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.     

Transthoracic and transesophageal comparative echocardiography in mitral valve prolapse]

OBJECTIVE: Transthoracic and transesophageal comparative analysis of functional and morphological abnormalities associated to idiopathic mitral valve prolapse (MVP). DESIGN: Prospective study. SETTING: Outpatients with MVP diagnosis referred to echocardiographic laboratory of Cardiology Institute in Madrid, Spain. MATERIAL AND METHODS: In each case we analyzed by TTE and TEE, anterior, posterior and double localization of MVP, number of prolapsed mitral leaflets/patient, total area of MVP to mitral valve plane, mitral annulus diameter, total area and spatial distribution of mitral regurgitation. RESULTS: TEE diagnosed a greater number of prolapsed mitral leaflets and a greater percentage of double (80%) MVP. MPV area by TEE (50 +/- 31 mm2) was considerably larger (96 +/- 30 mm2) than TTE MVP area (50 +/- 31 mm3. Associated mitral valve regurgitation area calculated through TEE was larger (558 +/- 502 mm2) than the same parameter evaluated by TTE (450 +/- 515 mm2). CONCLUSIONS: TEE is an efficient technique in MVP non invasive diagnosis and particularly sensitive to posterior MVP. Our data could be helpful in MVP cases scheduled for mitral valve repairment.     

Usefulness of transthoracic freehand three-dimensional echocardiography for the evaluation of mitral valve prolapse

BACKGROUND: Two-dimensional (2D) echocardiography is routinely used in evaluating patients with mitral valve prolapse but requires a systematic examination for accurate assessment of the involved lesion of mitral valve prolapse, because the sonographer is required to mentally reconstruct two-dimensional images into three dimensions. Recently, freehand three-dimensional (3D) echocardiography has been introduced in the clinical setting for three-dimensional visualization of the mitral valve apparatus. OBJECTIVES: To evaluate the accuracy of the freehand 3D echocardiography system in assessing the involved lesion in patients with mitral valve prolapse. METHODS: This study consisted of 25 consecutive patients (15 men, 10 women, mean age 55 +/- 17 years) with mitral valve prolapse who were scheduled for 3D echocardiography. Mitral valve was reconstructed in the view from the left atrium (surgeon's view) by 3D echocardiography. The location of the involved lesion in mitral valve was classified as the medial, middle and lateral portions of the anterior leaflet, and the medial, middle and lateral scallops of the posterior leaflet, respectively. The results by 3D echocardiography were compared with those of 2D echocardiography as the clinical standard. RESULTS: An adequate three-dimensional display of the entire mitral valve for analysis of the involved lesion could be reconstructed in all 25 patients (feasibility 100%). The sensitivity of 3D echocardiography for detecting the lesions at the medial, middle and lateral portions of the anterior leaflet was 80%, 100% and 75%, and the medial, middle and lateral scallops of the posterior leaflet was 100%, 100% and 0%, respectively. The specificities were 100% at all locations in the mitral valve. CONCLUSIONS: These results indicate that freehand 3D echocardiography is useful for assessment of the involved lesion of the mitral valve in patients with mitral valve prolapse.     

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)     

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.     

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.     

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.     

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.     

Comparison of accuracy of mitral valve regurgitation volume determined by three-dimensional transesophageal echocardiography versus cardiac magnetic resonance imaging

Direct planimetry of anatomic regurgitation orifice area (AROA) using 3-dimensional transesophageal echocardiography (TEE) has been described. This study sought to (1) compare mitral valve regurgitant volume (RV) derived by AROA using 3-dimensional TEE with RV obtained by cardiac magnetic resonance (CMR) imaging and (2) determine the impact of AROA and flow velocity changes throughout systole on the dynamic variation in mitral regurgitation. In 43 patients (71 ± 11 years old) with mild to severe mitral regurgitation, 3-dimensional TEE and CMR were performed. Mitral valve RV was determined based on (1) AROA at 5 subintervals of systole and analysis of the regurgitant continuous-wave Doppler signal at equal durations of systole, (2) effective regurgitation orifice area (EROA) using the proximal isovelocity surface area method, (3) CMR with subtraction of aortic outflow volume from left ventricular stroke volume. RV calculated by AROA tended to overestimate RV less than RV calculated by EROA compared to RV by CMR (average bias +20 ml, 95% confidence interval [CI] -41 to +81, vs +13 ml, 95% CI -22 to 47). In patients with RV >30 ml by CMR, overestimation of RV using the AROA method was less than using the EROA method (difference in means +18 ml, 95% CI 4 to 32, p <0.001). AROA determined by 3-dimensional TEE varied by only 18% among the 5 subintervals of systole, and the velocity time integral of the subinterval with the highest flow was 120% of the subinterval with the lowest flow. In conclusion, 3-dimensional TEE allows accurate analysis of mitral valve RV. In the clinically relevant group of patients with RV >30 ml as defined by CMR, the AROA method results in less overestimation of RV than the EROA method. Changes in AROA during systole contribute much less to dynamic variation in mitral regurgitation severity than changes in regurgitant flow velocity.     

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.     

Parachute mitral valve accompanied by bicuspid aortic valve on three-dimensional transesophageal echocardiography

We report the findings of three-dimensional (3D) transesophageal echocardiography (TEE) in a patient with a parachute mitral valve (MV) accompanied by aortic valve (AV) malformation. The results indicated an enhanced echo in MV anterior leaves, incrassate, and shortened subvalvular chordae tendineae, and posteromedial papillary muscle that had echo reinforcement, calcification, retroposition, and a significant decrease compared with anterolateral papillary muscle. In addition, the anterolateral papillary muscle was huge, with the bilateral papillary muscles fused partly, and the posterior subvalvular chordae tendineae incrassate, shortened, and attached parachute-like to the anterolateral papillary muscle. The MV appeared dome-shaped for the open limit in diastole with an MV area of 1.6cm. Moreover, the left ventricle increased in size and the bicuspid AV was malformed. Continuous wave Doppler angiograph showed that the flow rate increased to 398cm/seconds at the AV orifice area. A 3D form of the MV structure was observed from the left ventricle using 3D-TEE inspection. The anterolateral papillary muscle was fused with its posteromedial homologue. The chordae tendineae was attached to the anterolateral papillary with the parachute-like structure, indicating dome movement.     

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.     

Long-term echocardiography results of mitral valve repair for mitral valve prolapse

BACKGROUND AND AIM OF THE STUDY: The study aim was to assess the long-term durability of mitral valve (MV) repair for MV prolapse using echo-Doppler evaluation. METHODS: Between July 1991 and December 2006, MV repair was performed in 603 patients with nonischemic, severe mitral regurgitation (MR). A subset of 517 patients (mean age 56.3 +/- 12.0 years) with MR caused by leaflet prolapse resulting from degeneration of the MV was subsequently investigated. The main techniques used for MV repair included chordal replacement with ePTFE sutures for 274 of 278 patients with anterior leaflet (AL) prolapse, and leaflet resection for 239 patients with posterior leaflet (PL) prolapse. A prosthetic ring or band was used for annuloplasty in 340 patients, and a band of autologous pericardium in 161; no ring or band was used in the remaining 16 cases. Postoperative serial transthoracic echocardiography was performed for all hospital survivors before discharge, and on at least one occasion after discharge in 507 patients. Echocardiographic follow up was available for up to 15 years (mean 4.4 +/- 3.6 years). Residual MR flow detected by color Doppler echocardiography was classified according to the maximum regurgitant jet area (MRA). RESULTS: The 30-day mortality was 0.57% (three deaths). There were 21 late deaths and 22 reoperations (five of which were re-repair for hemolysis). Kaplan-Meier survival and freedom from reoperation at 14 years were 79.0 +/- 6.0% and 74.5 +/- 9.6%, respectively. Estimates of freedom from severe MR (MRA > or = 7.0 cm2) at five, 10 and 14 years were 94.2 +/- 1.5%, 82.8 +/- 3.6% and 77.5 +/- 5.5%, respectively. Freedom from severe MR at 14 years for 239 patients with isolated PL prolapse was 98.4 +/- 1.6%. CONCLUSION: Echocardiographic follow up of MV repair for MV prolapse demonstrates good long-term results. In particular, the results of MV repair for isolated PL prolapse were excellent.     

Localization and quantification of mitral valve prolapse using three-dimensional echocardiography.

AIMS: Mitral valve prolapse is a common source of severe mitral regurgitation in Western countries. Three-dimensional echocardiography can provide views of the entire valve, allowing a complete assessment of the valve leaflets and commissures. It has the potential to precisely locate and quantify mitral valve prolapse. METHODS AND RESULTS: Between January 1997 and December 2000, 91 patients with severe mitral regurgitation due to mitral valve prolapse underwent a transesophageal echocardiography with three-dimensional reconstruction of the mitral valve as part of their pre-operative work-up. The location and extent of the prolapse by echo was compared to the surgical status. The volume of prolapsing leaflet was calculated and compared to the volume of resected tissue whenever a repair was attempted. There was an excellent correspondence between the echographic localization of the prolapse and surgical inspection, and between the volume of prolapsing and surgically resected tissue (r=0.94, p<0.0001). CONCLUSIONS: In patients with severe mitral regurgitation due to mitral valve prolapse, 3D echo allowed a precise localization and an accurate quantification of the prolapsing portion of the leaflets. This technique can provide refinements in the surgical planning of mitral valve repair and in the selection of candidates for this intervention.