Results
A total of 200 patients with a surgical score underwent pre-bypass TEE scoring. Sixty-seven patients (34%) were surgically scored in the simple group, 92 patients (46%) in the intermediate group, and 41 patients (21%) in the complex group. Echocardiographically, 64 patients (32%) were scores in the simple group, 102 patients (51%) in the intermediate group and 34 patients (17%) in the complex group.
Overall, transesophageal echo scores were slightly lower (2[1,3]) than surgical scores (3[1,4]). The within-subject difference between TEE and surgical score was 0 [-1, 1]); p=0.759). Overall, agreement was 66% between the scoring methods, with a moderate kappa statistic (0.46). Considering the surgical scores as the “gold standard,” 70%, 71% and 46% of the simple, intermediate, and complex surgical scores were correctly evaluated by TEE, respectively (Table 2, Figure 2). Furthermore, when the simple and intermediate groups were combined to determine non-complex vs complex scores, the kappa was 0.36; sensitivity of the complex score was 0.46 and specificity was 0.91.
Amongst the various culprit lesions, posterior leaflet dysfunction and A2 prolapse were easiest to identify with TEE and had the highest agreement with surgical scoring. Agreement between TEE and surgical scoring for P1 prolapse was 79% (kappa 0.55), for P2 was 96% (kappa 0.8), for P3 was 77% (kappa 0.51), and for A2 was 88% (kappa 0.6). Mitral annular calcification (MAC) (92%, kappa 0.56) and any leaflet restriction (96%, kappa 0.41) had moderate agreement between the TEE and surgical scores. The lowest agreement occurred in the setting of A1 prolapse (kappa 0.05) and prolapse of the posteromedial commissure (kappa 0.14) (Figure 3). When significant disagreement was present, the TEE scores were more likely to rate the valve with a higher complexity compared to the surgical scores. McNemar’s test was significant for P1 prolapse (p=0.005), A1 prolapse (p=0.025), A2 (p=0.041), and posteromedial commissure prolapse (p<.0001).