Clinical Investigation
Valvular Heart Disease
Quantification of Mitral Valve Anatomy by Three-Dimensional Transesophageal Echocardiography in Mitral Valve Prolapse Predicts Surgical Anatomy and the Complexity of Mitral Valve Repair

https://doi.org/10.1016/j.echo.2012.03.010Get rights and content

Background

Three-dimensional (3D) transesophageal echocardiography (TEE) is more accurate than two-dimensional (2D) TEE in the qualitative assessment of mitral valve (MV) prolapse (MVP). However, the accuracy of 3D TEE in quantifying MV anatomy is less well studied, and its clinical relevance for MV repair is unknown.

Methods

The number of prolapsed segments, leaflet heights, and annular dimensions were assessed using 2D and 3D TEE and compared with surgical measurements in 50 patients (mean age, 61 ± 11 years) who underwent MV repair for mainly advanced MVP.

Results

Three-dimensional TEE was more accurate (92%–100%) than 2D TEE (80%–96%) in identifying prolapsed segments. Three-dimensional TEE and intraoperative measurements of leaflet height did not differ significantly, while 2D TEE significantly overestimated the height of the posterior segment P1 and the anterior segment A2. Three-dimensional TEE quantitative MV measurements were related to surgical technique: patients with more complex MVP (one vs two to four vs five or more prolapsed segments) showed progressive enlargement of annular anteroposterior (31 ± 5 vs 34 ± 4 vs 37 ± 6 mm, respectively, P = .02) and commissural diameters (40 ± 6 vs 44 ± 5 vs 50 ± 10 mm, respectively, P = .04) and needed increasingly complex MV repair with larger annuloplasty bands (60 ± 13 vs 67 ± 9 vs 72 ± 10 mm, P = .02) and more neochordae (7 ± 3 vs 12 ± 5 vs 26 ± 6, P < .01).

Conclusions

Measurements of MV anatomy on 3D TEE are accurate compared with surgical measurements. Quantitative MV characteristics, as assessed by 3D TEE, determined the complexity of MV repair.

Section snippets

Study Population

From October 2009 to November 2010, we prospectively enrolled 50 consecutive patients with severe MR due to MVP who underwent elective surgical MV repair at Toronto General Hospital (Toronto, ON, Canada). For patients without previous TEE (n = 17), study TEE was performed at our echocardiography laboratory. For patients with preoperative TEE performed at external institutions (n = 33), TEE was performed in the operating room. All patients underwent postoperative 2D transthoracic

Study Population

The study population consisted of 50 patients with a mean age of 61 ± 11 years (Table 1). The average 3D full-volume frame rate was 29.6 ± 8.4 Hz. The quality of the 3D full-volume data sets was insufficient for MV quantification in four patients, but qualitative MVP assessment remained feasible using the 3D zoom data sets.

Surgical Findings and Type of Surgery Performed

Twelve patients (24%) were found to have simple (one-segment) MVP, including three patients with FED and nine patients showing only mild myxomatous changes. Thirty-eight

Discussion

In this study of patients with mainly advanced MVP undergoing MV repair, the overall accuracy in detecting prolapse (correct detection of all prolapsed segments) was higher for 3D TEE than for 2D TEE. Compared with direct surgical measurements, 3D TEE was more accurate than 2D TEE in quantifying MV anatomy. Patients with more advanced MVP, as assessed by our integrative 3D transesophageal echocardiographic approach, required a more complex type of MV repair.

Conclusions

In a population of patients with mainly advanced degenerative MV disease, MV quantification on 3D TEE was comparable with direct surgical measurements, and the accuracy for detecting MVP was higher on 3D TEE compared with 2D TEE. Quantitative MV characteristics as assessed by 3D TEE determined the complexity of MV repair.

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