unfortunately, the pre-operative mean ET was not mentioned in the study of Takasaki (n=108), who also described the predictive value of Tei Index for ventricular dysfunction after MV repair. But, in contrast to the present study and the study of Mabrouk et al., the echocardiographic examination in the study of Takasaki was performed 9±27 days before and 4±3 days after the surgery. This could have a major impact because changes in pre- and afterload due to anesthesia cannot be excluded in intraoperative studies.

Unlike the patients of Mabrouk with a pre-operative Tei Index of 0.46 and the patients of Takasaki with a pre-operative Tei Index of 0.5, our study population had a pre-operative Tei Index of 0.66. Our findings are concordant with studies from Haque [14] and Al Mukhaini, [15] who also described pre-operative elevated Tei Indices in patients with significant MR.

The post-operative Tei Index in the present study decreased significantly from 0.66 to 0.41 in contrast to the study of Mabrouk et al., where it remained unchanged (0.46 vs. 0.47). A decrease of the Tei Index with changing afterload conditions is described in animal studies with normal and abnormal hearts. [8],[16] Haque showed that the Tei Index increases in patients with severe aortic stenosis after aortic valve replacement where the afterload was markedly reduced due to the operation. [14]

In contrast to Mabrouk et al., inotropic support was no exclusion criteria in our study. We observed similar changes in pre- and post-operative Tei index in patients who did not receive inotropic support compared with patients who were subjected to inotropic support (-0.25 vs. -0.22, P=0.576).

We found that absolute time of "a" decreased significantly (447±49 to 375±45, P<0.001) whereas the absolute time of "b" remained unchanged (274 ms±36 ms to 269 ms±31 ms, P=0.238) in our patients. That means that ratio of the ET to the duration of systole was significantly increased. The study of Lind et al. [5] is indirectly supporting this statement. He found afterload to be a significant determinant of MPI. The unchanged time interval "a" might be explained as the majority of our patients were classified NHYA I and II and diastolic dysfunction may not be present at the time of intervention.

The higher post-operative heart rate in our patients (58 beats/min pre-operatively vs. 79 beats/min post-operatively) should not have an influence on the Tei Index. Stack et al. reported that time intervals do not need correction for heart rate within a wide range of normal (50-110) beats/min. [17]

As depressed EF in patients suffering from MR usually represents advanced myocardial dysfunction, we divided the patients according to the recommendations for chamber quantification into subgroups with normal EF (>55%) or abnormal EF (<55%). [12] There were no significant differences between the two subgroups.

Nevertheless, our conflicting findings may be owed to the fact that most patients were classified as NYHA I or II, implying that they were relatively free from symptoms. According to Gaasch et al., patients remain free of symptoms at early stages and become symptomatic as LV remodelling progresses and hemodynamics deteriorate. [3]

The decrease in Tei Index expresses an improvement in global LV function, and might be due to an isolated amelioration in diastolic function, without alteration in the systolic component.

Study limitations

The echocardiographic measurements were performed under general anesthesia. This reflects the clinical reality of intraoperative echocardiography, but alterations of loading conditions due to general anesthesia should always be borne in mind in interpreting intraoperative echocardiography findings. This is however true for the pre-operative as well as for the post-operative examination, and therefore the relevance of this effect could be somewhat negated. An individual difference in response to cardioplegia on myocardial performance may also considerably effect post-operative LV function and therefore could have influenced the post-operative examinations; however, this also reflects the clinical scenario. Finally, we did not perform a follow-up post-operative echocardiographic examination to investigate for any remodelling effect of the left ventricle following MV repair, and this could also yield interesting results.

   Conclusion Top

In our study population, there was no correlation between pre-operative Tei Index and post-operative FAC or post-operative EF. Hence, we conclude that pre-operative Tei Index is not a good predictor for post-operative FAC or EF in patients with mitral insufficiency undergoing surgical repair in an intraoperative setting.

   References Top

1.Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, Detaint D, Capps M, Nkomo V, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005;352:875-83.  Back to cited text no. 1
2.Yotsumoto G, Sakata R, Ueno T, Iguro Y, Kinjo T, Kobayashi A, et al. Late development of mitral regurgitation after left ventricular reconstruction surgery. Ann Thorac Cardiovasc Surg 2005;11:159-63.  Back to cited text no. 2
3.Gaasch WH, Meyer TE. Left ventricular response to mitral regurgitation: Implications for management. Circulation 2008;118:2298-303.  Back to cited text no. 3
4.Tei C. New non-invasive index for combined systolic and diastolic ventricular function. J Cardiol 1995;26:135-6.  Back to cited text no. 4
5.Lind L, Andren B, Arnlov J. The Doppler-derived myocardial performance index is determined by both left ventricular systolic and diastolic function as well as by afterload and left ventricular mass. Echocardiography 2005;22:211-6.  Back to cited text no. 5
6.Mabrouk-Zerguini N, Leger P, Aubert S, Ray R, Leprince P, Riou B, et al. Tei index to assess perioperative left ventricular systolic function in patients undergoing mitral valve repair. Br J Anaesth 2008;101:479-85.  Back to cited text no. 6
7.Takasaki K, Gillinov AM, Yamano T, Matsumura Y, Toyono M, Shiota T. Detection of left ventricular dysfunction with Tei index in normal ejection fraction patients with mitral regurgitation before mitral valve surgery. Am J Cardiol 2009;103:1011-4.  Back to cited text no. 7
8.Cheung MM, Smallhorn JF, Redington AN, Vogel M. The effects of changes in loading conditions and modulation of inotropic state on the myocardial performance index: Comparison with conductance catheter measurements. Eur Heart J 2004;25:2238-42.  Back to cited text no. 8
9.Haney MF, A'Roch R, Johansson G, Poelaert J, Biber B. Beat-to-beat change in "myocardial performance index" related to load. Acta Anaesthesiol Scand 2007;51:545-52.  Back to cited text no. 9
10.Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB, et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: Recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999;89:870-84.  Back to cited text no. 10
11.Grayburn PA, Fehske W, Omran H, Brickner ME, Lüderitz B. Multiplane transesophageal echocardiographic assessment of mitral regurgitation by Doppler color flow mapping of the vena contracta. Am J Cardiol 1994;74:912-7.  Back to cited text no. 11
12.Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, et al. Recommendations for chamber quantification: A report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440-63.  Back to cited text no. 12
13.Eckberg DL, Gault JH, Bouchard RL, Karliner JS, Ross J Jr. Mechanics of left ventricular contraction in chronic severe mitral regurgitation. Circulation 1973;47:1252-9.  Back to cited text no. 13
14.Haque A, Otsuji Y, Yoshifuku S, Kumanohoso T, Zhang H, Kisanuki A, et al. Effects of valve dysfunction on Doppler Tei index. J Am Soc Echocardiogr 2002;15:877-83.  Back to cited text no. 14
15.Al-Mukhaini M, Argentin S, Morin JF, Benny C, Cusson D, Huynh T. Myocardial performance index as predictor of adverse outcomes following mitral valve surgery. Eur J Echocardiogr 2003;4:128-34.  Back to cited text no. 15
16.Lavine SJ. Index of myocardial performance is afterload dependent in the normal and abnormal left ventricle. J Am Soc Echocardiogr 2005;18:342-50.  Back to cited text no. 16
17.Stack RS, Lee CC, Reddy BP, Taylor ML, Weissler AM. Left ventricular performance in coronary artery disease evaluated with systolic time intervals and echocardiography. Am J Cardiol 1976;37:331-9.  Back to cited text no. 17

Correspondence Address:
Joerg Ender
Department of Anaesthesiology and Intensive Care Medicine II, Heartcentre, University Leipzig, Struempellstr. 39, 04289 Leipzig
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.95073

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