Incremental role of three-dimensional transesophageal echocardiography in the assessment of mitral-aortic intervalvular fibrosa abscess

We report a case of an elderly patient in whom live/real time three-dimensional transesophageal echocardiography (3DTEE) provided definitive diagnosis of mitral-aortic intervalvular fibrosa abscess. This could not be done by two-dimensional transthoracic echocardiography (2DTTE) and two-dimensional transesophageal echocardiography (2DTEE). 3DTEE was also helpful in ruling out associated mitral valve endocarditis, which was initially suspected by 2DTEE leading to a mitral valve sparing surgery. Thus, 3DTEE provided incremental information over 2DTTE and 2DTEE in this patient.     

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.     

Isolated cleft of both the anterior and posterior mitral valve leaflets

A 37 year‐old female patient in whom the transthoracic echocardiography examination revealed dilatation of left heart chambers with left ventricular ejection fraction of 30% and moderate‐to‐severe mitral valve regurgitation was admitted to our hospital. On 2DTEE examination, mitral valve was normal; however, on 3D images, clefts of both anterior and posterior leaflets were revealed. Isolated cleft mitral valve without any other feature of atrioventricular septal defect is uncommon. 2D echocardiography has limited capability in defining the complex 3D anatomic characteristics of the cleft. 3DTEE allows to visualize the cleft position, morphology, and size, and it is important for surgical planning.     

Three‐Dimensional Echocardiography‐Based Prediction of Posterior Leaflet Resection

Clinical long‐term outcomes have shown that partial leaflet resection followed by ring annuloplasty is a reliable and reproducible surgical repair technique for treatment of mitral valve (MV) leaflet prolapse. We report a 61‐year‐old male for three‐dimensional transesophageal echocardiography (3DTEE)‐based virtual posterior leaflet resection and ring annuloplasty. Severe mitral regurgitation was found and computational evaluation demonstrated substantial leaflet malcoaptation and high stress concentration. Following virtual resection and ring annuloplasty, posterior leaflet prolapse markedly decreased, sufficient leaflet coaptation was restored, and high stress concentration disappeared. Virtual MV repair strategies using 3DTEE have the potential to help optimize MV repair.     

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.     

The Incremental Value of RT Three‐Dimensional TEE in the Evaluation of Prosthetic Mitral Valve Ring Thrombosis Complicated with Thromboembolism

Purpose: Although nonobstructive prosthetic valve thrombosis (PVT) does not develop hemodynamic compromise, it carries potential risk for thromboembolism. Real time three‐dimensional transesophageal echocardiography (RT‐3DTEE), has emerged as a complementary tool in depicting “en face” views of prosthesis compared with two‐dimensional transesophageal echocardiography (2DTEE). We aimed to evaluate the utility of RT‐3DTEE in assessment of mitral ring‐located thrombosis. Method: We present 3 cases of mechanical mitral valve thrombosis complicated by thromboembolism, who were all examined and followed‐up by 2D transthoracic echocardiography (TTE), 2DTEE, and RT‐3DTEE. Result: The consequencies of thromboembolism in the patients were coronary embolism, transient ischemic attack, and ischemic stroke, respectively. They were all inadequately anticoagulated at the time of admission. 2DTTE and TEE examination was unsatisfactory; RT‐3DTEE depicted nonobstructive mitral ring thrombosis in each of the patients. The patients were followed up under effective anticoagulation and antiplatelet therapy. RT‐3DTEE was able to demonstrate the evolution of thrombus size in each of the patients. Conclusion: Nonobstructive ring‐located PVT which poses risk for thromboembolism, may be diagnosed with certainty and imaged with clarity utilizing RT‐3DTEE.     

Fenestrated Aneurysm of the Mitral Valve

Aneurysms of the cardiac valves remain rare. In this report, we describe the first case of a left ventricular to mitral valve aneurysm to left atrial shunt through a fenestrated aneurysm of the mitral valve diagnosed and successfully repaired under the guidance of transesophageal echocardiography. The transesophageal echocardiography provided substantial additional data to the transthoracic echocardiography, and was valuable in planning the surgical approach. Transesophageal echocardiography should be considered when clear-cut transthoracic echocardiographic interpretation cannot be made in patients with mitral regurgitation. (ECHOCARDIOGRAPHY, Volume 8, September 1991)     

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.     

A rare cause of retinal artery embolism: Accessory mitral valve tissue

A 42‐year‐old female patient was referred our clinic for investigation of a history of acute retinal artery occlusion. Transthoracic echocardiography showed a cyst‐like, mobile formation on posterior mitral valve leaflet. 2D and real time 3D transesophageal echocardiography showed a flexible circular mobile structure which was attached to posterior mitral valve leaflet. Echocardiographic appearance and morphological characteristics were suggestive of accessory mitral valve tissue.     

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.     

Surgical timing for mitral valve regurgitation

Advances in diagnostic and surgical techniques in the management of mitral regurgitation have resulted in improved survival rates and clinical outcomes. Echocardiography is a valuable noninvasive diagnostic tool in the determination of the timing of surgical correction of mitral regurgitation. Improved surgical techniques, the growing role of mitral valve repair, low operative mortality rates, and improved long-term survival rates are important considerations for earlier surgical intervention in symptomatic patients and in asymptomatic patients with echocardiographic criteria of left ventricular dilatation. Intraoperative transesophageal echocardiography is very useful in mitral valve repair and valve replacement with preservation of chordal structures.     

Intraoperative transesophageal echocardiographic diagnosis of a stuck bioprosthetic mitral valve leaflet

Stuck (immobilized) leaflet of a metallic mitral prosthetic valve due to obstruction by mitral subvalvular apparatus is a well recognized complication after placement of prosthetic valves. However, a stuck mitral valve leaflet involving a bioprosthetic valve has not been reported so far most likely because of increased pliability of tissue leaflets. We describe the first case of a stuck bioprosthetic mitral valve leaflet in which intraoperative transesophageal echocardiography was useful to make a definitive diagnosis and helped to resolve the problem immediately.     

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.     

Ruptured Mitral Valve Aneurysm: An Uncommon Cause of Acute Dyspnoea

The mitral valve aneurysm is a rare disease that is usually induced by infective endocarditis. While the mechanism of the development of this lesion is unclear, complications such as perforation can occur and lead to significant mitral regurgitation. We describe a patient presented with ruptured aneurysm of anterior mitral leaflet resulting in acute severe mitral regurgitation that was confirmed by transthoracic and transesophageal echocardiography. Early detection and prompt intervention are important to prevent the complications of valvular aneurysms, which include rupture, embolism, and endocarditis. This report emphasizes the role of echocardiography in evaluating the mitral valve aneurysms and its complications. (Echocardiography 2010;27:E119‐E121)     

Three-dimensional echocardiography and mitral valve prolapse diagnosis: new insights into leaflet and cardiac chamber morphology, and annulus dynamics

Objectives

This report will focus on current and future applications of three-dimensional echocardiography in both in the pre-operative (mainly transthoracic three-dimensional echocardiography) and intraoperative (transesophageal three-dimensional echocardiography) evaluation of prolapsed mitral valves. Both qualitative (morphologic) and quantitative advantages of this technique will be highlighted. Moreover, new insights into the morphology and dynamics of the leaflets, cardiac chamber and annulus are discussed.

Conclusions

Real-time 3D echocardiography offers distinct advantages over 2D imaging for evaluation of the mitral valve apparatus. It provides a more authentic representation of mitral valve morphology and is useful not only in the pre-operative and post-operative evaluation of patients undergoing mitral valve prolapse surgery, but is already used in several interventional procedures and may facilitate the continuous evolution of new techniques.     

经食管二维与实时三维超声结合在风湿性二尖瓣病变成形术中的应用

目的:研究经食管二维与实时三维超声结合在风湿性二尖瓣病变成形术中的作用。方法:26例临床诊断为风湿性二尖瓣病变拟行二尖瓣成形术患者,术前联合应用经食管二维超声与实时三维超声,对二尖瓣功能不全进行分类,详细定位病变部位,测量二尖瓣前后叶厚度、长度及瓣环径。术后即刻评价疗效。结果:术前超声诊断单纯风湿性二尖瓣关闭不全10例(38.5%),单纯二尖瓣狭窄4例(15.4%),二尖瓣关闭不全重度伴狭窄轻度9例(34.6%),二尖瓣关闭不全重度伴狭窄中度3例(11.5%);瓣膜功能不全Ⅱ型4例(15.4%),ⅡAⅢa-P型18例(69.2%),Ⅲa-AⅢa-P型4例(15.4%)。术后即刻超声评价疗效,3例在超声指导下2次成形,其中2例最终选择瓣膜置换术。结论:经食管二维和实时三维超声心动图结合,在风湿性二尖瓣病变成形术前对瓣膜功能不全进行分类诊断,能准确评估二尖瓣叶厚度和长度,指导术式和人工瓣环的选择。术后即刻评价疗效,在风湿性二尖瓣成形术中有重要的应用价值。     

Utility of Live/Real Time Three‐Dimensional Transesophageal Echocardiography in the Assessment and Percutaneous Intervention of Bioprosthetic Pulmonary Valve Stenosis

Accurate echocardiographic evaluation of the pulmonary valve is technically difficult because of its close proximity to the left lung, which often limits decision making. Pulmonary valvotomy is the intervention of choice for symptomatic pulmonary valve stenosis, but fluoroscopy lacks appropriate real time anatomic detail. In this report, we present a case where direct imaging of the pulmonary valve with live/real time three‐dimensional transesophageal echocardiography (3DTEE) aided in accurate evaluation and was then used to help guide and monitor successful valvuloplasty of a stenotic pulmonary valve bioprosthesis. We demonstrate that even in cases where two‐dimensional (2D) evaluation of the pulmonary valve is difficult, the use of live/real time 3DTEE allows for accurate evaluation of bioprosthetic pulmonary valve structure and function, and enhances the precision and monitoring of percutaneous valvuloplasty.     

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.     

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.     

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.