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Tusa M, Popolo Rubbio A, Sisinni A, Borin A, Barletta M, Grasso C, Adamo M, Denti P, Giordano A, De Marco F, Bartorelli AL, Montorfano M, Godino C, Citro R, De Felice F, Mongiardo A, Monteforte I, Villa E, Petronio AS, Giannini C, Munafò AR, Crimi G, Tarantini G, Testa L, Tamburino C, Bedogni F. Prognostic Significance of Flail Mitral Leaflet in Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation. Am J Cardiol 2023; 200:178-187. [PMID: 37331223 DOI: 10.1016/j.amjcard.2023.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 04/17/2023] [Accepted: 05/21/2023] [Indexed: 06/20/2023]
Abstract
Despite the growing experience with MitraClip in the broad spectrum of mitral regurgitation (MR), limited data are available regarding the independent prognostic role on survival of different mitral regurgitation etiology subtypes. We sought to evaluate the impact of flail leaflet etiology in a large series of patients with primary MR (PMR) who underwent MitraClip treatment. The study included 588 patients with significant PMR from the multicenter GIOTTO (Italian Society of Interventional Cardiology [GIse] registry Of Transcatheter treatment of mitral valve regurgitaTiOn), stratified into 2 groups according to MR etiology: flail+ (n = 300) and flail- (n = 288). The primary end point was a composite of cardiac death and first rehospitalization for heart failure (HF). To account for the baseline differences, patients were propensity score-matched 1:1. Flail leaflet etiology was present in about a half of the patients. Acute technical success was achieved in 98% of the overall cohort, with no significant differences between the study groups (p = 0.789). At the 2-year Kaplan-Meier analysis, the primary end point occurred in 13% of flail+ patients compared with 23% in flail- (p = 0.009). The flail+ group presented lower rates of both cardiac death and rehospitalization for HF, whereas a similar overall death rate was observed between the groups. A multivariate Cox regression analysis identified flail leaflet etiology as an independent predictor of favorable outcome in terms of the primary end point (hazard ratio 0.141, 95% confidence interval 0.049 to 0.401, p <0.001). After propensity score matching, flail+ patients had confirmed lower rates of cardiac mortality and rehospitalization for HF but similar rates of overall death. In conclusion, flail leaflet-related etiology was common in patients with PMR who underwent MitraClip treatment and was an independent predictor of midterm favorable clinical outcomes.
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Affiliation(s)
- Maurizio Tusa
- Department of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Antonio Popolo Rubbio
- Department of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy.
| | - Antonio Sisinni
- Department of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Andrea Borin
- Department of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - Carmelo Grasso
- Division of Cardiology, Centro Alte Specialità e Trapianti (CAST), Azienda Ospedaliero-universitaria Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Marianna Adamo
- Cardiothoracic Department, Spedali Civili Brescia, Brescia, Italy
| | - Paolo Denti
- Cardiac Surgery Department, San Raffaele University Hospital, Milan, Italy
| | - Arturo Giordano
- Invasive Cardiology Unit, Pineta Grande Hospital, Castelvolturno, Italy
| | - Federico De Marco
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Antonio L Bartorelli
- Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Matteo Montorfano
- Cardio-Thoracic-Vascular Department, San Raffaele University Hospital, Milan, Italy
| | - Cosmo Godino
- Cardio-Thoracic-Vascular Department, San Raffaele University Hospital, Milan, Italy
| | - Rodolfo Citro
- University Hospital San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Francesco De Felice
- Division of Interventional Cardiology, Azienda Ospedaliera S. Camillo Forlanini, Rome, Italy
| | | | - Ida Monteforte
- AORN Ospedali dei Colli, Monaldi Hospital, Naples, Italy
| | - Emmanuel Villa
- Cardiac Surgery Unit Poliambulanza Hospital, Fondazione Poliambulanza, Brescia, Italy
| | - Anna Sonia Petronio
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Cristina Giannini
- Cardiac Catheterization Laboratory, Cardiothoracic and Vascular Department, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Andrea Raffaele Munafò
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Gabriele Crimi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Science, Interventional Cardiology Unit, University of Padua, Padua, Italy
| | - Luca Testa
- Department of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Corrado Tamburino
- Division of Cardiology, Centro Alte Specialità e Trapianti (CAST), Azienda Ospedaliero-universitaria Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
| | - Francesco Bedogni
- Department of Cardiology, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Donato, San Donato Milanese, Milan, Italy
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Ahmed R, Moaddab A, Graham-Hill S. Mitral Leaflet Flail as a Late Complication of Infective Endocarditis: A Case Report. Cureus 2022; 14:e25854. [PMID: 35832763 PMCID: PMC9273166 DOI: 10.7759/cureus.25854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2022] [Indexed: 11/05/2022] Open
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Posada-Martinez EL, Ortiz-Leon XA, Ivey-Miranda JB, Trejo-Paredes MC, Chen W, McNamara RL, Lin BA, Lombo B, Arias-Godinez JA, Sugeng L. Understanding Non-P2 Mitral Regurgitation Using Real-Time Three-Dimensional Transesophageal Echocardiography: Characterization and Factors Leading to Underestimation. J Am Soc Echocardiogr 2020; 33:826-837. [PMID: 32387034 DOI: 10.1016/j.echo.2020.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 01/02/2020] [Accepted: 03/15/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND P2 prolapse is a common cause of degenerative mitral regurgitation (MR); echocardiographic characteristics of non-P2 prolapse are less known. Because of the eccentric nature of degenerative MR jets, the evaluation of MR severity is challenging. The aim of this study was to test the hypotheses that (1) the percentage of severe MR determined by transthoracic echocardiography (TTE) would be lower compared with that determined by transesophageal echocardiography (TEE) in patients with non-P2 prolapse and also in a subgroup with "horizontal MR" (a horizontal jet seen on TTE that hugs the leaflets without reaching the atrial wall, particularly found in non-P2 prolapse) and (2) the directions of MR jets between TTE and real-time (RT) three-dimensional (3D) TEE would be discordant. METHODS One hundred eighteen patients with moderate to severe and severe degenerative MR defined by TEE were studied. The percentage of severe MR between TTE and TEE was compared in P2 and non-P2 prolapse groups and in horizontal and nonhorizontal MR groups. Additionally, differences in the directions of the MR jets between TTE and RT 3D TEE were assessed. RESULTS Eighty-six percent of patients had severe MR according to TEE. TTE underestimated severe MR in the non-P2 group (severe MR on TTE, 57%; severe MR on TEE, 85%; P < .001) but not in the P2 group (severe MR on TTE, 79%; severe MR on TEE, 91%; P = .157). Most "horizontal" MR jets were found in the non-P2 group (85%), and this subgroup showed even more underestimation of severe MR on TTE (TTE, 22%; TEE, 89%; P < .001). There was discordance in MR jet direction between two-dimensional TTE and RT 3D TEE in 41% of patients. CONCLUSIONS Non-P2 and "horizontal" MR are significantly underestimated on TTE compared with TEE. There is substantial discordance in the direction of the MR jet between RT 3D TEE and TTE. Therefore, TEE should be considered when these subgroups of MR are observed on TTE.
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Affiliation(s)
- Edith L Posada-Martinez
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale University, New Haven, Connecticut; Laboratory of Echocardiography, National Institute of Cardiology "Ignacio Chavez", Mexico City, Mexico
| | - Xochitl A Ortiz-Leon
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale University, New Haven, Connecticut; Laboratory of Echocardiography, National Institute of Cardiology "Ignacio Chavez", Mexico City, Mexico
| | - Juan B Ivey-Miranda
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale University, New Haven, Connecticut; Department of Cardiology, Hospital de Cardiologia Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Maria C Trejo-Paredes
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale University, New Haven, Connecticut
| | - Wanwen Chen
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale University, New Haven, Connecticut
| | - Robert L McNamara
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale University, New Haven, Connecticut
| | - Ben A Lin
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Bernardo Lombo
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale University, New Haven, Connecticut
| | - Jose A Arias-Godinez
- Laboratory of Echocardiography, National Institute of Cardiology "Ignacio Chavez", Mexico City, Mexico
| | - Lissa Sugeng
- Laboratory of Echocardiography, Cardiovascular Division, Yale New Haven Hospital, Yale University, New Haven, Connecticut.
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Hessel EA, Egan TD. Michael K. Cahalan: In Celebration of His Life and Contributions to Cardiac Anesthesiology. J Cardiothorac Vasc Anesth 2020; 34:12-19. [DOI: 10.1053/j.jvca.2019.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/24/2019] [Accepted: 09/16/2019] [Indexed: 11/11/2022]
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Harari R, Bansal P, Yatskar L, Rubinstein D, Silbiger JJ. Papillary muscle rupture following acute myocardial infarction: Anatomic, echocardiographic, and surgical insights. Echocardiography 2017; 34:1702-1707. [PMID: 29082549 DOI: 10.1111/echo.13739] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Papillary muscle (PM) rupture is a rare complication of acute myocardial infarction which carries an excessive mortality rate. Optimal outcomes require rapid diagnosis and prompt surgical referral, and in this regard, echocardiography plays a crucial role. Comprehensive echocardiographic examination of the patient with PM rupture consists of identification of the ruptured PM segment, visualization of flail mitral valve segment(s), evaluation of mitral regurgitation severity, and assessment of left ventricular systolic function. This article discusses anatomic and echocardiographic features as well as the surgical management of PM rupture.
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Affiliation(s)
- Rafael Harari
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Priya Bansal
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Leonid Yatskar
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Thompson DS, Punjabi PP. An unusual presentation of ischaemic mitral regurgitation as P2 prolapse. Perfusion 2017; 32:706-708. [PMID: 28703036 DOI: 10.1177/0267659117720989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 54-year-old gentleman presented with pulmonary oedema secondary to anterolateral papillary muscle (PPM) rupture and acute mitral regurgitation subsequent to myocardial ischaemia (MI). Angiography revealed complete occlusion of the first obtuse marginal (OM1) branch of the circumflex coronary artery and a 70% occlusion of the left anterior descending (LAD) coronary artery. Operatively, unusual anatomy was noted; an accessory head was attached superiorly to the anterior lateral PPM. This gave rise to chordae that were subsequently attached to the posterior second (P2) scallop. Additionally, the P2 scallop was deficient in chordae from the posteromedial PPM, thus, loss of this accessory head led to severe mitral regurgitation. We review the PPM anatomy and pathological context of PPM rupture and ischaemic mitral regurgitation.
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Affiliation(s)
| | - Prakash P Punjabi
- 2 Cardiothoracic Surgery, Imperial College Healthcare, Hammersmith Hospital, London, UK
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Pagel PS, Dermody GM, Price BN, Rashid ZA, Iqbal Z. Narrow, Highly Mobile Structure in the Right Atrium: Large Eustachian Valve, Prominent Chiari Network, Thrombus, Vegetation, or Flail Tricuspid Chordae Tendineae? J Cardiothorac Vasc Anesth 2015; 29:1402-4. [DOI: 10.1053/j.jvca.2015.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Indexed: 11/11/2022]
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Initial misdiagnosis of acute flail mitral valve is not infrequent: The role of echocardiography. J Cardiovasc Dis Res 2013; 4:123-6. [PMID: 24027369 DOI: 10.1016/j.jcdr.2013.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 11/29/2012] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Acute flail mitral valve frequently results in severe mitral regurgitation. However, its clinical presentation can be similar to other disease processes, potentially leading to initial misdiagnosis and a morbid outcome. We sought to analyze baseline characteristics, clinical presentations, time to diagnosis, and in-hospital mortalities of patients with the acute flail mitral valve. METHODS Two hundred and sixty two consecutive echocardiograms with severe mitral regurgitation performed between February 2005 and October 2010 at the Jack D. Weiler Hospital (Bronx, New York, USA) were reviewed. Adult patients who had presented with new onset flail mitral valves were selected for this retrospective study. RESULTS Fifteen patients were found to have acute flail mitral valve. The majority was elderly male. Over half presented to the emergency room with a sudden onset of dyspnea. A mitral regurgitant murmur was appreciated in only a third of the patients. The chest X-ray of five patients had no acute pulmonary findings, whereas, two were found to have gross unilateral pulmonary edema. Clinically, 60% were misdiagnosed on admission. Using echocardiogram, the correct diagnosis of flail mitral valve was made in all cases, however, only 40% on the day of presentation. The maximum time to echocardiographic diagnosis was 4 days. The main cause of acute flail mitral valve was degenerative disease. Seven patients were managed surgically. Overall, there was only one mortality (7%) during incident hospitalization. CONCLUSIONS Initial misdiagnosis of acute flail mitral valve happens frequently. Early echocardiographic exam is essential in the timely diagnosis and management of acute flail mitral valve.
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Skinner HJ, Mahmoud A, Uddin A, Mathew T. An investigation into the causes of unexpected intra-operative transoesophageal echocardiography findings*. Anaesthesia 2012; 67:355-60. [DOI: 10.1111/j.1365-2044.2011.07022.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Chen X, Sun D, Yang J, Feng W, Gu T, Zhang Z, Xiu Z, Tang L, Ma C, Wang X, Cheng Y, Li N, Liu S. Preoperative Assessment of Mitral Valve Prolapse and Chordae Rupture Using Real Time Three-Dimensional Transesophageal Echocardiography. Echocardiography 2011; 28:1003-10. [DOI: 10.1111/j.1540-8175.2011.01474.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Minardi G, Pino PG, Manzara CC, Pulignano G, Stefanini GG, Viceconte GN, Leonetti S, Madeo A, Gaudio C, Musumeci F. Preoperative scallop-by-scallop assessment of mitral prolapse using 2D-transthoracic echocardiography. Cardiovasc Ultrasound 2010; 8:1. [PMID: 20044927 PMCID: PMC2806252 DOI: 10.1186/1476-7120-8-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 01/01/2010] [Indexed: 11/11/2022] Open
Abstract
Background This study was conducted to assess the accuracy of harmonic imaging 2D-transthoracic echocardiography (2D-TTE) segmental analysis compared to surgical findings, in degenerative mitral regurgitation (MR). Methods Seventy-seven consecutive patients with severe degenerative MR were prospectively enrolled. Preoperative 2D-TTE with precise localization of prolapsing or flailing scallops/segments was performed. All patients underwent mitral valve surgical repair. Surgical reports (SR), including valve description, were used as references for comparisons. A postoperative control 2D-TTE was performed. Results Out of 462 scallops/segments studied, surgical inspection identified 102 prolapses or flails (22%), 92 of which had previously been detected by 2D-TTE (90.2% sensitivity, 100% specificity). Agreement between preoperative 2D-TTE segmental analysis and SR was 97.8% (k = 0.93; p < 0.0001). Sixty-nine out of 77 2D-TTE reports were completely concordant with SR (89.6% diagnostic accuracy). None of the 8 non-concordant 2D-TTE reports were in complete disagreement with SR. P2 scallop was always involved in posterior leaflet prolapse or flail and was described correctly by 2D-TTE in 68 out of 69 patients (98,7% agreement, k = 0,93; 98.5% sensitivity). The anterior leaflet was involved in 14 patients (18%); A2 segment was involved in all of those cases and was correctly detected by 2D-TTE in 13 (98,7% agreement, k = 0,95; 92,8% sensitivity). Antero-lateral and postero-medial para-commissural prolapse or flail had a lower prevalence (14% and 10% respectively), with 2D-TTE sensitivity respectively of 64% and 50%. Conclusions 2D-TTE, performed by an experienced echo-lab, has very good diagnostic accuracy in localizing the scallops/segments involved in degenerative MR, particularly for the middle ones (P2-A2), which represent almost the totality of prolapses. More invasive, time consuming and expensive exams should be reserved to selected cases.
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Affiliation(s)
- Giovanni Minardi
- Department of Cardiovascular Science, S Camillo-Forlanini Hospital, Rome, Italy.
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Pizarro R, Bazzino OO, Oberti PF, Falconi M, Achilli F, Arias A, Krauss JG, Cagide AM. Prospective Validation of the Prognostic Usefulness of Brain Natriuretic Peptide in Asymptomatic Patients With Chronic Severe Mitral Regurgitation. J Am Coll Cardiol 2009; 54:1099-106. [PMID: 19744620 DOI: 10.1016/j.jacc.2009.06.013] [Citation(s) in RCA: 107] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 05/06/2009] [Accepted: 06/01/2009] [Indexed: 11/18/2022]
Affiliation(s)
- Rodolfo Pizarro
- Cardiology Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Hirata K, Pulerwitz T, Sciacca R, Otsuka R, Oe Y, Fujikura K, Oe H, Hozumi T, Yoshiyama M, Yoshikawa J, Di Tullio M, Homma S. Clinical Utility of New Real Time Three-Dimensional Transthoracic Echocardiography in Assessment of Mitral Valve Prolapse. Echocardiography 2008; 25:482-8. [DOI: 10.1111/j.1540-8175.2008.00630.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Czarnecki A, Thakrar A, Fang T, Lytwyn M, Ahmadie R, Pascoe E, Jassal DS. Acute severe mitral regurgitation: consideration of papillary muscle architecture. Cardiovasc Ultrasound 2008; 6:5. [PMID: 18205938 PMCID: PMC2248568 DOI: 10.1186/1476-7120-6-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 01/18/2008] [Indexed: 12/01/2022] Open
Abstract
We present a case of an individual who presented with acute severe mitral regurgitation in the setting of an inferior ST elevation myocardial infarction. Both transthoracic and transesophageal echocardiography demonstrated a posteriorly directed eccentric jet of severe mitral regurgitation with flail anterior mitral valve leaflet attached presumably to the anterior papillary muscle. Intraoperative findings demonstrated rupture of the postero-medial papillary muscle attached via chords to the anterior mitral valve leaflet. This case serves to remind us that both the anterior and posterior leaflets of the mitral valve are attached to both papillary muscle heads. The direction and eccentricity of the mitral regurgitant jet on echocardiography helps to locate the leaflet involved, but not necessarily the coexisting papillary muscle pathology.
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Affiliation(s)
- Andrew Czarnecki
- Department of Internal Medicine, St. Boniface General Hospital, Winnipeg, Manitoba, Canada.
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Rehfeldt KH, Click RL, Orszulak TA. Regurgitant jet direction in patients with prolapse of the anterolateral scallop of the posterior mitral valve leaflet. J Cardiothorac Vasc Anesth 2007; 21:581-3. [PMID: 17678792 DOI: 10.1053/j.jvca.2007.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2006] [Indexed: 11/11/2022]
Affiliation(s)
- Kent H Rehfeldt
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, USA.
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Beeri R, Streckenbach SC, Isselbacher EM, Akins CW, Vlahakes GJ, Adams MS, Levine RA. The Crossed Swords Sign: Insights into the Dilemma of Repair in Bileaflet Mitral Valve Prolapse. J Am Soc Echocardiogr 2007; 20:698-702. [PMID: 17543739 DOI: 10.1016/j.echo.2006.11.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND The need for bileaflet repair in bileaflet mitral valve prolapse (MVP) remains controversial. Will anterior leaflet prolapse resolve with posterior leaflet repair or should both leaflets be addressed? Single-leaflet MVP produces oppositely directed mitral regurgitant jets. Some patients show two crossed jets oppositely directed from the coaptation zone. We hypothesized that these indicate bileaflet lesions requiring complex repair. METHODS Echocardiograms and surgical reports of 52 consecutive patients with MVP undergoing surgery were reviewed. RESULTS First, all 14 patients with two oppositely directed jets had prolapse of more than one leaflet. Each jet was related to discrete leaflet distortions causing malcoaptation. Six underwent valve replacement. Seven had both leaflets repaired. One had posterior leaflet repair and annuloplasty, with persistent mitral regurgitation requiring valve replacement. Second, 36 of 38 patients with single jets had single-leaflet MVP. One underwent replacement; all others did well with single-leaflet repair. Two patients with bileaflet MVP but only one jet did well with single-leaflet repair or annuloplasty. CONCLUSION This crossed swords sign is an important clue to bileaflet mechanism of mitral regurgitation in MVP, associated with complex repair procedures. Thus, it provides a clue in the dilemma of bileaflet versus single-leaflet repair.
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Affiliation(s)
- Ronen Beeri
- Cardiac Ultrasound Laboratory, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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Cicioni C, Di Luzio V, Di Emidio L, De Remigis F, Fragassi G, Gregorini R, Mazzola A, Paparoni S, Prosperi F, Ferri C. Limitations and discrepancies of transthoracic and transoesophageal echocardiography compared with surgical findings in patients submitted to surgery for complications of infective endocarditis. J Cardiovasc Med (Hagerstown) 2006; 7:660-6. [PMID: 16932078 DOI: 10.2459/01.jcm.0000242998.74923.4d] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Transoesophageal echocardiography (TEE) is recognized to be superior to transthoracic echocardiography (TTE) in evaluating complications of infective endocarditis (IE). The aim of this study was to compare results from TTE and TEE with surgical findings, and to assess limitations and discrepancies of TEE as compared with surgical findings. METHODS A retrospective analysis was carried out in 63 consecutive patients undergoing surgical intervention for IE-related complications. All patients were submitted to TTE and TEE before surgery. Clinical, anaesthesiological and surgical data were reviewed for all patients as well as the TTE and TEE examinations recorded on S-VHS videotape. Patients were divided into two groups according to the time elapsed from TEE to surgery (> 72 h in group A and < 72 h in group B). RESULTS The study population included 44 patients with native valve endocarditis and 19 patients with prosthetic valve endocarditis for a total of 76 affected valves (54 native and 22 prosthetic valves). No significant differences were observed between groups in number of patients (31 vs. 32; P = NS), of native valves (29 vs. 27; P = NS), and of prosthetic valves (10 vs. 12; P = NS). Discrepancies between TEE and surgical findings were found in 14 cases (11/31 in group A vs. 3/32 in group B; P = 0.01). CONCLUSIONS Time between TEE and surgery seems to be an important factor affecting comparison. Lesion characteristics appear to be more precise and concordant with surgical findings the shorter the time elapsed from TEE to surgery. Changes resulting from disease progression require repeat TEE evaluation prior to surgical intervention for IE-related complications. This could be useful in providing the surgeon with a more accurate definition of valvular lesions for optimal planning of intervention.
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Affiliation(s)
- Catia Cicioni
- Division of Cardiology, Civic Hospital, Castiglione delle Stiviere (MN), Italy
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Khouzam RN, D'Cruz IA, Minderman D, Kaiser J. Local Intense Mosaic Pattern at Site of Flail Mitral Leaflet: Report of a New Color Doppler Sign. Echocardiography 2005; 22:743-5. [PMID: 16194168 DOI: 10.1111/j.1540-8175.2005.00155.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Color flow Doppler has been useful in diagnosing the presence and severity of mitral regurgitation (MR). We noted a hitherto unreported sign of MR due to flail mitral leaflet: intense local mosaic pattern at the site of the flail leaflet. This sign was seen well in 11 of 14 patients (79%) with the two-dimensional echocardiographic features of flail mitral leaflet, all with moderate or severe MR. In 3 other patients, the sign was absent; two of those had flail mitral leaflet with severe MR. No local mosaic pattern was seen on color Doppler in 20 other patients with MR but no flail mitral leaflet. We speculate that the focal intense mosaic color Doppler morphology may have been caused by intrusion of the flail leaflet into the MR stream, or to a Coanda-like effect of the MR jet "adhering" to the flail leaflet.
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Affiliation(s)
- Rami N Khouzam
- Cardiology Section, Memphis VA Medical Center, Memphis, Tennessee 38104, USA.
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Monin JL, Dehant P, Roiron C, Monchi M, Tabet JY, Clerc P, Fernandez G, Houel R, Garot J, Chauvel C, Gueret P. Functional Assessment of Mitral Regurgitation by Transthoracic Echocardiography Using Standardized Imaging Planes. J Am Coll Cardiol 2005; 46:302-9. [PMID: 16022959 DOI: 10.1016/j.jacc.2005.03.064] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2005] [Revised: 03/12/2005] [Accepted: 03/15/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES We sought to assess the value of transthoracic echocardiography (TTE) using standardized imaging planes for the functional analysis of mitral regurgitation (MR) as well as for postoperative outcome implications. BACKGROUND The feasibility of mitral valve repair is based on functional assessment of MR, mainly by transesophageal echocardiography (TEE). Considering the recent advances in TTE imaging, the incremental value of TEE in this setting needs to be re-examined. METHODS Consecutive patients (n = 279; 181 men; median age 68 years [quartiles, 61 to 74]) who underwent surgery for MR were enrolled prospectively in two tertiary care centers. The accuracy of TTE (harmonic imaging) versus TEE for functional assessment of MR was evaluated against surgical findings. RESULTS Valve repair (n = 237 patients, 85%) or replacement (n = 42) was predicted accurately by TTE in 97% of cases; TEE added significant information for only two patients. In the subgroup of degenerative MR (n = 190), agreement with surgical findings for the localization of prolapsed segments was 91% for TTE (kappa, 0.81) and 93% for TEE (kappa, 0.85) without incremental value of TEE (p = 0.40). Patients with single prolapse of the middle posterior scallop (P2) had a better postoperative outcome as compared with patients who had non-P2 lesions (p = 0.008). Furthermore, mitral replacement predicted by TTE was an independent predictor for postoperative long-term mortality (odds ratio 5.7, 95% confidence interval 1.97 to 16.4, p = 0.001). CONCLUSIONS In experienced hands, functional assessment of MR by TTE can predict accurately valve repairability and has a strong influence on postoperative outcome. Thus, in most cases preoperative TEE is not mandatory, provided intraoperative TEE is performed.
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Affiliation(s)
- Jean-Luc Monin
- Department of Cardiology, Henri Mondor Hospital, Créteil, France (Assistance Publique Hôpitaux de Paris).
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Mills WR, Barber JE, Ratliff NB, Cosgrove DM, Vesely I, Griffin BP. Biomechanical and echocardiographic characterization of flail mitral leaflet due to myxomatous disease: further evidence for early surgical intervention. Am Heart J 2004; 148:144-50. [PMID: 15215804 DOI: 10.1016/j.ahj.2004.01.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Flail mitral leaflet (FML) is a common complication of mitral valve prolapse, often leading to severe mitral regurgitation (MR) and left ventricular dysfunction. In the absence of timely surgical correction, survival is significantly impaired. Early recognition of FML and identification of risk factors is important because early intervention increases the chances of survival. METHODS We studied 123 patients undergoing mitral valve surgery for severe MR caused by myxomatous disease. Chart review, echocardiography, and tensile testing were performed. RESULTS Thirty-eight patients had FML, and 85 patients had non-flail mitral leaflet (non-FML). Patients with FML were younger (53.7 +/- 1.8 vs 59.3 +/- 1.4 years, P =.02), had more severe MR (3.89 +/- 0.04 vs 3.76 +/- 0.04, P =.02), were less likely to be in New York Heart Association class III or IV heart failure (5% vs 20%, P =.037), and were less likely to have bileaflet mitral valve prolapse (5% vs 38%, P <.001) than non-FML patients. Valve tissue from patients with FML had less stiff chordae (23.5 +/- 3.6 vs 59.1 +/- 11.7 Mpa, P =.006) that tended to have a lower failure stress (3.8 +/- 0.9 vs 9.6 +/- 2.2 Mpa, P =.07) and had more extensible leaflets (56.4% +/- 7.9% vs 42.9% +/- 2.7% strain, P =.04) compared with that of non-FML patients. CONCLUSIONS The development of FML may result from intrinsic tissue abnormalities and is associated with a distinct subset of the myxomatous population. Identification of such clinical characteristics in this population and knowledge of an implicit mechanical abnormality of valve tissue may further the argument for early surgical correction.
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Affiliation(s)
- William R Mills
- Department of Cardiology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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22
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Agricola E, Oppizzi M, De Bonis M, Maisano F, Toracca L, Bove T, Alfieri O. Multiplane transesophageal echocardiography performed according to the guidelines of the American Society of Echocardiography in patients with mitral valve prolapse, flail, and endocarditis: diagnostic accuracy in the identification of mitral regurgitant defects by correlation with surgical findings. J Am Soc Echocardiogr 2003; 16:61-6. [PMID: 12514636 DOI: 10.1067/mje.2003.23] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Multiplane transesophageal echocardiography is a useful tool to study mitral regurgitation. We evaluated the diagnostic accuracy of multiplane transesophageal echocardiography performed according to the guidelines of the American Society of Echocardiography. We used 4 midesophageal and 2 transgastric views in 313 patients with degenerative lesions, endocarditic lesions, or both to identify regurgitant defects, comparing transesophageal echocardiography results with surgical findings. The overall diagnostic accuracy using individual scallops was 97.2% (P <.00001) with a sensitivity of 96.6% and a specificity of 97.6%. Considering the single sections of the mitral valve, an accuracy of 98%, 97.1%, and 98%, was found, respectively, for the lateral, middle, and medial third of the anterior leaflet. For the posterior leaflet, the accuracy was 98% for the lateral scallop, 98.4% for the middle, and 96.1% for the medial. This strategy provides good accuracy in diagnosing both simple and challenging mitral-valve lesions and its widespread use should be recommended.
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Affiliation(s)
- Eustachio Agricola
- Department of Noninvasive Cardiology, San Raffaele Hospital, IRCCS, Milano, Italy.
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23
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Colombo PC, Wu RH, Weiner S, Marinaccio M, Brofferio A, Banchs J, Malla S, Frater R, Shirani J, Nanna M. Value of quantitative analysis of mitral regurgitation jet eccentricity by color flow Doppler for identification of flail leaflet. Am J Cardiol 2001; 88:534-40. [PMID: 11524064 DOI: 10.1016/s0002-9149(01)01733-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Early surgical intervention improves the outcome of patients with mitral regurgitation (MR) secondary to flail leaflet. Current criteria for the diagnosis of flail leaflet require a detailed definition of mitral valve anatomy, which is often challenging by transthoracic echocardiography (TTE) and, occasionally, even by transesophageal echocardiography (TEE). We studied 57 patients (mean age 63 +/- 15 years) with anatomically confirmed flail mitral leaflet and a control group of 57 patients (mean age 68 +/-14 years) with at least moderate MR but no flail leaflet. In patients with flail mitral leaflet, the mean angle formed by the axis of the MR jet and the plane of the mitral annulus was 33 +/- 11 degrees and 29 +/- 16 degrees when measured with TTE and TEE, respectively. In controls the mean angle was 66 +/- 16 degrees and 66 +/- 17 degrees by TTE and TEE, respectively (p <0.0001). Based on receiver- operating characteristic analysis, the optimal cutoff jet angle value for diagnosing flail mitral leaflet was 45 degrees with TTE (sensitivity 88%, specificity 88%), and 47 degrees by TEE (sensitivity 88%, specificity 88%). MR jet angles < or =45 degrees were also correctly identified by visual assessment of TTE images in >90% of cases, with good interobserver agreement (k = 0.76). Thus, quantitative analysis of MR jet eccentricity by color flow Doppler is highly sensitive and specific for diagnosing flail mitral leaflet.
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Affiliation(s)
- P C Colombo
- Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York 10467, USA
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24
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Enriquez-Sarano M, Freeman WK, Tribouilloy CM, Orszulak TA, Khandheria BK, Seward JB, Bailey KR, Tajik AJ. Functional anatomy of mitral regurgitation: accuracy and outcome implications of transesophageal echocardiography. J Am Coll Cardiol 1999; 34:1129-36. [PMID: 10520802 DOI: 10.1016/s0735-1097(99)00314-9] [Citation(s) in RCA: 128] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES This study was performed to determine the accuracy and outcome implications of mitral regurgitant lesions assessed by echocardiography. BACKGROUND In patients with mitral regurgitation (MR), valve repair is a major incentive to early surgery and is decided on the basis of the anatomic mitral lesions. These lesions can be observed easily with transesophageal echocardiography (TEE), but the accuracy and implications for outcome and clinical decision-making of these observations are unknown. METHODS In 248 consecutive patients operated on for MR, the anatomic lesions diagnosed with TEE were compared with those observed by the surgeon and those seen on 216 transthoracic echocardiographic (TTE) studies, and their relationship to postoperative outcome was determined. RESULTS Compared with surgical diagnosis, the accuracy of TEE was high: 99% for cause and mechanism, presence of vegetations and prolapsed or flail segment, and 88% for ruptured chordae. Diagnostic accuracy was higher for TEE than TTE for all end points (p < 0.001), but the difference was of low magnitude (<10%) except for mediocre TTE imaging or flail leaflets (both p < 0.001). The type of mitral lesions identified by TEE (floppy valve, restricted motion, functional lesion) were determinants of valve repairability and postoperative outcome (operative mortality and long-term survival; all p < 0.001) independent of age, gender, ejection fraction and presence of coronary artery disease. CONCLUSIONS Transesophageal echocardiography provides a highly accurate anatomic assessment of all types of MR lesions and has incremental diagnostic value if TTE is inconclusive. The functional anatomy of MR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome. Therefore, the mitral lesions assessed by echocardiography represent essential information for clinical decision making, particularly for the indication of early surgery for MR.
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Affiliation(s)
- M Enriquez-Sarano
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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25
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Grewal KS, Malkowski MJ, Kramer CM, Dianzumba S, Reichek N. Multiplane transesophageal echocardiographic identification of the involved scallop in patients with flail mitral valve leaflet: intraoperative correlation. J Am Soc Echocardiogr 1998; 11:966-71. [PMID: 9804102 DOI: 10.1016/s0894-7317(98)70139-7] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Although the role of multiplane transesophageal echocardiography in the diagnosis of flail mitral valve leaflet is well described, the accuracy of this modality in localizing the involved posterior leaflet scallop (medial, middle, or lateral) has never been validated. For 54 patients undergoing intraoperative transesophageal echocardiography for severe mitral regurgitation due to flail mitral valve leaflet, we assessed the accuracy of a systematic approach to localization of the flail mitral valve leaflet. Surgical confirmation was performed for all patients. At blinded review, a sensitivity of 78%, specificity of 92%, and overall diagnostic accuracy of 88% were achieved for correct localization of the flail posterior leaflet scallop. The middle scallop was most commonly affected in this series. The medial scallop was affected least often, and diagnosis of lesions in that area was least accurate. This diagnostic approach appears to be accurate and feasible and may assist in planning specific surgical therapy for this disorder.
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Affiliation(s)
- K S Grewal
- Allegheny University of the Health Sciences, Allegheny General Hospital, Pittsburgh, PA, USA
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26
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Foster GP, Isselbacher EM, Rose GA, Torchiana DF, Akins CW, Picard MH. Accurate localization of mitral regurgitant defects using multiplane transesophageal echocardiography. Ann Thorac Surg 1998; 65:1025-31. [PMID: 9564922 DOI: 10.1016/s0003-4975(98)00084-8] [Citation(s) in RCA: 130] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Appropriate patient selection for surgical repair of the mitral valve depends on the specific location and mechanism of regurgitation, which, in turn, has necessitated a more detailed method to accurately describe mitral pathology. This study tests a strategy of using multiplane transesophageal echocardiography to systematically localize mitral regurgitant defects and compares these results with the surgical findings. METHODS Fifty patients with mitral regurgitation underwent intraoperative transesophageal echocardiography for the evaluation of mitral pathology and potential repair. Mitral regurgitant defects were localized using a systematic strategy and a simple nomenclature that divides each mitral valve into six sections (three sections per leaflet) and each prosthetic sewing ring into six sections (60 radial degrees = one section). RESULTS Thirty-nine patients with native mitral valves were studied, for a total of 234 sections evaluated. Eighty-seven of these sections contained regurgitant defects by transesophageal echocardiography (mean number of regurgitant defects per valve, 2.2; range, 1 through 6). There was agreement between the transesophageal echocardiographic and surgical localizations in 96% (224/234; p < 0.0001) of the sections. Eleven patients with prosthetic mitral valves were studied, for a total of 66 sections evaluated. Twenty-three of these sections contained paravalvular leaks by transesophageal echocardiography (mean number of leaks per prosthesis, 2.1; range, 1 through 6). There was agreement between the transesophageal echocardiographic and surgical localizations in 88% (58/66; p < 0.001) of the sections. CONCLUSIONS This transesophageal echocardiographic strategy provides a systematic method to accurately localize mitral regurgitant lesions and has the potential to improve the preoperative assessment of patients with significant mitral regurgitation.
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Affiliation(s)
- G P Foster
- Cardiac Unit, Massachusetts General Hospital and Harvard Medical School, Boston, USA
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27
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Hutchison SJ, Rosin BL, Curry S, Chandraratna PAN. Transesophageal Echocardiographic Assessment of Lesions of the Right Ventricular Outflow Tract and Pulmonic Valve. Echocardiography 1996; 13:21-34. [PMID: 11442900 DOI: 10.1111/j.1540-8175.1996.tb00864.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
To establish the role of biplane transesophageal echocardiography (TEE) in the assessment of congenital and acquired lesions involving the right ventricular outflow tract (RVOT) and pulmonic valve (PV), 28 consecutive RVOT and PV lesions in 22 consecutive patients were studied by two-dimensional and color Doppler transthoracic echocardiograms (n = 22), horizontal (n = 22) and vertical (n = 22) plane TEEs, cardiac catheterization (n = 15), cardiac surgery (n = 6), and magnetic resonance imaging (n = 1). Sixteen patients had congenital lesions, and six had acquired lesions. Longitudinal TEE clearly imaged 25 of 28 abnormalities, transverse TEE clearly imaged 12 of 28, and transthoracic echocardiography clearly imaged 9 of 28. Two-dimensional TEE scanning revealed the lesion or site of stenosis. Color Doppler revealed conspicuous mosaic jets in relation to a structural abnormality in most cases. Longitudinal TEE was more sensitive in the detection of small vegetations of the PV, in the depiction of PV doming in cases of valvar pulmonic stenosis, and in the display of the RVOT and PV so that the longitudinal extent of involvement of larger masses could be appreciated. However, longitudinal TEE was not able to assess the gradient of a stenosis at the RVOT or PV level in any case. Biplane TEE is helpful in the anatomic assessment of congenital and acquired lesions of the RVOT and PV in adults. (ECHOCARDIOGRAPHY, Volume 13, January 1996)
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Affiliation(s)
- Stuart J. Hutchison
- Division of Cardiology, LAC/USC School of Medicine, 2025 Zonal Avenue, Room 7621, Los Angeles, CA 90033
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28
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Enriquez-Sarano M, Sinak LJ, Tajik AJ, Bailey KR, Seward JB. Changes in effective regurgitant orifice throughout systole in patients with mitral valve prolapse. A clinical study using the proximal isovelocity surface area method. Circulation 1995; 92:2951-8. [PMID: 7586265 DOI: 10.1161/01.cir.92.10.2951] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND In patients with mitral valve prolapse, spontaneous changes of the effective regurgitant orifice during systole are not well documented. Such changes can now be analyzed by use of the proximal isovelocity surface area method, but the changes raise concern about the reliability of this method for assessing overall severity of regurgitation in these patients. METHODS AND RESULTS In a prospective study of 42 patients with mitral valve prolapse, the effective mitral regurgitant orifice was calculated at four phases of systole (early, mid, mid-late, and late) as the ratio of regurgitant flow to regurgitant velocity by use of the proximal isovelocity surface area method. Throughout systole, the effective regurgitant orifice increased significantly, from 32 +/- 27 mm2 in early systole to 41 +/- 27 in midsystole, 55 +/- 30 in mid-late systole, and 107 +/- 66 mm2 during late systole (P < .0001). Phasic regurgitant volume increased from early to mid-late systole but decreased in late systole. For quantitation of the overall effective regurgitant orifice, four approaches using the proximal isovelocity surface area were compared with simultaneously performed quantitative Doppler echocardiography (54 +/- 30 mm2) and quantitative two-dimensional echocardiography (51 +/- 29 mm2). All correlations were good (r > .95), but overestimation was considerable when the largest flow convergence was used (70 +/- 39 mm2; both P < .0001), significant when the simple mean of the four phases was used (59 +/- 36 mm2; P = .005 and P = .0007, respectively), mild when a weighted mean of the four phases was used (55 +/- 33 mm2; P = .41 and P = .01, respectively), and no overestimation was observed when the effective regurgitant orifice calculated at maximum regurgitant velocity was used (54 +/- 30 mm2; P = .29 and P = .17, respectively). CONCLUSIONS Phasic changes of mitral regurgitation are observed in patients with mitral valve prolapse. The effective regurgitant orifice increases throughout systole. Regurgitant volume also increases initially but tends to decrease in late systole. These changes can lead to overestimation of the overall degree of regurgitation, but properly timed measurements made by use of the proximal isovelocity surface area method allow an accurate estimation of the overall effective regurgitant orifice.
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Affiliation(s)
- M Enriquez-Sarano
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Simpson IA, de Belder MA, Kenny A, Martin M, Nihoyannopoulos P. How to quantitate valve regurgitation by echo Doppler techniques. British Society of Echocardiography. Heart 1995; 73:1-9. [PMID: 7612391 PMCID: PMC483890 DOI: 10.1136/hrt.73.5_suppl_2.1] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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30
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CHANDLER ARCHIEH, NOMEIR A, KITZMAN DALANEW. Papillary Muscle Rupture Following Myocardial Infarction. Echocardiography 1995. [DOI: 10.1111/j.1540-8175.1995.tb00526.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Willens HJ, Lamet M, Migikovsky B, Kessler KM. A technique for performing transesophageal echocardiography safely in patients with Zenker's diverticulum. J Am Soc Echocardiogr 1994; 7:534-7. [PMID: 7986551 DOI: 10.1016/s0894-7317(14)80012-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Transesophageal echocardiography was indicated for evaluation of mitral valve pathology in a patient with a Zenker's diverticulum. However, transesophageal echocardiography is potentially dangerous and therefore relatively contraindicated in such patients. Our gastroenterologist directly intubated the esophagus with a fiberoptic endoscope and introduced an overtube through which transesophageal echocardiography was performed without incident.
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Affiliation(s)
- H J Willens
- Department of Medicine, University of Miami School of Medicine, FL
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32
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Kronzon I, Tunick PA, Freedberg RS. Transesophageal echocardiography in pericardial disease and tamponade. Echocardiography 1994; 11:493-505. [PMID: 10150626 DOI: 10.1111/j.1540-8175.1994.tb01091.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
While most pericardial disorders can be imaged by transthoracic echocardiography, transesophageal echocardiography may be required in those cases where pericardial pathology is clinically suspected, but cannot be imaged adequately with transthoracic echocardiography. Transesophageal echocardiography is especially helpful in patients after heart or chest surgery, with cardiac compression by a loculated pericardial hematoma, in patients with dissection, endocarditis, or interatrial shunting associated with pericardial effusion, in patients with pericardial tumors, and in the differential diagnosis between constrictive pericarditis and restrictive cardiomyopathy.
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Affiliation(s)
- I Kronzon
- Department of Medicine, New York University Medical Center, NY 10016, USA
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33
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Flow reversal in the descending aorta: A guide to intraoperative assessment of aortic regurgitation with transesophageal echocardiography. J Thorac Cardiovasc Surg 1994. [DOI: 10.1016/s0022-5223(94)70270-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Khoury AF, Afridi I, Quiñones MA, Zoghbi WA. Transesophageal echocardiography in critically ill patients: feasibility, safety, and impact on management. Am Heart J 1994; 127:1363-71. [PMID: 8172066 DOI: 10.1016/0002-8703(94)90057-4] [Citation(s) in RCA: 78] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Transesophageal echocardiography (TEE) is being used with increasing frequency in critically ill patients in whom transthoracic echocardiography (TTE) is often unsatisfactory in providing much needed information. We reviewed the indications, feasibility, and clinical impact of TEE in the intensive care setting at our institution. TEE was performed in 77 critically ill patients (age range 19 to 83 years) in whom TTE was inadequate or inconclusive. The general indications for performing a TEE were as follows: Hemodynamic instability (41%), possible endocarditis (34%), possible embolic source (21%), and possible aortic dissection (4%). In the subset of patients with hemodynamic instability, severe native mitral regurgitation was the most common underlying cause (25%), followed by hypovolemia after cardiac surgery (22%). TEE was feasible in all patients, 47% of whom were on mechanical ventilation. Two patients required stabilization before TEE, including a femoral artery-to-vein bypass in a patient with shock from a prosthetic valve obstruction. Complications, none of which proved to be fatal, occurred in two. Echocardiography led to a significant change in patient management in 46 of the 77 patients (60%), of which 48% was due solely to TEE. In these patients (n = 37), the TEE findings led to a change in medical management in 19% and to surgical intervention in 29%. While TTE remains the first line of diagnostic ultrasound and Doppler in critically ill patients, it can be technically difficult or inconclusive. In this setting, TEE provides a safe and powerful diagnostic tool that can help guide patient management.
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Affiliation(s)
- A F Khoury
- Department of Medicine, Baylor College of Medicine, Houston, Texas 77030
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35
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WILLENS HOWARDJ, CHAKKO SIMON, LEVY RALPH, BAUERLEIN EJOSEPH, KESSLER KENNETHM. Redundant Mitral Valve Simulating an Intracardiac Mass on Transesophageal Echocardiography. Echocardiography 1994. [DOI: 10.1111/j.1540-8175.1994.tb01072.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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36
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von Bibra H, Becher H, Firschke C, Schlief R, Emslander HP, Schömig A. Enhancement of mitral regurgitation and normal left atrial color Doppler flow signals with peripheral venous injection of a saccharide-based contrast agent. J Am Coll Cardiol 1993; 22:521-8. [PMID: 8335824 DOI: 10.1016/0735-1097(93)90059-a] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES The saccharide ultrasound contrast agent SHU 508 A was used to test the hypothesis that an intravenous, transpulmonary contrast method can enhance color Doppler flow signals in the left atrium in a clinically useful manner. BACKGROUND Color Doppler display of mitral regurgitation may be unreliable because of variable signal to noise ratios that are at times poor. Traditional contrast agents enhance color Doppler flow signals in the right heart chambers. This study describes our observation of a recently developed contrast agent, SHU 508 A, capable of pulmonary transit after peripheral venous injection. METHODS Control subjects (n = 10) and patients with suspected mitral regurgitation (n = 23) were studied by color Doppler flow imaging before and after 3-g intravenous doses of SHU 508 A. Reference grading of mitral regurgitation (0 to 3) was formulated from left ventricular angiography. In the four-chamber view of the left atrium, we selected for analysis the systolic frame with the maximal retrograde jet of mitral regurgitation (aliased/blue) and the diastolic frame with the maximal color coding from anterograde pulmonary venous flow (red) for planimetry and for grading the intensity of the color Doppler signal (0 to 5). RESULTS The score of the color Doppler signal intensity increased by > or = 2.5 after 3 g of SHU 508 A (p < 0.001). Flow detection improved, as shown by the increased jet area of mitral regurgitation (> or = 170%), after 3 g of SHU 508 A (3 +/- 3 vs. 12 +/- 8 cm2, p < 0.001) and by a > or = 200% increase in normal anterograde flow area (p < 0.001) in both the mitral regurgitation group and the control group. After contrast enhancement, the correlation between angiographic grading and the relation of jet area to the left atrial area increased from r = 0.79 to r = 0.91. CONCLUSIONS Contrast-mediated increased echogenicity of the left atrial blood pool improves the signal to noise ratio of Doppler images of mitral regurgitation and anterograde atrial flow. The technique is safe and simple and seems to minimize variability due to instrument design and anatomic signal attenuation.
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Affiliation(s)
- H von Bibra
- I. Medizinische Klinik, Technical University, Munich, Germany
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Affiliation(s)
- A Ansari
- Department of Medicine, Fiarview Southdale Hospital, Edina, MN
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Shyu KG, Lei MH, Hwang JJ, Lin SC, Kuan P, Lien WP. Morphologic characterization and quantitative assessment of mitral regurgitation with ruptured chordae tendineae by transesophageal echocardiography. Am J Cardiol 1992; 70:1152-6. [PMID: 1414938 DOI: 10.1016/0002-9149(92)90047-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
To compare the accuracy of transesophageal echocardiography (TEE) with that of transthoracic echocardiography (TTE) in the detection of morphologic characteristics and in the quantitative assessment of the severity of mitral regurgitation with ruptured chordae tendineae, 40 patients with ruptured chordae tendineae (group 1) and 20 patients with moderate or severe mitral regurgitation due to other causes (group 2) were studied. All echocardiograms were recorded before cardiac surgery. Cardiac catheterization was performed in 55 patients (92%). TEE showed greater sensitivity and negative predictive value than TTE (100 vs 65%, and 100 vs 56%, respectively; p < 0.005) in the diagnosis of ruptured chordae tendineae. Visualization of the ruptured chordae (termed snake-tongue sign) was highly sensitive and specific (93 and 95%, respectively) for establishing the diagnosis of ruptured chordae tendineae. The severity of mitral regurgitation in group 1 patients evaluated by TTE color flow mapping was underestimated by 2 grades in 1 patient and by 1 grade in 6 patients, and overestimated by 1 grade in 1 patient, compared with left ventriculography. In contrast, by TEE color flow mapping it was underestimated by 1 grade in 1 and overestimated by 1 grade in 1 patient. TEE color flow mapping showed better correlation with angiography than did TTE color flow mapping (r = 0.82 vs r = 0.49).
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Affiliation(s)
- K G Shyu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Republic of China
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Freeman WK, Schaff HV, Khandheria BK, Oh JK, Orszulak TA, Abel MD, Seward JB, Tajik AJ. Intraoperative evaluation of mitral valve regurgitation and repair by transesophageal echocardiography: incidence and significance of systolic anterior motion. J Am Coll Cardiol 1992; 20:599-609. [PMID: 1512339 DOI: 10.1016/0735-1097(92)90014-e] [Citation(s) in RCA: 134] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This study was designed to delineate the utility and results of intraoperative transesophageal echocardiography in the evaluation of patients undergoing mitral valve repair for mitral regurgitation. BACKGROUND Mitral valve reconstruction offers many advantages over prosthetic valve replacement. Intraoperative assessment of valve competence after repair is vital to the effectiveness of this procedure. METHODS Intraoperative transesophageal echocardiography was performed in 143 patients undergoing mitral valve repair over a period of 23 months. Before and after repair, the functional morphology of the mitral apparatus was defined by two-dimensional echocardiography; Doppler color flow imaging was used to clarify the mechanism of mitral regurgitation and to semiquantitate its severity. RESULTS There was significant improvement in the mean mitral regurgitation grade by composite intraoperative transesophageal echocardiography after valve repair (3.6 +/- 0.8 to 0.7 +/- 0.7; p less than 0.00001). Excellent results from initial repair with grade less than or equal to 1 residual mitral regurgitation were observed in 88.1% of patients. Significant residual mitral regurgitation (grade greater than or equal to 3) was identified in 11 patients (7.7%); 5 underwent prosthetic valve replacement, 5 had revision of the initial repair and 1 patient had observation only. Of the 100 patients with a myxomatous mitral valve, the risk of grade greater than or equal to 3 mitral regurgitation after initial repair was 1.7% in patients with isolated posterior leaflet disease compared with 22.5% in patients with anterior or bileaflet disease. Severe systolic anterior motion of the mitral apparatus causing grade 2 to 4 mitral regurgitation was present in 13 patients (9.1%) after cardiopulmonary bypass. In 8 patients (5.6%), systolic anterior motion resolved immediately with correction of hyperdynamic hemodynamic status, resulting in grade less than or equal to 1 residual mitral regurgitation without further operative intervention. Transthoracic echocardiography before hospital discharge demonstrated grade less than or equal to 1 residual mitral regurgitation in 86.4% of 132 patients studied. A significant discrepancy (greater than 1 grade) in residual mitral regurgitation by predischarge transthoracic versus intraoperative transesophageal echocardiography was noted in 17 patients (12.9%). CONCLUSIONS Transesophageal echocardiography is a valuable adjunct in the intraoperative assessment of mitral valve repair.
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Affiliation(s)
- W K Freeman
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905
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Affiliation(s)
- T Winslow
- Division of Medicine, John Henry Mills Echocardiography Laboratory, University of California, San Francisco 94143
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Tribouilloy C, Shen WF, Quéré JP, Rey JL, Choquet D, Dufossé H, Lesbre JP. Assessment of severity of mitral regurgitation by measuring regurgitant jet width at its origin with transesophageal Doppler color flow imaging. Circulation 1992; 85:1248-53. [PMID: 1555268 DOI: 10.1161/01.cir.85.4.1248] [Citation(s) in RCA: 121] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND The ability of transesophageal color Doppler echocardiography to provide high-resolution images of both cardiac structure and blood flow in real time is advantageous for many clinical purposes. This study was performed to determine the utility of the regurgitant jet width at its origin measured by transesophageal Doppler color flow imaging in the assessment of severity of mitral regurgitation. METHODS AND RESULTS Sixty-three consecutive patients with mitral regurgitation underwent transesophageal color Doppler examination, and the diameter of regurgitant jet at its origin was measured. Both right and left cardiac catheterizations were performed within 24 hours of Doppler studies, and angiographic grading of mitral regurgitation and regurgitant stroke volume were evaluated. There was a close relation between the jet diameter at its origin measured by transesophageal Doppler color flow imaging and the angiographic grade of mitral regurgitation (r = 0.86, p less than 0.001). A jet diameter of 5.5 mm or more identified severe mitral regurgitation (grade III or IV) with a sensitivity of 92%, specificity of 92%, and positive and negative predictive values of 88% and 95%, respectively. In 31 patients with isolated mitral regurgitation, the jet diameter correlated well with the regurgitant stroke volume determined by a combined hemodynamic-angiographic method (r = 0.85, p less than 0.001). A jet diameter of 5.5 mm or more identified a regurgitant stroke volume of 60 ml or more with a sensitivity of 88%, specificity of 93%, and positive and negative predictive values of 94% and 87%, respectively. CONCLUSIONS The regurgitant jet width at its origin measured by transesophageal Doppler color flow imaging provides a simple and useful method of measuring the severity of mitral regurgitation, and it may allow differentiation between mild and severe mitral regurgitation.
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Affiliation(s)
- C Tribouilloy
- Department of Cardiology, South Hospital, University of Picardie, Amiens, France
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Pearlman AS, Gardin JM, Martin RP, Parisi AF, Popp RL, Quinones MA, Stevenson JG, Schiller NB, Seward JB, Stewart WJ. Guidelines for physician training in transesophageal echocardiography: recommendations of the American Society of Echocardiography Committee for Physician Training in Echocardiography. J Am Soc Echocardiogr 1992; 5:187-94. [PMID: 1571176 DOI: 10.1016/s0894-7317(14)80552-x] [Citation(s) in RCA: 114] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- A S Pearlman
- Division of Cardiology, University of Washington School of Medicine, Seattle 98195
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