Role of real-time three-dimensional transesophageal echocardiography in mitral valve repair

Background and objective Pre-operative assessment of mitral valve (MV) anatomy is essential to surgical design in patients undergoing MV repair.Although 2-dimensional (2D) echocardiography provides precise information regarding MV anatomy,RT-3D TEE could increase the understanding of MV apparatus and individual scallop identification.We aimed to investigate the value of RT- 3DTEE in MV repair.Methods RT-3DTEE was performed in six patients with mitral valve prolapse (MVP) by using Philips 1E33 with X7-2t probe.Preoperative RT-3DTEE studies were compared with surgical findings in patients undergoing surgical mitral valve repair,and quantitative evaluation was performed by QLab 6.0 software before and after surgical mitral valve repair.Results RT- 3DTEE could display dynamic morphology of MV,the location of prolapse,and spatial relation to the surrounding tissue.It could provide surgical views of the valves and the valvular apparatus.These results were consistent with surgical findings.The quantitative evaluation before and after surgical MV repair indicated that anterolateral to posteromedial diameter of annulus,anterior to posterior diameter of annulus,perimeter of annulus,and area of annulus in projection plane were significantly smaller after operation compared with those before operation (P<0.05).The length of posterior leaflet,the area of anterior and posterior leaflet,the maximal prolapse height,the volume of leaflet prolapse and the length of coaptation in projection plane were significantly reduced after operation (P<0. 05).Conclusion RT-3DTEE is a unique new modality for rapid and accurate evaluation ofmitral valve prolapse and mitral valve repair.     

Three-dimensional Echocardiography in Valvular Heart Disease

Recent technologic advances in 3-dimensional (3D) echocardiography, using parallel processing to scan a pyramidal volume, have allowed for a superior ability to describe valvular anatomy using both transthoracic and transesophageal echocardiography. Although still in evolution and at an early phase of adaptation with respect to its clinical application, 3D echocardiography has emerged as an important clinical tool in the assessment of valvular heart disease. Three-dimensional echocardiography provides unique perspectives of valvular structures by presenting "en face" views of valvular structures, allowing for a better understanding of the topographical aspects of pathology, and a refined definition of the spatial relationships of intracardiac structures. Three-dimensional echocardiography makes available indices not described by 2D echocardiography and has been demonstrated to be superior to 2D echocardiography in a variety of valvular disease scenarios. The information gained from 3D echocardiography has especially made an impact in guiding clinical decisions in the evaluation of mitral valve (MV) disease. The decision of early surgery in degenerative MV disease is based on the suitability of repair, and the suitability of repair is generally based on echocardiography. The superior understanding of MV anatomy afforded by 3D echocardiography has been shown to be quite valuable in this setting. This review will describe the contemporary use of 3D echocardiography in the assessment of valvular heart disease, including MV, aortic, tricuspid, and prosthetic valve abnormalities. This article illustrates how 3D echocardiography can complement current echocardiography techniques in the management of valvular heart disease.     

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)     

Real-time three-dimensional transesophageal echocardiography for assessment of mitral valve functional anatomy in patients with prolapse-related regurgitation

The aim of the study was to evaluate the additional diagnostic value of real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) for surgically recognized mitral valve (MV) prolapse anatomy compared to 2-dimensional transthoracic echocardiography (2D-TTE), 2D-transesophageal echocardiography (2D-TEE), and real-time 3D-transthoracic echocardiography (RT3D-TTE). We preoperatively analyzed 222 consecutive patients undergoing repair for prolapse-related mitral regurgitation using RT3D-TEE, 2D-TEE, RT3D-TTE, and 2D-TTE. Multiplanar reconstruction was added to volume-rendered RT3D-TEE for quantitative prolapse recognition. The echocardiographic data were compared to the surgical findings. Per-patient analysis of RT3D-TEE identified prolapse in 204 patients more accurately (92%) than 2D-TEE (78%), RT3D-TTE (80%), and 2D-TTE (54%). Even among those 60 patients with complex prolapse (>1 segment localization or commissural lesions), RT3D-TEE correctly identified 58 (96.5%) compared to 42 (70%), 31 (52%), and 21 (35%) detected by 2D-TEE, RT3D-TTE, and 2D-TTE (p < 0.0001). Multiplanar reconstruction enabled RT3D-TEE to differentiate dominant (≥5-mm displacement) and secondary (2 to <5-mm displacement) prolapsed segments in agreement with surgically recognized dominant lesions (100%), but with a low predictive value (34%) for secondary lesions. In addition, owing to the identification of clefts and subclefts (indentations of MV tissue that extended ≥50% or <50% of the total leaflet height, respectively), RT3D-TEE accurately characterized the MV anatomy, including that which deviated from the standard nomenclature. In conclusion, RT3D-TEE provided more accurate mapping of MV prolapse than 2D imaging and RT3D-TTE, adding quantitative recognition of dominant and secondary lesions and MV anatomy details.     

Clinical utility of new real time three-dimensional transthoracic echocardiography in assessment of mitral valve prolapse

BACKGROUND: Noninvasive and accurate assessment of mitral valve anatomy has become integral in the presurgical evaluation of patients with mitral valve prolapse (MVP). Recently developed real time three-dimensional (RT3D) ultrasound allows online acquisition, rendering, and can provide accurate information on cardiac structures. We sought to evaluate the feasibility of RT3D for the assessment of MVP segments when compared with transesophageal echocardiography (TEE) and intraoperative findings. METHODS: We examined 42 patients with MVP using RT3D, two-dimensional (2D) transthoracic echocardiography (TTE) and TEE. For RT3D analysis, cropping planes were used to slice the 3D volume on line to visualize the prolapsed segments of the mitral valve leaflets. The mitral valve was divided into six segments based on the American Society of Echocardiography's recommendations. Two experienced cardiologists evaluated echocardiographic images. RESULTS: Adequate RT3D images of the mitral valve were acquired in 40 out of 42 patients. The sensitivity and specificity of RT3D for defining prolapsed segments when compared with TEE were 95% and 99%, respectively (anterior leaflet: 96% and 99%, posterior leaflets: 93% and 100%, respectively). The sensitivity and specificity of TTE were 93% and 97%, respectively (anterior leaflet: 96% and 98%, posterior leaflets: 90% and 97%, respectively). Interobserver agreement for RT3D (Kappa 0.95, 95% confidence interval [CI] 0.91-1.00) was significantly greater than for TTE (Kappa 0.85, 95% CI 0.78-0.93) (P < 0.05). The elapsed time for completion of RT3D (14.4 +/- 2.8 min) was shorter than for TEE (26.4 +/- 4.7 min, P < 0.0001) and TTE (19.0 +/- 3.1 min, P< 0.0001). CONCLUSIONS: RT3D is fast, accurate, and highly reproducible for assessing MVP.     

Functional assessment of mitral regurgitation by transthoracic echocardiography using standardized imaging planes diagnostic accuracy and outcome implications

OBJECTIVES: We sought to assess the value of transthoracic echocardiography (TTE) using standardized imaging planes for the functional analysis of mitral regurgitation (MR) as well as for postoperative outcome implications. BACKGROUND: The feasibility of mitral valve repair is based on functional assessment of MR, mainly by transesophageal echocardiography (TEE). Considering the recent advances in TTE imaging, the incremental value of TEE in this setting needs to be re-examined. METHODS: Consecutive patients (n = 279; 181 men; median age 68 years [quartiles, 61 to 74]) who underwent surgery for MR were enrolled prospectively in two tertiary care centers. The accuracy of TTE (harmonic imaging) versus TEE for functional assessment of MR was evaluated against surgical findings. RESULTS: Valve repair (n = 237 patients, 85%) or replacement (n = 42) was predicted accurately by TTE in 97% of cases; TEE added significant information for only two patients. In the subgroup of degenerative MR (n = 190), agreement with surgical findings for the localization of prolapsed segments was 91% for TTE (kappa, 0.81) and 93% for TEE (kappa, 0.85) without incremental value of TEE (p = 0.40). Patients with single prolapse of the middle posterior scallop (P2) had a better postoperative outcome as compared with patients who had non-P2 lesions (p = 0.008). Furthermore, mitral replacement predicted by TTE was an independent predictor for postoperative long-term mortality (odds ratio 5.7, 95% confidence interval 1.97 to 16.4, p = 0.001). CONCLUSIONS: In experienced hands, functional assessment of MR by TTE can predict accurately valve repairability and has a strong influence on postoperative outcome. Thus, in most cases preoperative TEE is not mandatory, provided intraoperative TEE is performed.     

Functional anatomy of mitral regurgitation: accuracy and outcome implications of transesophageal echocardiography.

OBJECTIVES: This study was performed to determine the accuracy and outcome implications of mitral regurgitant lesions assessed by echocardiography. BACKGROUND: In patients with mitral regurgitation (MR), valve repair is a major incentive to early surgery and is decided on the basis of the anatomic mitral lesions. These lesions can be observed easily with transesophageal echocardiography (TEE), but the accuracy and implications for outcome and clinical decision-making of these observations are unknown. METHODS: In 248 consecutive patients operated on for MR, the anatomic lesions diagnosed with TEE were compared with those observed by the surgeon and those seen on 216 transthoracic echocardiographic (TTE) studies, and their relationship to postoperative outcome was determined. RESULTS: Compared with surgical diagnosis, the accuracy of TEE was high: 99% for cause and mechanism, presence of vegetations and prolapsed or flail segment, and 88% for ruptured chordae. Diagnostic accuracy was higher for TEE than TTE for all end points (p < 0.001), but the difference was of low magnitude (<10%) except for mediocre TTE imaging or flail leaflets (both p < 0.001). The type of mitral lesions identified by TEE (floppy valve, restricted motion, functional lesion) were determinants of valve repairability and postoperative outcome (operative mortality and long-term survival; all p < 0.001) independent of age, gender, ejection fraction and presence of coronary artery disease. CONCLUSIONS: Transesophageal echocardiography provides a highly accurate anatomic assessment of all types of MR lesions and has incremental diagnostic value if TTE is inconclusive. The functional anatomy of MR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome. Therefore, the mitral lesions assessed by echocardiography represent essential information for clinical decision making, particularly for the indication of early surgery for MR.     

Role of real-time three-dimensional transesophageal echocardiograpny in mitral valve repair

Background and objective Pre-operative assessment of mitral valve(MV)anatomy is essential to surgical design in patientsundergoing MV repair.Although 2-dimensional(2D)echocardiography provides precise information regarding MV anatomy,RT-3DTEE could increase the understanding of MV apparatus and individual scallop identification.We aimed to investigate the value of RT-3DTEE in MV repair. Methods RT-3DTEE was performed in six patients with mitral valve prolapse(MVP) by using Philips IE33with X7-2t probe.Preoperative RT-3DTEE studies were compared with surgical findings in patients undergoing surgical mitral valverepair,and quantitative evaluation was performed by QLab 6.0 software before and after surgicalmitralvalve repair.Results RT-3DTEE could display dynamic morphology of MV,the location of prolapse,and spatial relation to the surrounding tissue.It couldprovide surgical views of the valves and the valvular apparatus.These resuIts were consistent with surgical findings.The quantitativeevahuation before and after surgical MV repair indicated that anterolateral to posteromedial diameter of annalus.anterior to posteriordiameter of annulus,perimeter of annullus.,and area of annalus in projectionplane were significantlv smaller after operation comparedwith those before operation(P＜0.05).The length of posterior leaflet,,the area of anterior and posterior leaflet,the maximal prolapseheight,the volume of leaflet prolapse and the length of coaptation in projection planewere significantly reduced after operation(P＜0.05).Conclusion RT-3DTEE is a unique new medality for rapid and accurate evaluation of mitral valve prolapse and miwal valverepair.     

Qualitative and quantitative evaluation of mitral valve morphology by intraoperative volume-rendered three-dimensional echocardiography

BACKGROUND AND AIM OF THE STUDY: Two-dimensional echocardiography (2DE) performed to evaluate mitral valve anatomy during valve repair has certain limitations and pitfalls. The study aim was to assess the feasibility, accuracy and incremental value of three-dimensional echocardiography (3DE), coupled with 2DE in evaluating mitral valve structure, before and after repair and pericardial posterior annuloplasty. METHODS: The site and extent of mitral valve prolapse, systolic and diastolic changes of mitral annular area were evaluated using 2D and 3D transesophageal echocardiography (TEE), both pre- and postoperatively in 34 patients before and after mitral valve repair and pericardial posterior annuloplasty. RESULTS: Concordance between 2DE and surgery in evaluating prolapsing mitral valve scallops was 76% for the anterior leaflet and 75% for the posterior leaflet; for 3DE and surgery, concordance was 87% and 93% respectively. There was a significant reduction in maximal and minimal annular area after surgery, with a statistically significant difference between systolic-diastolic changes. CONCLUSION: 3DE, coupled with 2DE, is feasible and accurate in delineating the extent and location of prolapsing scallops of the mitral valve. The combined approach is also valuable in planning mitral valve surgery and evaluating the mitral valve annulus in vivo.     

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.     

Stereolithographic biomodeling to create tangible hard copies of cardiac structures from echocardiographic data: in vitro and in vivo validation

OBJECTIVES: This study investigated the feasibility, accuracy and clinical potential of creating polymer hard copies of echocardiographic data using stereolithography. BACKGROUND: Three-dimensional (3D) echocardiography has so far been limited by the need to display reconstructed 3D objects on a two-dimensional screen. Thus, tangible stereolithographic polymer models created from echocardiographic data could enhance our spatial perception of cardiac anatomy and pathology. METHODS: Hard-copy replicas of water-filled latex balloon phantoms (n = 7) and porcine liver specimens (n = 12) were generated from echocardiographic images using stereolithography (computerized laser polymerization). In addition, we created 24 models of the mitral valve from 12 transesophageal studies (normal = 6, mitral stenosis n = 4, prolapse/flail leaflet n = 8, annular dilation n = 2, leaflet restriction n = 2 and following mitral valve repair n = 2). RESULTS: Excellent agreement was found for comparison of volumes (r = 0.98, SEE = 3.46 mm3, mean difference = 0.25 +/- 3.33 mm3) and maximal dimensions (r = 0.99, SEE = 0.16 cm, mean difference = 0.03 +/- 0.16 cm) between phantoms and their corresponding replicas. Visual and tactile examination of mitral valve models by two blinded observers allowed correct depiction of mitral valve anatomy and pathology in all cases. CONCLUSIONS: Stereolithographic modeling of echocardiographic images is feasible and provides tangible polyacrylic models that are true to scale, shape and volume. Such models offer accurate depiction of mitral valve anatomy and pathology in patients studied with transesophageal echocardiography. This technique could have substantial impact on diagnosis, management and preoperative planning in complex cardiovascular disorders.     

实时三维经食管超声心动图定位二尖瓣脱垂部位临床应用

目的:分析二尖瓣脱垂的三维经食管超声心动图(RT-3D-TEE)表现,探讨其诊断二尖瓣脱垂的应用价值。方法:选取由于二尖瓣脱垂引起二尖瓣关闭不全,进行二尖瓣修复或置换的患者23例,术前及术后即刻均行RT-3D-TEE检查,分析二尖瓣脱垂的RT-3D-TEE表现特征及脱垂部位,并与术中所见进行对比。RT-3D-TEE成像切面均采用二尖瓣左心房面外科视野观。结果:23例患者术前即刻二尖瓣左心房面外科视野观均显示清楚,观察二尖瓣小叶共138个。术前RT-3D-TEE判断二尖瓣脱垂小叶33个,无脱垂小叶105个,其中腱索断裂17例;发现3例瓣叶赘生物。术中发现二尖瓣脱垂小叶35个,无脱垂小叶103个,其中腱索断裂16例;赘生物3例。RT-3D-TEE诊断二尖瓣脱垂的敏感性为91.4%,特异性为99%,阳性预测值为97.0%,阴性预测值为97.1%,总符合率为97.1%。RT-3D-TEE判断腱索断裂的准确性为99.3%;诊断瓣叶赘生物的准确性为100%。结论:二尖瓣脱垂的RT-3D-TEE表现具有特征性,RT-3D-TEE是诊断二尖瓣脱垂的有效手段,亦可以提供一些额外信息。     

Quantification of mitral regurgitation by the proximal flow convergence method--comparison of transthoracic and transesophageal echocardiography

BACKGROUND: No dataexist to indicate whether transthoracic (TTE) and transesophageal echocardiography (TEE) are of comparable value for the detection and quantification of mitral regurgitation using the proximal flow convergence method. HYPOTHESIS: The study was performed to compare the value of TTE and TEE for the detection and quantification of mitral regurgitation using this method. METHODS: The study included 57 patients with and 11 patients without mitral regurgitation. In all patients, the proximal flow convergence region was imaged by transthoracic and transesophageal color Doppler echocardiography, and proximal isovelocity surface area radii were determined. In 19 patients, monoplane TEE and in 49 patients multiplane TEE was performed. Thirty-one patients with mitral regurgitation underwent cardiac catheterization. RESULTS: Both methods had a comparable sensitivity for the detection of mitral regurgitation. Proximal isovelocity surface area radii derived from TTE and TEE agreed moderately (mean difference -0.5 +/- 1.3 mm). TTE and TEE correlated significantly with the angiographic grade (rank correlation coefficients 0.83 and 0.81), and both differentiated mild to moderate from severe mitral regurgitation with an accuracy of 90%. Regurgitant volumes derived from both echocardiographic techniques and cardiac catheterization correlated moderately (correlation coefficients between 0.67 and 0.81). CONCLUSIONS: TTE and TEE were of comparable value for the detection and quantification of mitral regurgitation using the proximal flow convergence method.     

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.     

Intraoperative transesophageal echocardiography for evaluation of mitral valve repair.

BACKGROUND AND AIM OF THE STUDY: Although mitral valve repair is a well-established procedure, incorrect assessment of the repaired valve may occasionally lead to the need for reoperation. This study was performed to evaluate the accuracy of color Doppler in assessing the competence of the repaired mitral valve. METHODS: Transesophageal echocardiography (TEE) and left ventriculography were each performed in 72 patients to compare the two techniques and a semi-quantitative index derived. Using this relationship, post bypass intraoperative TEE was then performed in 34 patients who underwent mitral valve repair, in order to assess the competence of the repaired valve. RESULTS: Significant differences were apparent in maximal regurgitant mosaic area between angiographic grade 0, and grades 1+ (p = 0.0006), 1+ and 2+ (p < 0.0001) and 2+ and 3+ (p = 0.0010). A maximal regurgitant area < 2 cm2 predicted angiographic grade as 0 (sensitivity 100%, specificity 95%), an area of 2-4 cm2 as 1+ (sensitivity 82%, specificity 100%), an area of 4-7 cm2 as 2+ (sensitivity 78%, specificity 90%), and an area > 7 cm2 as grade 3+ or 4+ (sensitivity 79%, specificity 93%). All 34 patients completed valve repair with the maximal regurgitant mosaic area < 2.5 cm2. Postoperative left ventriculography showed grade +1 in only five patients; four of these completed mitral valve repair with a maximal mosaic area > 2.0 cm2 as assessed by post bypass intraoperative TEE. During follow up, transthoracic echocardiography (TTE) detected recurrent mitral regurgitation which required mitral valve replacement in one patient, and rapid progression of mitral regurgitation in three patients. CONCLUSIONS: It is important that mitral valve repair should be completed with a maximal mosaic area < 2.0 cm2 as assessed by intraoperative TEE, in order to reduce the need for reoperation.     

Localization of mitral valve prolapse zones with multiplane transesophageal echocardiography

CONTEXT: There are few literature data on the localization and extent of mitral valve prolapse zones with transesophageal echocardiography (TEE). AIM OF THE STUDY: To assess a standardized imaging technique for the localization and extent determination of prolapse zones, based on 3 easily reproducible views with multiplane TEE. METHODS: Seventy patients with severe mitral regurgitation due to valve prolapse requiring a multiplane TEE prior to surgery (valve repair or replacement) have been retrospectively assessed. Data of TEE on the localization and extent of prolapse zones have been confronted to per-operative anatomical observations (gold standard). RESULTS: The sensitivity of TEE for the identification of isolated P2 prolapse, prolapse with commisural extension, isolated rupture of the posterior commisure and bi-valvular prolapses were respectively at 96%, 88%, 86% and 80%. The corresponding specificities were from 98% to 100%. CONCLUSIONS: The use of a standardized technique with the use of 3 easily reproducible incidences with multiplane TEE allows a precise definition of the localization and extent of mitral valve prolapse zones, in order to potentially indicate valve repair.     

超声测量二尖瓣对合高度对二尖瓣脱垂成形效果的评价

目的:应用超声心动图技术测量二尖瓣成形术后即刻对合高度,并观察随访术后6个月该指标的变化情况,探索用对合高度作为超声定量指标,评价成形效果的可行性。方法:选取20例因单纯二尖瓣脱垂行二尖瓣成形术的患者作为手术组,用经食管超声测量其术后即刻的瓣叶各分区对合高度,与正常组对照分析、比较两组超声对合高度值差异;同时,比较术后即刻的外科直视测量对合高度值与经食管超声测值的差异。随访总结12例患者二尖瓣各小叶分区对合高度值,并与术后即刻超声测量数据相对比,观察对合高度的变化。结果:20例手术患者外科直视测量及超声测量二尖瓣对合高度的方法具有较好的一致性。12例患者实现术后6个月随访,2例出现明显反流区域对合高度较术后即刻均有明显降低。结论:超声测量对合高度的方法是可行的,对合高度能够作为二尖瓣成形术后评价二尖瓣对合程度的定量指标。     

Update on Echocardiography in the Management of Infective Endocarditis

Echocardiography is the major imaging modality used for the diagnosis of infective endocarditis (IE). It is also useful in detecting the complications of IE which often necessitate surgical intervention and strongly influence patient outcomes. Transesophageal echocardiography (TEE), with proven superiority over transthoracic echocardiography (TTE) for the detection of vegetations and complications such as abscess, should be performed in the vast majority of cases especially when TTE image quality is poor or implanted devices are present. Three-dimensional (3D) TEE provides enhanced display of anatomic-spatial relationships allowing more precise delineation of complex pathology, particularly of the mitral valve and annulus. Importantly, echocardiographic findings can be non-specific and should always be interpreted in the context of the pre-test probability of IE based on careful clinical assessment. IE remains a challenging disease associated with variable clinical presentations, and high mortality. Whenever IE is suspected, echocardiography should be utilized early for both diagnosis and detection of complications.     

Usefulness of three-dimensional echocardiography for the evaluation of mitral valve prolapse: an intraoperative study

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the feasibility of intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) in patients referred for mitral valve prolapse (MVP) repair and to compare two-dimensional (2D) TEE and 3D TEE and surgical findings. METHODS: Forty-six patients (mean age 67 +/- 11 years) underwent 3D TEE intraoperatively. Measurements were made of the posterior part of mitral annulus circumference (PMAC), and the width of mitral valve surgical resection on the mitral annulus (WMVR). Using 3D TEE, MVP topography was described, and PMAC in diastole and the width of implantation of MVP on the mitral annulus (WMVP) in systole were measured. RESULTS: 3D TEE was successful in 42 patients (91%). 2D and 3DTEE correctly predicted MVP localization in 38 (90%) and 36 (86%) patients, respectively (p = NS). 3D TEE and surgical PMAC were 89 +/- 13 and 93 +/- 21 mm, respectively (p = 0.01, R = 0.42). WMVR and WMVP were 28 +/- 11 mm and 26 +/- 11 mm, respectively (p <0.0001, R = 0.82). WMVR/anatomic PMAC (0.29 +/- 0.11) and WMVP/3D echo PMAC (0.32 +/- 0.11) were correlated (p <0.0001, R= 0.69). CONCLUSION: Intraoperative 3D TEE evaluation of MVP is feasible. MVP width and its ratio to the mitral annulus were assessed, and found to correlate with surgical findings. These 3D data may be of value to the surgeon when performing mitral valve repair.     

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.