Feasibility of measurements of valve dimensions in en-face-3D transesophageal echocardiography

Measurement of mitral valve area by direct three dimensional planimetry compared to multiplanar reconstruction in patients with rheumatic mitral stenosis

Mitral valve area (MVA) measurement by three-dimensional transesophageal echocardiography (3D-TEE) has a crucial role in the evaluation of mitral stenosis (MS) severity. Three-dimensional direct (3D-direct) planimetry has been proposed as a new technique to measure mitral valve area. This study aimed to compare the 3D-direct mitral valve planimetry to conventional three-dimensional multiplanar reconstruction (3D-MPR) in severe MS using 3D-TEE. In this cross-sectional, prospective study; 149 patients with severe MS who were referred for transesophageal echocardiography in Shahid Madani Hospital (Tabriz Iran), just before percutaneous transmitral commissurotomy (PTMC), recruited consecutively. All patients underwent 2D transthoracic echocardiography (2D-TTE) and 3D-TEE in a single session before PTMC. During 2D-TTE planimetry, pressure half time (PHT), and proximal isovelocity surface area (PISA) were applied to measure the MVA. Transmitral mean pressure gradient (MPG) was measured. During 3D-TEE, MVA planimetry was carried out with both 3D-direct and 3D-MPR methods. 3D-direct was applied from both atrial and ventricular views. The consistency of MVA measurements with 3D-direct, 3D-MPR, and 2D-TTE methods was statistically investigated. Our sample consisted of 109 (73.2%) women and 40 (26.8%) men. The mean age was 51.75 ± 9.81 years. The agreement between 3D-direct and 3D-MPR planimetry was significant and moderate (0.99 ± 0.29 cm2 vs. 1.12 ± 0.26 cm2, intraclass correlation = 0.716, p value = 0.001).The accuracy of the 3D-direct method reduced significantly compared to the MPR method at MVA > 1.5 cm2. The maximum difference between two methods was observed in cases with MVAs larger than 1.5 cm2. MVA measured with the 3D-MPR method was significantly correlated with a 2D-TTE method, with a moderate agreement (intraclass correlation = 0.644, p value = 0.001). Also, 2D-TTE and 3D-direct TEE techniques yielded significantly consistent measurements of the MVA (1.06 ± 0.026 cm2 vs. 0.99 ± 0.29 cm2, intraclass correlation = 0.787, p value = 0.001); however, with a slight overestimation of the MVA by the former with a net difference of 0.06 ± 0.013 cm2. Mitral valve pressure gradient (MPG) had no significant correlation with planimetry results. A significant inverse correlation was seen between the MVA and pulmonary arterial systolic pressure. 3D-direct planimetry has an acceptable agreement with 3D-MPR planimetry at MVA less than 1.5 cm2, but their correlation decreases significantly at MVA above 1.5 cm2. 3D-direct planimetry underestimates MVA compared to 3D-MPR, especially at MVA above 1.5 cm2. It seems that the saddle shape of mitral valve, interferes with 3D-direct measurement of commissures at moderate MS. The 2D-TTE planimetry has generally acceptable accuracy, but its correlation to the 3D-TEE methods is significantly reduced in cases with moderate to severe MS (i.e. MVA > 1.0 cm2).

ACR Appropriateness Criteria® Dyspnea-Suspected Cardiac Origin (Ischemia Already Excluded): 2021 Update

Dyspnea is the symptom of perceived breathing discomfort and is commonly encountered in a variety of clinical settings. Cardiac etiologies of dyspnea are an important consideration; among these, valvular heart disease (Variant 1), arrhythmia (Variant 2), and pericardial disease (Variant 3) are reviewed in this document. Imaging plays an important role in the clinical assessment of these suspected abnormalities, with usually appropriate procedures including resting transthoracic echocardiography in all three variants, radiography for Variants 1 and 3, MRI heart function and morphology in Variants 2 and 3, and CT heart function and morphology with intravenous contrast for Variant 3. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Three-dimensional transesophageal echocardiography measurement of mitral valve area in patients with rheumatic mitral stenosis: multiplanar reconstruction or 3D direct planimetry?

3D direct planimetry is increasingly used in clinical practice as a rapid way to measure the mitral valve area (MVA) in patients with rheumatic mitral stenosis (MS) who underwent three-dimensional transesophageal echocardiography (3D-TEE). However, data on its accuracy and reliability are scarce. This study aimed to compare the MVA measurements obtained by 3D direct planimetry to the conventional technique multiplanar reconstruction (MPR) in MS patients using 3D-TEE. We retrospectively included 49 patients with rheumatic MS undergoing clinically-indicated 3D-TEE in the study. We determined the 3D direct planimetry measurements of MVA from the left atria aspect (MVA_LA) and the left ventricle aspect (MVA_LV), and compared those with the MPR method (MVA_MPR). We also assessed the major and minor diameters of the mitral valve orifice using MPR and 3D direct planimetry. We found an excellent agreement between the MVA measurements obtained by the MPR method and 3D direct planimetry (MVA_LA and MVA_LV) [intraclass correlation coefficients (ICC) = 0.951 and 0.950, respectively]. However, the MVA_MPR measurements were significantly larger than the MVA_LA and MVA_LV (p < 0.001; mean difference: 0.12 ± 0.15 cm² and 0.11 ± 0.16 cm², respectively).The inter-observer and intra-observer variability ICC were 0.875 and 0.856 for MVA_MPR, 0.982 and 0.984 for MVA_LA, and 0.988 and 0.986 for MVA_LV, respectively. The major diameter measured by MPR (1.90 ± 0.42 cm) was significantly larger than that obtained by 3D direct planimetry (1.72 ± 0.35 cm for the LA aspect, p < 0.001; 1.73 ± 0.36 cm for the LV aspect, p < 0.001). The minor diameter measured by MPR (0.96 ± 0.25 cm) did not differ from that derived by 3D direct planimetry (0.94 ± 0.25 cm for the LA aspect, p = 0.07; 0.95 ± 0.27 cm for the LV aspect, p = 0.32). 3D direct planimetry provides highly reproducible measurements of MVA and yields data in excellent agreement with those obtained by the MPR method. The discrepancy between the two techniques may be due to differences in major diameter measurements of the mitral valve orifice.

Measurement of mitral valve area in patients with mitral stenosis by 3D echocardiography: A comparison between direct planimetry on 3D zoom and 3D quantification

BACKGROUND

Measurement of the mitral valve area (MVA) in patients with mitral stenosis (MS) by 3D echocardiography (3DE) is usually done via 3D quantification (3DQ). The present study on patients with severe MS sought to evaluate the agreement regarding the MVA measurement between 3DQ and direct planimetry on 3D zoom and also between 3DE and 2DE.

METHODS

Twenty-six patients (22 female, mean age:34.5 ± 14.0 years) with severe MS diagnosed by 2D transthoracic echocardiography(2DTTE) underwent 3D transesophageal echocardiography (3DTEE). Direct planimetry, the pressure half-time (PTH), and the continuity equation(CE) constituted 3 conventional 2DTTE methods, and 3DQ and direct planimetry on 3D zoom comprised two 3DTEE methods applied for the MVA measurement. Agreement between the 2D and 3D methods was assessed using the Bland-Altman plot and measuring the intra-class correlation coefficient (ICC).

RESULTS

The mean MVA measured by 3DQ was significantly larger than that derived by direct planimetry on 3D zoom (0.935 ± 0.23 cm² vs 0.846 ± 0.22 cm² , respectively; P = 0.026). The agreement between 3DQ and 3D zoom for the MVA measurement was moderate to good by the Bland-Altman plot (ICC = 0.67). The mean MVA measured by 2DE (all 3 methods of direct planimetry, the PTH, and the CE) was significantly larger than that derived by 3DE (both methods of 3DQ and direct planimetry on 3D zoom) (all Ps < 0.05). A moderate agreement between 3DQ and 2D planimetry (ICC = 0.43) was found by the Bland-Altman plot.

CONCLUSIONS

The MVA measurement by direct planimetry on 3D zoom showed a moderate-to-good agreement with 3DQ; it may, thus, be used in clinical practice as a simple method for the measurement of the MVA in patients with MS.

Role of 3D Echocardiography in Cardiac Surgery: Strengths and Limitations

PURPOSE OF REVIEW

This review aims to highlight the general and specific strengths and limitations of intraoperative 3D echocardiography. This article explains the value of real-time three-dimensional transesophageal echocardiography (RT 3D TEE) during cardiac surgery and cardiac interventions.

RECENT FINDINGS

Recently published recommendations and guidelines include the use of RT 3D TEE. RT 3 D TEE provides additional value particularly for guidance during cardiac interventions (i.e., transcatheter mitral valve repair, left atrial appendix and atrial septal defect closures), assessment of the mitral valve in surgical repair, measurement of left ventricular outflow tract area for transcatheter valvular replacements, and estimating right and left ventricular volumes and function. The exact localization of paravalvular leakage is another strength of RT 3D TEE. The major limitation is the reduced temporal resolution compared to 2D TEE.

SUMMARY

Three-dimensional echocardiography is a powerful tool that improves communication and accurate measurements of cardiac structures.