Transesophageal echocardiographic diagnosis of a dehisced Carpentier mitral ring

We describe an unusual case of gross dehiscence of a Carpentier mitral ring, not due to bacterial endocarditis, causing severe mitral valve insufficiency and cardiac failure. Diagnosis was made by transesophageal echocardiography (TEE). Mitral valve replacement was then performed.     

Assessment of mitral valve volume by quantitative three-dimensional echocardiography in patients with rheumatic mitral valve stenosis

Background: Thickening of mitral leaflets in rheumatic mitral valve stenosis is well described in necropsy studies; however, volume computation of the thickening mitral leaflets has not been attempted. Atrial fibrillation is one of the complications of rheumatic mitral stenosis. Quantitative assessment of thickened mitral valve and its relation to clinical complications is clinically desirable. Hypothesis: The study was undertaken to compare measurement of mitral valve volume in normal subjects and in patients with rheumatic mitral valve stenosis. Methods: An HP Sonos 2500 echocardiography system with 5 MHz multiplane transesophageal transducer was used for data acquisition, and TomTec Echoscan computer setup was used to off-line volume computation. Study subjects included 10 normal subjects (mean age 44.8 years) and 36 patients with rheumatic mitral valve stenosis (22 female, 14 male) with an age range of 25 to 69 years (mean age 47 $pL 9.6 years). Mitral valve volumes were compared between the normal subjects and patients with mitral valve stenosis, and further comparison was made between the sinus rhythm (SR) and atrial fibrillation (AF) groups in patients with mitral valve stenosis. In all study subjects, the mitral valve area (MVA) was determined by two-dimensional echocardiography. Results: Quantitative three-dimensional (3-D) echocardiography showed that mitral valve volume was significantly larger in patients with mitral valve stenosis than in normal subjects (9.0 $pL 2.2 and 4.5 $pL 0.7 ml, respectively, p<0.001). When patients with mitral valve stenosis were divided into the SR and AF groups, mitral valve volume was found to be significantly larger in the AF group than in the SR group (9.76 $pL 2.2 ml.and 7.72 $pL 1.5 ml, respectively, p < 0.01) and patients in the AF group tended to be older (p < 0.05) with larger left atrial diameter (LAD) (p<0.01). However, MVA between the two groups showed no statistical significance (1.1 $pL 0.43 and 1.0 $pL 0.34 cm², respectively, p >0.2). When the study subjects were divided into two groups (< 50 and > 50 years) according to age, the comparison of mitral valve volume between these two groups (9.37 $pL 2.18 and 8.56 $pL 2.14 ml, p >0.2) showed no statistical significance. Conclusions: Quantitative 3-D echocardiography can be applied for the measurement of mitral valve volume in vivo. Patients with rheumatic mitral valve stenosis with atrial fibril lation have a propensity to have a larger mitral valve volume and are older than the patients with sinus rhythm; however, the age per se does not seem to be a cause for larger mitral valve volume.     

Echocardiography in mitral valve disease: A review

Summary Echocardiographic evaluation of the mitral valve has attracted much attention and generated much discussion since its beginnings, some thirty years ago. Echocardiography affords the physician a detailed assessment of mitral valve integrity unequalled by any other non-invasive test. Aside from the normal appearance of the valve, a variety of pathological conditions have been studied in detail; mitral stenosis was the first and over the years the state-of-the-art has evolved from simply looking at the EF slope as an indicator of severity to the accurate quantification utilizing planimetry and pressure half-time. Mitral regurgitation, although not as well quantified as mitral stenosis, can be detected and its etiology usually determined. Mitral valve prolapse may easily be overdiagnosed by echocardiography, however together with auscultation, ultrasound remains the best way to evaluate this common condition. Echocardiography is also invaluable in the evaluation of endocarditis and prosthetic mitral valves.     

A rare case series of mitral valve clefts diagnosed by 3D echocardiography and mini‐review of the literature

Mitral valve cleft is a rare entity. However, it must be recognized as a differential mechanism for mitral valve regurgitation. 3D transesophageal echocardiography plays an essential role in the evaluation of single and multiple mitral valve clefts, improving morphological and functional assessment of the valve, with potential implications on surgical planning. The authors present four rare cases of mitral valve cleft presenting during adulthood, followed by a mini‐review about the role of 3D echocardiography, as well as its pitfalls, in the assessment of this complex congenital mitral valve disease.     

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.     

Isolated Cleft Mitral Valve with Posterior and Anterior Clefts: a Rare Cause of Congenital Valve Regurgitation

We report a case of isolated cleft mitral valve with two clefts in the posterior and one in the anterior leaflet. Our case adds to the few reports of posterior and multiple mitral valve clefts and to our knowledge is the first using real‐time transoesophageal three‐dimensional echocardiography (3DE) for assessment of isolated cleft mitral valve. (Echocardiography 2010;27:E50‐E52)     

Echocardiography of the mitral valve

Mitral valve disease is the second most common valvular heart disease after the aortic valve worldwide. Mitral valve has historically been a structure of interest by pioneers in echocardiography. One of the earliest applications of echocardiography was in the diagnosis of valvular heart disease, particularly mitral stenosis. In this review we wish to take the reader through the structural and hemodynamic evaluation of the normal mitral valve.     

Evaluation of mitral valve repair by intraoperative transoesophageal echocardiography

Background: Mitral valve repair is the procedure of choice in the surgical management of mitral regurgitation. Intraoperative confirmation of successful repair is essential to the effectiveness of this procedure.
Aims: The aims of this study were: (a) to compare intraoperative transoesophageal echocardiography (TOE) with the surgeon's assessment of valve competence; (b) to assess the impact of routine intraoperative imaging on the hospital echocardiography laboratory.
Methods: Eighty-six consecutive patients undergoing mitral valve repair formed the study population. Valve competence following repair was assessed intraoperatively by: TOE; saline insufflation of the flaccid left ventricle; and evaluation of the pulmonary capillary wedge pressure for the presence of a significant V wave.
Results: TOE demonstrated successful valve repair (≤ 1 + residual regurgitation) in 75 patients (87%) and detected significant residual regurgitation (≥3 +) in seven (8.2%). The mechanism of regurgitation was also clearly shown. Of these seven patients, four underwent immediate valve replacement, two had successful revision of the initial repair and one required valve replacement one week later. In all seven patients the valve repair had been assessed as successful by saline testing and only one had a post-repair V wave 10 mmHg above the mean pulmonary capillary wedge pressure. In 30 non-selected patients the imaging equipment was required in theatre for 43 ± 18 minutes.
Conclusions : TOE is currently the most sensitive method for detection and quantitation of residual mitral regurgitation following valve repair. Evaluation can be performed within a similar time to that required for one complete transthoracic study and can usually be performed with minimal disruption to the hospital echocardiography laboratory. (Aust NZ J Med 1993; 23: 463–469.)     

Three-dimensional echocardiography in mitral valve disease.

Three-dimensional echocardiography offers great promise for improving the understanding of the mitral valve anatomy, function, and pathology. It may have important implications for medical or surgical management of different mitral valve disease. In this article we provide an overview of the three-dimensional anatomy of the mitral valve. Based on the studies using three-dimensional echocardiography we describe the topography of the mitral valve, its nonplanarity as well as dynamics of the mitral annulus. Furthermore, we review the use of three-dimensional echocardiography in the evaluation of different mitral valve disease. Three-dimensional echocardiography has become a new clinical standard in the assessment of the severity of mitral stenosis by means of accurate mitral valve area measurement. Also, unconventional indices, like the geometry and mitral valve volume may be assessed by three-dimensional echocardiography. It is a very suitable technique for monitoring the efficacy and complications of percutaneous mitral valvuloplasty. Three-dimensional echocardiography allows accurate identification and quantification of prolapse of individual segments of the mitral valve leaflets. Three-dimensional color flow imaging makes echocardiography an accurate method also in the assessment of mitral regurgitation severity. Finally, we outline three-dimensional echocardiography as a potentially useful guide for a surgeon, particularly in mitral valve repair.     

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)     

Use of three‐dimensional transesophageal echocardiography to evaluate mitral valve morphology for risk stratification prior to mitral valvuloplasty

Mitral stenosis is often managed percutaneously with an interventional procedure such as balloon commissurotomy. Although this often results in an increased mitral valve area and improved clinical symptoms, this procedure is not benign and may have serious complications including the development of hemodynamically significant mitral valve regurgitation. Multiple scoring systems have been developed to attempt to risk stratify these patients prior to their procedure. Case: A 64‐year‐old patient underwent an emergent mitral valve replacement after having percutaneous mitral balloon commissurotomy complicated by development of severe mitral regurgitation. Prior to valvuloplasty, her mitral valve was evaluated by traditional methods including calculation of a Wilkins score. Her mitral valve was evaluated after valvuloplasty and preoperatively with three‐dimensional transesophageal echocardiography. This examination demonstrated heterogeneous distribution of calcification affecting the mitral valve commissures more than the leaflets, which is consistent with the noncommissural leaflet tearing that occurred during her procedure, causing severe mitral regurgitation. In the future, careful 3D evaluation of mitral valve morphology including leaflets, annular calcification, and subvalvular apparatus may help risk stratify patients prior to intervention.     

An Incidental Finding of Mitral Valve Network

A 63‐year‐old male presented with a 6‐month history of worsening exertional dyspnea and was found to have three‐vessel coronary artery disease. Transesophageal echocardiography revealed a filamentous structure attached to the anterior mitral valve leaflet, which was confirmed during surgery as filamentous network. To our knowledge, this is the first report to describe such a network attached to the mitral valve. (Echocardiography 2010;27:E87‐E89)     

Usefulness of two‐ and three‐dimensional transesophageal echocardiography in combined mitral valve‐in‐valve implantation and paraprosthetic leak closure

We demonstrate the usefulness of two‐ and live/real time three‐dimensional transesophageal echocardiography in a procedure, which combined transcatheter mitral valve‐in‐valve deployment and paraprosthetic leak closure in the same setting using the less invasive transfemoral approach in an adult patient with bioprosthetic mitral valve degeneration. We also highlight the additive value of three‐dimensional echocardiography over the two‐dimensional technique.     

Culture-negative suppurative endocarditis causing severe mitral valve obstruction: complementary use of transesophageal and transthoracic echocardiography

Infective endocarditis causes a myriad number of serious complications. Mitral valve obstruction is a rare complication. We report a 48-year-old Asian female who presented with two-week duration of fever and rapidly developed acute pulmonary edema and cardiogenic shock. Sequential transthoracic and transesophageal echocardiography revealed a rapidly growing vegetation on the anterior mitral leaflet with severe stenosis of the valve. All the blood cultures were negative. The patient underwent a successful mitral valve replacement. A review of 21 previously reported cases of mitral valve obstruction from endocarditis demonstrates the poor prognosis of this entity and supports early surgery.     

经食管超声心动图评价人工心脏瓣膜的功能

本文利用经胸及经食管超声技术观察了51例人工瓣膜置换术后的瓣膜功能及反流程度,并比较了两种技术在评价人工瓣膜中的优缺点。结果表明:(1)经食管超声心动图(TEE)在观察左房及左心耳血栓,判定二尖瓣位人工机械瓣反流程度及鉴别反流与瓣周漏方面均优于经胸超声心动图(TTE)技术,(2)TEE在检出人工二尖瓣反流方面明显优于TTE,且TEE及TTE对人工二尖瓣反流的检出率分别为87.76%和14.29%,(3)TEE在检出主动瓣反流方面与TTE比较,无显著性差异(P>0.05),但可低估瓣膜反流程度。经食管超声技术是判定二尖瓣位人工瓣功能异常的敏感、可靠方法。     

Detection of spontaneous echocardiographic contrast within the left atrium by transesophageal echocardiography: spontaneous echocardiographic contrast

Transesophageal echocardiography was performed in 314 patients over a period of 24 months using a 3.5 MHz phased-array system fitted to the distal end of a conventional 12 mm endoscope. In 12 patients (2.6%) transesophageal echocardiography could not be performed because of adverse reaction to the gastroscopic procedure. Side effects were a transient A-V block in one patient and asthmatic attack in another. Mitral valve lesions were found in 99 of 314 patients. In 9 of these 99 patients (11%), including 1 patient with mitral valve stenosis and sinus rhythm, 2 with atrial fibrillation, 3 with disc, and 3 with porcine mitral prosthesis, spontaneous echocardiographic contrast was found within the left atrium, described as faint echoes in 2 patients and dense echoes filling the whole left atrium and following turbulent flow in the other 7 patients. Only in 2 patients was left atrium shown to have additional echoes within its cavity in the four-chamber view by transthoracic echocardiography. Signs of cerebral emboli were found in 5 of 9 patients and of peripheral embolism in 3 of 9 patients. Their mechanism seems to involve red cell aggregation, which is greatest at low flow velocity such as in dilated left atria in the case of mitral valve stenosis or prosthesis. The additional effect of platelet aggregation must be discussed because increased platelet aggregation was detected in all patients with spontaneous echocardiographic contrast. Transesophageal echocardiography seems to be of great diagnostic value in patients with mitral valve lesions and cerebral and peripheral embolism, giving new insight into the pathophysiologic mechanism and possibly improving the therapeutic approach in the near future.     

Factors determining early improvement in mitral regurgitation after aortic valve replacement for aortic valve stenosis: a transthoracic and transesophageal prospective study

BACKGROUND: Mitral regurgitation (MR) is frequently associated with aortic stenosis. Previous reports have shown that coexisting mitral insufficiency can potentially regress after aortic valve replacement. HYPOTHESIS: This study sought to assess the frequency and severity of MR before and after aortic valve replacement for aortic stenosis and to define the determinants of its postoperative evolution. METHODS: For this purpose, 30 adult patients referred for aortic valve surgery underwent pre- and postoperative transthoracic and transesophageal echocardiography and color Doppler examination. RESULTS: Mean preoperative left ventricular ejection fraction was 57 +/- 16% and remained unchanged postoperatively. Preoperative MR was usually mild to moderate and correlated with aortic stenosis severity and left ventricular systolic dysfunction. The color Doppler mitral regurgitant jet area significantly decreased during the postoperative period (p = 0.016) as left ventricular loading conditions returned to normal, suggesting an early decrease of the functional part of MR. On the other hand, the mitral regurgitant jet width at the origin remained unchanged. Statistical analysis found pulmonary artery pressure (p = 0.02) an d indexed left ventricular mass (p = 0.009) to be preoperative predictive factors of postoperative MR improvement. Predictive factors of postoperative MR severity were left atrial diameter (p = 0.02), pulmonary artery pressure (p = 0.003), and the presence of mitral calcifications (p = 0.004). CONCLUSION: In our cohort of patients with normal left venticular ejection fraction, the majority of moderate MR, associated with severe aortic stenosis, regresses early after aortic valve replacement. Mitral calcifications and/or left atrial dilation seem to be predictive factors of fixed MR.     

Three-Dimensional Echocardiographic Evaluation of Aortic and Mitral Valve Stenosis

Dynamic volume rendered three-dimensional echocardiography allows the spatial recognition of anatomy and function of the aortic and mitral valves with acceptable image quality. The aortic valve can be best visualized in a view from the ascending aorta down to the valve level, thus allowing an overview of the aortic aspect of the valve in a surgeon's perspective in ∼ 80% of patients. Planimetric measurement of the aortic valve area was possible in 88% of patients, and there is no systematic overestimation or underestimation of aortic valve area compared with two-dimensional echocardiography and catheterization. The entire valvular circumference of the mitral valve can be assessed from both a left atrial and a left ventricular perspective. Advantages of the three-dimensional transesophageal echocardiography mitral valve area determination compared with transthoracic two-dimensional planimetry and Doppler-derived pressure half-time method are present in patients with severely calcified mitral valves and in those with combined aortic regurgitation.     

肥厚型梗阻性心肌病患者二尖瓣叶长度及对合形态异常的超声心动图随访研究

目的:应用超声心动图评估肥厚型梗阻性心肌病(HOCM)患者二尖瓣叶长度及对合形态的特点,以及单纯行扩大室间隔切除术后二尖瓣叶对合形态的改变。方法:入组2012年至2017年间中国医学科学院阜外医院由同一个有经验术者行扩大室间隔切除术(术中未特殊处理二尖瓣叶)的HOCM患者52例为HOCM组,同时纳入性别和年龄相匹配的健康受试者23例为正常对照组。比较两组二尖瓣参数以及左心房、室指标的差异,且随访观察HOCM组患者在扩大室间隔切除术前、术后二尖瓣参数和左心房、室指标的变化以及是否出现新发的、有血流动力学意义的二尖瓣反流。平均随访(7.10±7.57)个月。结果:与正常对照组比较,HOCM组患者二尖瓣瓣环前后径(Ann D)、二尖瓣前叶长度(ALL)、后叶长度(PLL)、前乳头肌根部直径(APM)和反乳头肌根部直径(PPM)均增大(P均<0.01),前叶在瓣环上的投影长度(Pro L)及其占瓣环总长度的比例(Pro R)均减小(P均<0.01),左心房前后径(LAD)增大,室间隔基底段厚度(IVS)明显增加,左心室舒张末期内径(LVEDD)减小(P<0.01),瓣叶对合高度(Ten H)无差异(P>0.01),瓣叶对合点到前室间隔的最近距离(C-sept)及乳头肌连线平面与前室间隔的距离(S-P)均明显减小(P<0.01)。与术前比较,HOCM组患者在扩大室间隔切除术后,二尖瓣反流明显减少(P<0.01),二尖瓣反流均在轻度以下,未见新发的有血流动力学意义的反流;Ann D、Pro L、Pro R、Ten H与术前比较均无明显差异(P均>0.01),C-sept及S-P较术前均明显增大(P均<0.01);LAD、IVS、左心室后壁厚度(LVPWD)、左心室射血分数(LVEF)较术前均明显减小,LVEDD较术前增大(P均<0.01)。结论:HOCM患者经过充分的室间隔切除,二尖瓣反流均能得到明显改善。虽然二尖瓣前后叶均延长,但术后中期随访结果未见新发的、有血流动力学意义的二尖瓣反流。HOCM患者二尖瓣对合形态异常、对合点前移,手术解除梗阻后,异常的对合形态未见恢复。     

经食道超声心动图在二尖瓣关闭不全瓣膜修补术中的应用

对严重的二尖瓣关闭不全病人进行二尖瓣修补术与置换相比，有着明显的利益，然而，部分病例修补术后可能持续存在二尖瓣返流，且传统的术中评价二尖瓣修补术效果的方法往往不可靠。本组术中经食道超声心动图（TEE）发现二尖瓣修补术后仍有22％（2／9）的病例存在严重的二失瓣返流，根据这一信息．这2例病人当即进行了二尖瓣置换术。随访16～24个月，7例二尖瓣修补术的病人心功能一级，无需再次手术。因此，术中TEE技术是快速准确的评价瓣膜修补术效果的方法，保证了手术的成功，能使更多更复杂的病例进行二尖瓣修补术。