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Three-dimensional Echocardiography of the Mitral Valve Leaflet Anatomy and Repair

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Abstract

Three-dimensional echocardiography (3DE) has made tremendous strides in the past decade and its promise of a seamless integration into clinical practice is being increasingly realized. Its realistic views of the mitral valve (MV) provide a unique surgical perspective. From its detailed morphologic characteristics to its reproducible quantitative analysis of the MV, 3DE’s role in complex MV disease has become indispensible. In this article we review the current utilization of 3DE and its incremental role over two-dimensional echocardiography in various clinical situations, including etiologic classification and severity of degenerative MV disease, understanding the complex geometric changes and interactions of the MV components in ischemic mitral regurgitation, and facilitation of surgical and percutaneous MV repair by intra-procedural guidance as well as reliable post-repair assessment.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Bonow RO, Carabello BA, Chatterjee K, et al.: 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008, 52:e1–e142.

    Article  PubMed  Google Scholar 

  2. Garcia-Orta R, Moreno E, Vidal M, et al.: Three-dimensional versus two-dimensional transesophageal echocardiography in mitral valve repair. J Am Soc Echocardiogr 2007, 20:4–12.

    Article  PubMed  Google Scholar 

  3. Otsuji Y, Handschumacher MD, Schwammenthal E, et al.: Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation 1997, 96:1999–2008.

    CAS  PubMed  Google Scholar 

  4. Levine RA, Handschumacher MD, Sanfilippo AJ, et al.: Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse. Circulation 1989, 80:589–598.

    CAS  PubMed  Google Scholar 

  5. Watanabe N, Ogasawara Y, Yamaura Y, et al.: Quantitation of mitral valve tenting in ischemic mitral regurgitation by transthoracic real-time three-dimensional echocardiography. J Am Coll Cardiol 2005, 45:763–769.

    Article  PubMed  Google Scholar 

  6. Zamorano J, Cordeiro P, Sugeng L, et al.: Real-time three-dimensional echocardiography for rheumatic mitral valve stenosis evaluation: an accurate and novel approach. J Am Coll Cardiol 2004, 43:2091–2096.

    Article  PubMed  Google Scholar 

  7. Sugeng L, Coon P, Weinert L, et al.: Use of real-time 3-dimensional transthoracic echocardiography in the evaluation of mitral valve disease. J Am Soc Echocardiogr 2006, 19:413–421.

    Article  PubMed  Google Scholar 

  8. Hung J, Lang R, Flachskampf F, et al.: 3D echocardiography: a review of the current status and future directions. J Am Soc Echocardiogr 2007, 20:213–233.

    Article  PubMed  Google Scholar 

  9. Salgo IS, Gorman JH 3rd, Gorman RC, et al.: Effect of annular shape on leaflet curvature in reducing mitral leaflet stress. Circulation 2002, 106:711–717.

    Article  PubMed  Google Scholar 

  10. Levine RA, Weyman AE, Handschumacher MD: Three-dimensional echocardiography: techniques and applications. Am J Cardiol 1992, 69:121H–130H; discussion 131H–134H.

    Article  CAS  PubMed  Google Scholar 

  11. Gross L, Kugel MA: Topographic anatomy and histology of the valves in the human heart. Am J Pathol 1931, 7:445–474.7.

    CAS  PubMed  Google Scholar 

  12. Carpentier A: Cardiac valve surgery—the “French correction.” J Thorac Cardiovasc Surg 1983, 86:323–337.

    CAS  PubMed  Google Scholar 

  13. Rusted IE, Scheifley CH, Edwards JE: Studies of the mitral valve. I. Anatomic features of the normal mitral valve and associated structures. Circulation 1952, 6:825–831.

    CAS  PubMed  Google Scholar 

  14. • Salcedo EE, Quaife RA, Seres T, Carroll JD: A framework for systematic characterization of the mitral valve by real-time three-dimensional transesophageal echocardiography. J Am Soc Echocardiogr 2009, 22:1087–1099. In this review, the authors present a framework for the application of 3D-TEE in the evaluation of patients with structural or functional MV disease, outline an examination protocol, and address the advantages and limitations of the current platform for 3D-TEE.

    Article  PubMed  Google Scholar 

  15. Schwalm SA, Sugeng L, Raman J, et al.: Assessment of mitral valve leaflet perforation as a result of infective endocarditis by 3-dimensional real-time echocardiography. J Am Soc Echocardiogr 2004, 17:919–922.

    Article  PubMed  Google Scholar 

  16. Langer F, Rodriguez F, Ortiz S, et al.: Subvalvular repair: the key to repairing ischemic mitral regurgitation? Circulation 2005, 112(9 Suppl):I383–I389.

    PubMed  Google Scholar 

  17. Avierinos JF, Gersh BJ, Melton LJ 3rd, et al.: Natural history of asymptomatic mitral valve prolapse in the community. Circulation 2002, 106:1355–1361.

    Article  PubMed  Google Scholar 

  18. Barlow JB, Pocock WA: Billowing, floppy, prolapsed or flail mitral valves? Am J Cardiol 1985, 55:501–502.

    Article  CAS  PubMed  Google Scholar 

  19. Carpentier A, Chauvaud S, Fabiani JN, et al.: Reconstructive surgery of mitral valve incompetence: ten-year appraisal. J Thorac Cardiovasc Surg 1980, 79:338–348.

    CAS  PubMed  Google Scholar 

  20. Ahmed S, Nanda NC, Miller AP, et al.: Usefulness of transesophageal three-dimensional echocardiography in the identification of individual segment/scallop prolapse of the mitral valve. Echocardiography 2003, 20:203–209.

    Article  PubMed  Google Scholar 

  21. Pepi M, Tamborini G, Maltagliati A, et al.: Head-to-head comparison of two- and three-dimensional transthoracic and transesophageal echocardiography in the localization of mitral valve prolapse. J Am Coll Cardiol 2006, 48:2524–2530.

    Article  PubMed  Google Scholar 

  22. • Grewal J, Mankad S, Freeman WK, et al.: Real-time three-dimensional transesophageal echocardiography in the intraoperative assessment of mitral valve disease. J Am Soc Echocardiogr 2009, 22:34–41. Use of real-time 3D-TEE not only identified specific MV pathology intraoperatively, but was superior to 2D-TEE imaging in the diagnosis of P1, A2, A3, and bileaflet disease.

    Article  PubMed  Google Scholar 

  23. • Adams DH, Anyanwu AC: Seeking a higher standard for degenerative mitral valve repair: begin with etiology. J Thorac Cardiovasc Surg 2008, 136:551–556. This important article highlights the significance of etiologic distinction in the field of degenerative MV repair and makes a case for matching the surgical complexity of the lesion with surgical ability.

    Article  PubMed  Google Scholar 

  24. • Beraud AS, Schnittger I, Miller DC, Liang DH: Multiplanar reconstruction of three-dimensional transthoracic echocardiography improves the presurgical assessment of mitral prolapse. J Am Soc Echocardiogr 2009, 22:907–913. In this study, the authors’ use of mutliplanar reconstruction in 3D transthoracic echocardiographic imaging improved the accuracy of the description of the MV prolapse compared to 2D, especially in identifying presence or extent of commissural prolapse.

    Article  PubMed  Google Scholar 

  25. Flameng W, Herijgers P, Bogaerts K: Recurrence of mitral valve regurgitation after mitral valve repair in degenerative valve disease. Circulation 2003, 107:1609–1613.

    Article  PubMed  Google Scholar 

  26. Sitges M, Jones M, Shiota T, et al.: Real-time three-dimensional color doppler evaluation of the flow convergence zone for quantification of mitral regurgitation: validation experimental animal study and initial clinical experience. J Am Soc Echocardiogr 2003, 16:38–45.

    Article  PubMed  Google Scholar 

  27. Iwakura K, Ito H, Kawano S, et al.: Comparison of orifice area by transthoracic three-dimensional Doppler echocardiography versus proximal isovelocity surface area (PISA) method for assessment of mitral regurgitation. Am J Cardiol 2006, 97:1630–1637.

    Article  PubMed  Google Scholar 

  28. Biner S, Rafique A, Rafii F, et al.: Reproducibility of proximal isovelocity surface area, vena contracta, and regurgitant jet area for assessment of mitral regurgitation severity. JACC Cardiovasc Imaging 2010, 3:235–243.

    Article  PubMed  Google Scholar 

  29. Sugeng L, Weinert L, Lang RM: Real-time 3-dimensional color Doppler flow of mitral and tricuspid regurgitation: feasibility and initial quantitative comparison with 2-dimensional methods. J Am Soc Echocardiogr 2007, 20:1050–1057.

    Article  PubMed  Google Scholar 

  30. Little SH, Pirat B, Kumar R, et al.: Three-dimensional color Doppler echocardiography for direct measurement of vena contracta area in mitral regurgitation: in vitro validation and clinical experience. JACC Cardiovasc Imaging 2008, 1:695–704.

    Article  PubMed  Google Scholar 

  31. Mascherbauer J, Rosenhek R, Bittner B, et al.: Doppler echocardiographic assessment of valvular regurgitation severity by measurement of the vena contracta: an in vitro validation study. J Am Soc Echocardiogr 2005, 18:999–1006.

    Article  PubMed  Google Scholar 

  32. Plicht B, Kahlert P, Goldwasser R, et al.: Direct quantification of mitral regurgitant flow volume by real-time three-dimensional echocardiography using dealiasing of color Doppler flow at the vena contracta. J Am Soc Echocardiogr 2008, 21:1337–1346.

    Article  PubMed  Google Scholar 

  33. Skaug TR, Hergum T, Amundsen BH, et al.: Quantification of mitral regurgitation using high pulse repetition frequency three-dimensional color Doppler. J Am Soc Echocardiogr 2010, 23:1–8.

    Article  PubMed  Google Scholar 

  34. Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA: Mechanism of ischemic mitral regurgitation. An experimental evaluation. Circulation 1991, 84:2167–2180.

    CAS  PubMed  Google Scholar 

  35. Messas E, Guerrero JL, Handschumacher MD, et al.: Paradoxic decrease in ischemic mitral regurgitation with papillary muscle dysfunction: insights from three-dimensional and contrast echocardiography with strain rate measurement. Circulation 2001, 104:1952–1957.

    Article  CAS  PubMed  Google Scholar 

  36. Otsuji Y, Handschumacher MD, Liel-Cohen N, et al.: Mechanism of ischemic mitral regurgitation with segmental left ventricular dysfunction: three-dimensional echocardiographic studies in models of acute and chronic progressive regurgitation. J Am Coll Cardiol 2001, 37:641–648.

    Article  CAS  PubMed  Google Scholar 

  37. Otsuji Y, Kumanohoso T, Yoshifuku S, et al.: Isolated annular dilation does not usually cause important functional mitral regurgitation: comparison between patients with lone atrial fibrillation and those with idiopathic or ischemic cardiomyopathy. J Am Coll Cardiol 2002, 39:1651–1656.

    Article  PubMed  Google Scholar 

  38. Liel-Cohen N, Guerrero JL, Otsuji Y, et al.: Design of a new surgical approach for ventricular remodeling to relieve ischemic mitral regurgitation: insights from 3-dimensional echocardiography. Circulation 2000, 101:2756–2763.

    CAS  PubMed  Google Scholar 

  39. Yamaura Y, Yoshida K, Hozumi T, et al.: Three-dimensional echocardiographic evaluation of configuration and dynamics of the mitral annulus in patients fitted with an annuloplasty ring. J Heart Valve Dis 1997, 6:43–47.

    CAS  PubMed  Google Scholar 

  40. Tsukiji M, Watanabe N, Yamaura Y, et al.: Three-dimensional quantitation of mitral valve coaptation by a novel software system with transthoracic real-time three-dimensional echocardiography. J Am Soc Echocardiogr 2008, 21:43–46.

    Article  PubMed  Google Scholar 

  41. Sugeng L, Weinert L, Lammertin G, et al.: Accuracy of mitral valve area measurements using transthoracic rapid freehand 3-dimensional scanning: comparison with noninvasive and invasive methods. J Am Soc Echocardiogr 2003, 16:1292–1300.

    Article  PubMed  Google Scholar 

  42. Binder TM, Rosenhek R, Porenta G, et al.: Improved assessment of mitral valve stenosis by volumetric real-time three-dimensional echocardiography. J Am Coll Cardiol 2000, 36:1355–1361.

    Article  CAS  PubMed  Google Scholar 

  43. Mannaerts HF, Kamp O, Visser CA: Should mitral valve area assessment in patients with mitral stenosis be based on anatomical or on functional evaluation? A plea for 3D echocardiography as the new clinical standard. Eur Heart J 2004, 25:2073–2074.

    Article  PubMed  Google Scholar 

  44. Zamorano J, Perez de Isla L, Sugeng L, et al.: Non-invasive assessment of mitral valve area during percutaneous balloon mitral valvuloplasty: role of real-time 3D echocardiography. Eur Heart J 2004, 25:2086–2091.

    Article  PubMed  Google Scholar 

  45. Abraham TP, Warner JG Jr, Kon ND, et al.: Feasibility, accuracy, and incremental value of intraoperative three-dimensional transesophageal echocardiography in valve surgery. Am J Cardiol 1997, 80:1577–1582.

    Article  CAS  PubMed  Google Scholar 

  46. De Castro S, Salandin V, Cartoni D, et al.: Qualitative and quantitative evaluation of mitral valve morphology by intraoperative volume-rendered three-dimensional echocardiography. J Heart Valve Dis 2002, 11:173–180.

    PubMed  Google Scholar 

  47. Perk G, Lang RM, Garcia-Fernandez MA, et al.: Use of real time three-dimensional transesophageal echocardiography in intracardiac catheter based interventions. J Am Soc Echocardiogr 2009, 22:865–882.

    Article  PubMed  Google Scholar 

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Disclosure

Dr. Sugeng is a member of the Speakers’ Bureau for Philips Medical Systems.

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Authors and Affiliations

  1. University of Chicago, MC 5084, 5841 South Maryland Avenue, Chicago, IL, 60637, USA

    Sonal Chandra, Lissa Sugeng & Roberto M. Lang

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  1. Sonal Chandra
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  2. Lissa Sugeng
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  3. Roberto M. Lang
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Correspondence to Roberto M. Lang.

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Chandra, S., Sugeng, L. & Lang, R.M. Three-dimensional Echocardiography of the Mitral Valve Leaflet Anatomy and Repair. Curr Cardiovasc Imaging Rep 3, 268–275 (2010). https://doi.org/10.1007/s12410-010-9035-7

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