Preoperative assessment of mitral valve prolapse and chordae rupture using real time three-dimensional transesophageal echocardiography

Background: Mitral valve (MV) repair provides a better outcome in patients with significant mitral regurgitation than MV replacement. Valve repair requires a thorough understanding of MV morphology. Recently developed real time three‐dimensional transesophageal echocardiography (RT3D TEE) can provide online acquisition and accurate information of cardiac structures. The study aim was to evaluate the feasibility and accuracy of using RT3D TEE to assess mitral valve prolapse (MVP) and chordae rupture for surgical planning purposes. Methods: Fifty‐six consecutive patients with moderate to severe mitral regurgitation due to MVP received two‐dimensional (2D) TEE and RT3D TEE the day before operation. The accuracy of the assessment of MVP and chordae rupture by RT3D TEE was determined and compared with assessment by 2D TEE using surgical inspection as the gold standard. Results: The overall sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 2D TEE in detection of MVP were 87%, 96%, 93%, 88%, and 95%, respectively, whereas those of RT3D TEE were 100%, 99%, 99%, 98%, and 100%, respectively (P < 0.05 for all comparisons). The receiver operating characteristic (ROC) curve areas for assessment of anterior leaflet and posterior leaflet segment involvement using RT3D TEE (ROC areas 0.96 and 0.99) were higher than for those using 2D TEE (ROC areas 0.86 and 0.94). Interobserver agreement for RT3D TEE (κ= 0.97, 95% confidence interval [CI] 0.92–1.00) was significantly greater than for 2D TEE (κ= 0.89, 95% CI 0.81–0.93) (P < 0.05). Conclusion: RT3D TEE is a feasible, accurate and reproducible method for evaluating MVP and chordae rupture in the clinical setting. (Echocardiography 2011;28:1003‐1010)     

Usefulness of live/real time three-dimensional transthoracic echocardiography in the identification of individual segment/scallop prolapse of the mitral valve

In this report, we present 34 patients in whom surgical intervention was undertaken for severe mitral insufficiency due to mitral valve prolapse (MVP). Location and severity of MVP and regurgitation were assessed preoperatively by live/real time three-dimensional transthoracic echocardiography and closely agreed with the surgical findings.     

二尖瓣和瓣环的Voxel模型三维重建超声显像及其在二尖瓣脱垂中的应用

本文旨在评价经食管体元模型动态三维重建超声显像在二尖瓣脱垂诊断中的价值.研究对象为22例门诊和住院心血管病患者,男12例,女10例,年龄27～56岁,平均40.6±9.3岁,其中三尖瓣正常者12例,经手术证实的二尖瓣脱垂患者10例.图像采集选用美国HewlettPackard Sonos 2500多功能超声诊断仪和5MHz多平面经食管探头.动态三维超声重建采用德国Tomtec计算机工作站.12例二尖瓣正常者和10例二尖瓣脱垂者均能耐受经食管三维超声检查,获得满意的三维图像.用提取法对收缩期二尖瓣环进行三维重建,可得到一静态、立体的二尖瓣环形态.其前叶侧和后叶侧瓣环最高,左右交界侧瓣环最低,整个二尖瓣环呈一立体“马鞍”形,正常组和脱垂组二尖瓣环形态相似.10例二尖瓣脱垂者均能立体显示病变瓣膜的形态特征.从左房往左室方向观察,在心脏收缩期,脱垂部位象“伞面”状飘向在心房,并可精确显示二尖瓣脱垂累及前叶、后叶、前后叶均累及的情况,以及脱垂的具体部位.此外,三维重建后还能直接测量瓣叶脱垂的横径和纵径,明确脱垂大小.结果与术中所见相似.经食管体元模型动态三维重建超声显像能够正确诊断二尖瓣脱垂,且无假阳性和假阴性,具有临床推广意义.     

Comparison of real time two-dimensional with live/real time three-dimensional transesophageal echocardiography in the evaluation of mitral valve prolapse and chordae rupture

We compared live/real time three-dimensional transesophageal echocardiography (3D TEE) with real time two-dimensional transesophageal echocardiography (2D TEE) in the assessment of individual mitral valve (MV) segment/scallop prolapse and associated chordae rupture in 18 adult patients with a flail MV undergoing surgery for mitral regurgitation. 2D TEE was able to diagnose the prolapsing segment/scallop and associated chordae rupture correctly in only 9 of 18 patients when compared to surgery. In three of these, 2D TEE diagnosed an additional segment/scallop not confirmed at surgery. In the remaining nine patients, surgical findings were missed by 2D TEE. On the other hand with 3D TEE, the prolapsed segment/scallop and associated ruptured chords correlated exactly with the surgical findings in the operating room in 16 of 18 patients. The exceptions were two patients. In one, 3D TEE diagnosed prolapse and ruptured chordae of the A3 segment and P3 scallop, while the surgical finding was chordae rupture of the A3 segment but only prolapse without chordae rupture of the P3 scallop. In the other patient, 3D TEE diagnosed prolapse and chordae rupture of P1 scallop and prolapse without chordae rupture of the A1 and A2 segments, while at surgery chordae rupture involved A1, A2, and P1. This preliminary study demonstrates the superiority of 3D TEE over 2D TEE in the evaluation of individual MV segment/scallop prolapse and associated ruptured chordae.     

Multiplane two-dimensional versus real time three-dimensional transesophageal echocardiography in ischemic mitral regurgitation

Objectives: Intraoperative three‐dimensional (3D) transesophageal echocardiography (TEE) has been suggested to be a valuable technique for the evaluation of the mechanisms of ischemic mitral regurgitation (IMR). Studies comparing multiplane two‐dimensional (2D) with 3D TEE reconstruction of the mitral valve using the new mitral valve quantification (MVQ) software are lacking. We undertook a prospective comparison between multiplane 2D and 3D TEE for the assessment of IMR. Methods: We evaluated echocardiographically 45 patients with IMR who underwent mitral valve surgery in our institution. 2D and 3D TEE examinations followed by a 3D offline assessment of the mitral valve apparatus were performed in all patients. Offline analysis of mitral valve apparatus was conducted with QLAB–MVQ. Results: 3D TEE image acquisitions were performed in a short period of time and were feasible in all patients. Real time 3D TEE imaging was superior to 2D in identifying specific mitral scallops (A1, A3, P1, P3) and commissures. When compared with 2D TEE, 3D offline reconstruction of the mitral valve allows an accurate quantification of the shape and diameters of the mitral annulus. Both approaches provide almost similar values for the tenting area and the coaptation depth. The 3D approach gave the advantage of direct calculation of the leaflets angles, tenting volume, and surface of the leaflets. The interpapillary muscles distance at the level of the papillary muscle head was greater in 2D than in 3D. Conclusions: 3D TEE imaging provides valuable and complementary information to multiplane 2D TEE for the assessment of patients with IMR. (Echocardiography 2011;28:1125‐1132)     

Incremental utility of real time three-dimensional tranthoracic echocardiography in the assessment of congenitally malformed aortic valve

Objectives: To study the feasibility and additional value of real time three-dimensional transthoracic echocardiography (RT3D-TTE) for anatomical and functional assessment of malformed aortic valve (AV) compared to conventional two-dimensional TTE (2D-TTE). Methods: Malformed AV was evaluated in 35 patients (mean age 18 ±9.5years, 70% male) by both 2D-TTE and RT3D-TTE. The anatomical definition of aortic cusps (number, direction, and commissures) was evaluated by a 3-point visualization score (1: nonvisualized, 2: inadequate, 3: adequate). 2D-TTE and RT3D-TTE measurements included AV area and maximum diameters of both AV annulus and left ventricular outflow tract (LVOT). Results: Adequate visualization of AV cusps was achieved in 86% of patients by RT3D-TTE compared to 63% by 2D-TTE. The mean and median visualization score obtained by RT3D-TTE were higher than that by 2D-TTE. The opening of commissures was detected in (80%) of patients by RT3D-TTE compared to (34%) by 2D-TTE. AV area planimetry could be obtained in 77% of patients by RT3D-TTE compared to 43% by 2D-TTE. RT3D-TTE visualization score of AV cusps and commissures showed better interobserver agreement (Kappa: 0.62 and 0.72, respectively) than 2D-TTE (0.58 and 0.69, respectively). RT3D-TTE and 2D-TTE measurements of AV annulus and LVOT were well correlated (r = 0.85; P < 0.001) but the RT3D-TTE measurements were significantly larger than that obtained by 2D-TTE (2.05 ± 0.7 cm and 2.5 ± 0.86 cm vs 1.94 ± 0.67 cm and 1.98 ± 0.74 cm; P < 0.01). Conclusion: RT3D-TTE is a feasible technique that allows comprehensive quantitative and qualitative assessment of malformed AV. (Echocardiography, 2012;**:1-6).     

Usefulness of transesophageal three-dimensional echocardiography in the identification of individual segment/scallop prolapse of the mitral valve

We evaluated the potential usefulness of three-dimensional (3D) transesophageal echocardiography (TEE) in assessing individual scallop/segment prolapse in 36 adult patients with mitral valve prolapse (MVP) undergoing surgical correction. Intraoperative 3D TEE correctly identified the location of scallop/segment prolapse in 34 of 36 patients (94%). However, in 6 of these patients 3D TEE images revealed more scallops or segments with prolapse than the surgeon noted intraoperatively. Prolapse of these areas was less prominent and this could possibly explain the lack of correlation with the surgical findings in these patients. In another 2 patients areas of prolapse seen by the surgeon were missed by 3D TEE because some of those scallops/segments could not be well imaged due to image "drop out" and artifacts. Thus, perfect correlation between 3D TEE and surgery was noted in 28 of 36 (78%) patients. Noncoaptation of the MV was also identified in 2 patients. The prolapsed area of posterior (n = 28 observations) and anterior (n = 9 observations) MV leaflets ranged from 1 cm2 to 9 cm2 (mean 3.50 cm2+/- 2.14) and 1.20 cm2 to 5.99 cm2 (mean 3.21 cm2+/- 1.33), respectively. Interobserver and intraobserver agreement for location and area of MVP was excellent (r = 0.97 and r = 0.99, respectively; all P values are <0.0001). In conclusion, 3D TEE is useful in identifying the location of MVP. It may also be potentially useful in assessing the extent of individual scallop/segment prolapse and identifying sites of MV noncoaptation. This information could aid the surgeon in deciding the extent of MV resection.     

Pitfalls of mitral regurgitation assessment in the presence of mitral valve prolapse

Adequate grading of mitral regurgitation (MR) in patients with mitral valve prolapse (MVP) in the presence of mid-late systolic jets can represent a major challenge. In this entity, jets are commonly overestimated by echocardiography. Correct quantification is crucial and highly relevant for the further management and prognosis of these oftentimes young patients. This case points out potential pitfalls and underlines the importance to systematically include qualitative, quantitative, and semi-quantitative parameters into the echocardiographic assessment.     

Multiplanar visualization in 3D transthoracic echocardiography for precise delineation of mitral valve pathology

A novel multiplanar reformatting (MPR) technique in three-dimensional transthoracic echocardiography (3D TTE) was used to precisely localize the prolapsed lateral segment of posterior mitral valve leaflet in a patient symptomatic with mitral valve prolapse (MVP) and moderate mitral regurgitation (MR) before undergoing mitral valve repair surgery. Transesophageal echocardiography was avoided based on the findings of this new technique by 3D TTE. It was noninvasive, quick, reproducible and reliable. Also, it did not need the time-consuming reconstruction of multiple cardiac images. Mitral valve repair surgery was subsequently performed based on the MPR findings and corroborated the findings from the MPR examination.     

Comparison of accuracy of aortic valve area assessment in aortic stenosis by real time three-dimensional echocardiography in biplane mode versus two-dimensional transthoracic and transesophageal echocardiography

Our aim was to validate the clinical feasibility of assessment of the area of the aortic valve orifice (AVA) by real time three-dimensional echocardiography (RT3DE) in biplane mode by planimetry and to compare it with the echo-Doppler methods more commonly used to evaluate valvular aortic stenosis (AS).RT3DE in biplane mode is a novel technique that allows operators to visualize the aortic valve orifice anatomy in any desired plane orientation. Its usefulness and accuracy have not previously been established.Using this technique, we studied a series of patients with AS and compared the results with those obtained by two-dimensional transesophageal echocardiography (TEE) planimetry and two-dimensional transthoracic echocardiography using the continuity equation (TTE-CE). RT3DE planimetries in biplane mode were measured by two independent observers. Bland-Altman analysis was used to compare these two methods.Forty-one patients with AS were enrolled in the study (15 women, 26 men, mean age 73.5 +/- 8.2 years). RT3DE planimetry was feasible in 92.7%. Average AVA determined by TTE-CE was 0.76 +/- 0.20 cm, by TEE planimetry 0.73 +/- 0.1 cm, and by RT3DE planimetry 0.76 +/- 0.20 cm(2). The average differences in AVA were-0.001 +/- 0.254 cm(2) and 0.03 +/- 0.155 cm(2) (RT3DE/TEE). The correlation coefficient for AVA (RT3DE/TTE-CE) was 0.82 and for AVA (RT3DE/TEE) it was 0.94, P < 0.0001. No significant intra- and interobserver variability was observed. In conclusion, RT3DE in biplane mode provides a feasible and reproducible method for measuring the area of the aortic valve orifice in aortic stenosis.     

Unusual bileaflet tricuspid valve by real time three-dimensional echocardiography

The right atrioventricular valve is formed by three leaflets as described by the classic anatomic studies. Two-dimensional transthoracic echocardiography (2DE) shows the tricuspid valve (TV) in its long axis. However, short-axis views of the TV leaflets are not generally obtained and therefore distinction between leaflets by 2DE is difficult. Real time three-dimensional echocardiography (RT3DE) overcomes this limitation of 2DE and facilitates obtaining short axis view (enface view) of the TV. In the current case study, en face view of the TV obtained by RT3DE was found to be formed of only two leaflets with two commissures. The surgical findings were consistent with that of RT3DE.     

青少年特发性二尖瓣脱垂的超声评价及其与HLA的相关性研究

目的：评价青少年特发性二尖瓣脱垂（MVP）的超声诊断价值及特点，探讨HLA与特发性MVP的相关性。方法：回顾性分析29例经手术及病理证实的特发性MVP伴有严重二尖瓣关闭不全的超声检查结果：用PCR－SSP方法检测29例福建籍特发性MVP患HLA－DR的特异性抗原频率，并与65例本地区正常人相对照。结果：29例中有20例被二维超声正确诊断为特发性MVP，其中3例仅在心尖四心腔可见瓣膜脱垂，超声显像示瓣叶冗长、不增厚、无粘连，瓣口面积大；另9例被超声误诊为风湿性病变，超声显像示二尖瓣均有不同程度增厚及粘连，舒张期二尖瓣开放稍呈穹隆样；但均无钙化，且合并有严重的二尖瓣关闭不全。特发性MVP的HLA－DR15抗原频率明显增高，有显差异（P＜0．05）。结论：青少年患瓣膜脱垂伴有严重关闭不全而无明显瓣膜粘连、增厚及狭窄均应考虑患有本病。此外特发性MVP的发病与HLA－DR15的异常表达有关。     

Colour Doppler echocardiographic assessment of regurgitant flow in mitral valve prolapse

Colour flow mapping was used to examine the pattern of regurgitantflow in 46 patients with mitral regurgitation due to mitralvalve prolapse. Valve morphology was assessed from the real-timetwo-dimensional image and the presence of mitral regurgitationwas determined from real time Doppler. On morphological criteria11 (24%) patients had isolated or predominant anterior leafletprolapse, 22 (48%) patients posterior and 13 (28%) patientsbi-leaflet prolapse. A single regurgitant jet was detected in43 patients (93%) and multiple jets in three (7%). The directionof the regurgitant jet was assessed in multiple views in twoorthogonal planes (antero-posterior and medial-lateral) definedin relation to the mitral valve leaflets. The regurgitant jetwas eccentric in the antero-posterior plane of the mitral leafletsin 40 of 45 (89%) cases and in the medial-lateral plane in 36of 40 (90%) cases. Posterior leaflet prolapse was usually associatedwith antero-medially directed jets, anterior leaflet prolapsewith postero-central or postero-lateral jets and bi-leafletprolapse with predominantly postero-medial jets. In a subgroupof patients with significant mitral regurgitation and an eccentricregurgitant jet, a ‘swirling’ effect was producedwith late systolic flow in the body of the left atrium towardthe mitral valve. Colour flow mapping in patients with mitral regurgitation dueto mitral valve prolapse demonstrated eccentric jets in mostpatients. The direction of regurgitant flow appeared to dependgreatly on the dynamic anatomy of the mitral valve leafletsduring systole. Although a single jet was detected in most patients,multiple jets did occur in a minority.     

Tissue Doppler echocardiography reveals insufficient contractile reserve recruitment during effort in subjects with mitral valve prolapse and those with thick mitral valve

OBJECTIVE: To assess by tissue Doppler echocardiography (TDE), the tissue velocities, both at rest and after exercise stress testing, in subjects with mitral valve prolapse (MVP) and those with thick mitral valve (TMV). METHODS: Twenty individuals with typical MVP, 30 with TMV, and 30 healthy controls were enrolled. TDE was performed at the basal-inferior wall and the parameters evaluated were the S, Em, and Am velocities, as well as the Em/Am ratio. RESULTS: The mean S-wave at rest was higher in subjects with MVP compared to that of the TMV (P < 0.01) and the control groups (P = 0.00005), whereas after exercise it was higher in the control group compared to either MVP (P = 0.013) or TMV group (P = 0.00002). The mean Em wave at rest was higher in the control individuals both at rest (P = 0.007 compared with MVP group and P = 0.013 compared with TMV group), and after exercise (P = 0.0002 and 0.0009, respectively). The Am wave in the MVP group was higher compared with TMV and control subjects at rest (P = 0.022 and 0.00001, respectively) but it was not after exercise (P = ns for both comparisons). The Em/Am ratio of the control group at rest was higher than that of the MVP (P = 0.0000) and TMV (P = 0.00028) groups. However, after exercise, it was higher only when compared with the MVP group (P = 0.016). CONCLUSIONS: Subjects with MVP and those with TMV exhibit a less effective contractile response to exercise compared to healthy individuals. Some degree of diastolic dysfunction, particularly after exercise, was also detected in the individuals with MVP.     

Mitral valve aneurysm revealed by cross-sectional echocardiography in a patient with mitral valve prolapse

We report a cerebral ischemia in a 23-year-old woman, in whom a mitral valve aneurysm with thrombotic masses was diagnosed by cross-sectional echocardiography. A prolapsing mitral leaflet was also visualized.     

The echocardiographic association of mitral valve prolapse and mitral anulus calcification

Mitral anulus calcification (MAC) and mitral valve prolapse (MVP) are frequently diagnosed conditions. We studied two patients with mild or moderate mitral regurgitation who demonstrated both MAC and MVP on angiography and echocardiography. M-mode echocardiography is probably the definitive test for confirming the presence of MVP. Echocardiography is moderately sensitive in the diagnosis of cardiac calcification, such as MAC, but M-mode echocardiography may not detect the MAC in the majority of patients with both MVP and MAC demonstrated by angiography.     

实时三维经食管超声心动图在二尖瓣脱垂合并感染性心内膜炎中的应用

目的 评价实时三维经食管超声心动图(RT-3D-TEE)在二尖瓣脱垂合并感染性心内膜炎(IE)中的应用价值。方法 选择二尖瓣脱垂合并IE患者20例,术前行经胸超声心动图(TTE)和RT-3D-TEE检查,分析脱垂部位及表现特征,并与术中所见进行对比。结果1RT-3D-TEE在二尖瓣脱垂的敏感性、特异性、阳性预测值、阴性预测值、总符合率方面整体均高于TTE。2RT-3D-TEE在诊断二尖瓣赘生物形成、腱索断裂、穿孔方面的敏感性、特异性整体均高于TTE。结论 1.RT-3D-TEE较TTE更能准确定位二尖瓣脱垂的部位2.RT-3D-TEE能准确显示IE的各种表现形式,对术前手术方式的选择有重要指导作用。     

Moderate exercise does not increase the severity of mitral regurgitation due to mitral valve prolapse

Background: Mitral regurgitation (MR) secondary to ischemic heart disease (IHD) increases during exercise. We tested the hypothesis that the same is also true for MR due to mitral valve prolapse (MVP). Methods: Consecutive patients with asymptomatic MR of varying severity underwent exercise test on a supine bicycle with workload up to a maximum of 100 W. Echocardiographic measurements were performed at rest and at peak exercise. The study was designed to detect an effective regurgitant orifice (ERO) change of at least 10 mm² during exercise. Results: Twenty‐six patients (21 male, age 56 ± 12 years (mean ± SD)) were included. Patients had an ERO of 35 ± 23 mm² (mean ± SD) and regurgitation volume of 48 ± 38 mL (mean ± SD). In these patients, ERO remained unchanged (an increase of 2 ± 15 mm² during exercise, P = 0.6). The regurgitation volume (RVol) decreased with 11 ± 16 mL (mean ± SD), P = 0.003. When calculated for 1 minute, RVol increased during exercise (P = 0.01), but in relation to the total cardiac output it decreased significantly (P = 0.02). Conclusion: Exercise does not increase the severity of MR due to MVP, in contrast to MR secondary to IHD. Different disease mechanisms behind these two types of MR could explain this difference. (Echocardiography 2010;27:1031‐1037)