Valvular heart disease
Real-Time Three-Dimensional Transesophageal Echocardiography for Assessment of Mitral Valve Functional Anatomy in Patients With Prolapse-Related Regurgitation

https://doi.org/10.1016/j.amjcard.2010.12.048Get rights and content

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.

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Methods

From May 2008 to January 2009, we prospectively enrolled 222 consecutive patients referred to our institute for surgical repair of prolapse-related mitral regurgitation. The inclusion criteria for the study were MV prolapse with related severe mitral regurgitation (effective regurgitant orifice ≥0.4 cm2, vena contracta >7 mm, regurgitant volume >60 ml); a complete transthoracic and transesophageal preoperative echocardiographic study; and surgical MV repair within 1 uneventful week from the

Results

Interpretable RT3D-TEE was feasible in all patients, with optimal (90%) and suboptimal (10%) imaging, although off-line reconstruction, removing artifacts, and/or optimizing the ultrasound gain and the smoothing setting improved the suboptimal quality of the examinations. All RT3D-transesophageal echocardiographic zoom mode studies were suitable for quantitative analysis. However, the full-volume data sets were excluded because of the high incidence (60%) of stitching artifacts during off-line

Discussion

The main finding of the present study was that RT3D-TEE is highly accurate for valve lesion mapping in patients with prolapse-related mitral regurgitation who undergo surgical repair. Furthermore, RT3D-TEE provided a quantitative patient-related analysis to determine the objective diagnosis of prolapse in all MV segments along the standard anteroposterior annular plane, together with the recognition of dominant or secondary prolapse. Using the findings from RT3D-TEE, the ≥5-mm leaflet

Acknowledgment

We thank Michael John, BA, of the Vita-Salute San Raffaele University for the English language revision of our report.

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