Real-Time 3D Transesophageal Echocardiography for the Evaluation of Rheumatic Mitral Stenosis

Long-Term Impact of Small Mitral Valve Orifice Area after Transcatheter Edge-to-Edge Mitral Valve Repair on Clinical Outcome: A Three-Dimensional Echocardiography Study

BACKGROUND

Iatrogenic mitral stenosis is a complication associated with transcatheter edge-to-edge mitral valve repair. Some reports revealed the impact of mean transmitral pressure gradient after procedure on long-term clinical outcomes. However, the association between prognosis and mitral valve orifice area (MVA) after the procedure has been poorly studied. This study aimed to investigate the association between postprocedural small MVA, derived from three-dimensional (3D) transesophageal echocardiography (TEE), and long-term clinical outcomes in 2 cohorts: the degenerative mitral regurgitation (MR) cohort and the functional MR cohort.

METHODS

This retrospective study assessed 279 consecutive patients with 3D TEE data during transcatheter edge-to-edge mitral valve repair between January 2010 and December 2016. Mitral valve orifice area after device implantation was measured by 3D planimetry. The patients with degenerative and functional MR were stratified separately into 2 groups according to postprocedural MVA: normal MVA (MVA > 1.5 cm2) group and small MVA (MVA ≤ 1.5 cm2) group.

RESULTS

Of the 279 patients, 142 (51%) had degenerative MR and 137 (49%) had functional MR. The number of degenerative MR patients with small MVA was 38, whereas 42 patients were in the functional MR cohort. Patients with small MVA had higher rate of all-cause mortality in the degenerative MR group (log-rank test: P = .01) but not in the functional MR group (log-rank test: P = .52). In multivariate analysis small MVA was independently associated with all-cause mortality but not postprocedural transmitral pressure gradient. Neither small MVA nor transmitral pressure gradient was associated with all-cause mortality in patients with functional MR.

CONCLUSION

Small MVA measured by 3D TEE after transcatheter mitral edge-to-edge repair was associated with poor prognosis in patients with degenerative MR.

Reproducibility of transthoracic 3D echocardiography in the assessment of mitral valve area in patients with rheumatic mitral stenosis: real time versus ECG-gated 3D echocardiography

PURPOSE

To assess reproducibility of Real time 3D echocardiography (RT3D) and ECG-gated 3D echocardiography (EG3D) when measuring the mitral valve area (MVA) in rheumatic mitral stenosis (MS).

METHODS

MVA was assessed by three operators in 68 MS patients using RT3D and EG3D. Reproducibility of each technique was determined by calculating the standard error of measurements (SEM).

RESULTS

SEM was similar between RT3D and EG3D. MVA variability was of 0.4 cm² or 30% of any RT3D or EG3D measured MVA. The minimal change in MVA above which two measurements should be considered to differ significantly for the same operator was of 0.4 cm² for RT3D and 0.5 cm² for EG3D. For two different operators making successive measurements, the minimum significant change was of 0.5 cm² for RT3D and 0.6 cm² for EG3D. The minimum significant difference when switching from RT3D to EG3D or vice versa is of 0.6 cm². Low temporal resolution of 6 Hz has the least variability when using RT3D (0.19 cm² vs. 0.26 cm², p = 0.009) but significantly underestimated MVA (1.3 ± 0.4 cm² vs. 1.4 ± 0.4 cm², p < 10- 3) when compared to EG3D. MVA variability was significantly higher in mild MS when compared to severe MS whether it is RT3D (0.23 cm² vs. 0.18 cm², p = 0.02) or EG3D (0.27 cm² vs. 0.16 cm², p < 0.001).

CONCLUSION

RT3D and EG3D are equally reproducible in the assessment of MVA in patients with MS. Further measurements standardization is required to have a clinically acceptable estimations of the true 3D MVA and minimal detectable differences.

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).

[Rheumatic mitral aggression. Usefulness of 3d transesophageal echocardiography]

Rheumatic heart disease is the leading cause of cardiovascular disease in children under 25 years of age worldwide, with the highest prevalence in low-income countries. The usual and distinctive finding of rheumatic aggression is mitral stenosis, which leads to serious cardiovascular consequences. International guidelines establish transthoracic echocardiography (TTE) as the diagnostic test for rheumatic heart disease; however, it has limitations in the measurement of planimetry and those inherent to Doppler. Transesophageal 3D echocardiography (TTE-3D) is a new modality that shows realistic images of the mitral valve and has the added value of accurately locating the plane of maximum stenosis and better determining commissural involvement.

The role of three dimensional transesophageal echocardiography novel-score in the success of redo percutaneous balloon mitral valvuloplasty

Mitral valve commissure evaluation is known to be important in the success of percutaneous balloon mitral valvuloplasty (PBMV) and Wilkins score (WS) is used in clinical practice. In our study, we aimed to determine whether WS in redo PBMV is sufficient in the success of procedure and additionally we have evaluated a novel scoring system including three dimensional (3D) transesophageal echocardiography (TEE) of the mitral valve structure before redo PBMV in terms of success of the procedure. Fifty patients who underwent redo PBMV were included in the study. The patients were divided into two groups according to the success of the Redo PBMV procedure which was defined as post-procedural MVA ≥ 1.5 cm² and post-procedural mitral regurgitation less than moderate by echocardiographic evaluation after PBMV. A novel score based on 3D TEE findings was created by analyzing the images recorded before Redo PBMV and by evaluating the mitral commissure and calcification. The role of traditional WS and novel score in the success of the procedure were investigated. In the study group, 36 patients (72%) had successful redo PBMV procedure. WS was 8 (IQR 7-9) and novel 3D TEE score was found 4 (IQR 3-4) in the whole study group. While no statistically significant relationship was found between WS and procedural success (p = 0.187), a statistically significant relationship was found between novel 3D TEE score and procedural success (p = 0.042). Specifically, the procedural successes rate was > 90% when novel 3D TEE score was < 4. The novel 3D TEE score might be an informative scoring system in the selection of suitable patients for successful redo PBMV, especially in patients who are considered for surgery due to the high WS.

Anatomical and Technical Predictors of Three-Dimensional Mitral Valve Area Reduction After Transcatheter Edge-To-Edge Repair

BACKGROUND

Among current transcatheter therapies for the treatment of mitral regurgitation, the MitraClip (MC; Abbott Vascular, Abbott Park, IL) system is the most commonly used. MitraClip implantation is usually contraindicated in patients with a mitral valve area (MVA) < 4.0 cm². However, little is known about the real impact of MC implantation on MVA. Our goal was to investigate the factors influencing MVA reduction and derive the minimal MVA required to prevent the development of a clinically significant mitral stenosis (MVA < 1.5 cm²) in different clinical scenarios.

METHODS

Using three-dimensional data sets, the annulus and leaflet anatomy and MVA before clip implantation (MVA_BC) were assessed. After each MC implant (NTR or XTR), the relative MVA reduction and the absolute residual MVA were measured and their predictors evaluated.

RESULTS

The present analysis included 116 patients. An MC XTR was the first device implanted in 50% of the subjects, and 53% were treated with a single implant. The MVA reduction following one XTR was 57% ± 7% versus 52% ± 8% after one NTR (P = .001). A lower MVA reduction was observed when the MC was placed commissural/central versus paracentral (50% ± 8% vs 57% ± 7%, P < .0001). After a second device, the additional MVA reduction was higher when creating a triple-compared with a double-orifice morphology (34% ± 11% vs 25% ± 9%, P = .001). The MVA after one MC correlated with MVA_BC as well as with the clip type and position (r = 0.91, P < .0001). The MVA_BC, orifice morphology, and first device position predicted MVA after two implants (r = 0.82, P < .0001). Based on the mathematical relationship between these parameters, the minimal MVA_BC needed in eight different clinical scenarios was summarized in a decision algorithm: the values ranged from 3.5 to 4.7 cm² for one and 4.5 to 6.3 cm² for two MC strategies.

CONCLUSIONS

The minimal native MVA preventing clinically relevant MS after transcatheter edge-to-edge repair is predicted by the number and location of clip(s), orifice morphology, and device type. Based on these parameters, an algorithm has been derived to optimize patient selection and preprocedural planning.

Agreement between three-dimensional planimetry and mitral navigation method in the assessment of mitral valve area in rheumatic severe mitral stenosis

INTRODUCTION

Rheumatic heart disease predisposes to structural changes in the mitral valve including commissural fusion and calcification with subsequent narrowing of the mitral valve orifice resulting in rheumatic mitral stenosis (RMS). To define the best therapeutic strategy, an accurate measurement of mitral valve area (MVA) for RMS is of paramount importance. The propose of the present study was to assess the agreement between the mitral navigation method (MVN) and three-dimensional (3D) planimetry in the assessment of MVA in patients with RMS.

METHODS

Patients who were diagnosed with a different degree of mitral stenosis with the standard transthoracic echocardiography methods such as the pressure half time and planimetry underwent 3D transesophageal echocardiography (TEE) examination. 3D TEE zoom mitral valve planimetry was measured in the diastolic frame during the mitral valve's largest opening. By using MVN software of the Philips Q-Lab, MVA was measured at its maximum diastolic opening. Both 3D planimetry (3DPL) and MVN were measured at the mid diastole during the mitral valve's largest opening.

RESULTS

In this retrospective analysis, we examined consecutive 37 RMS patients (mean age 51.1 ± 11.6 years, 31 patients were female). MVA measured by the MVN method was found to be highly correlated with the 3D MVA measured by 3DPL (r = 0.937, p<.001).

CONCLUSIONS

Based on our results, we showed that the MVN method may be additionally used in detecting the severity of RMS.

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.

Three-Dimensional Echocardiography - Role in Clinical Practice and Future Directions

Echocardiography has become an extension of the physical examination in cardiovascular practice. Frequently, it is used to confirm a clinical diagnostic suspicion. Another important role is to detect the underlying cardiovascular lesion to explain a patient's symptom complex or an abnormality found on chest radiography, electrocardiography, or cardiac enzyme tests. Patients are referred to the echocardiography laboratory because of their symptoms or due to non-specific laboratory abnormalities, and echocardiographers are expected to provide a definite diagnosis or a therapeutic clue. The introduction of the matrix array transducer into clinical practice allowed the acquisition of three-dimensional (3D) datasets. 3D echocardiography (3DE) has many advantages over 2-dimensional echocardiography, such as: (1) improved visualization of the complex shapes and spatial relations between cardiac structures; (2) improved quantification of the cardiac volumes and function; and (3) improved display and assessment of valve dysfunction. 3DE is increasingly utilized during routine clinical practice. This review article is aimed to examine the current clinical utility and future directions of 3DE.

New perspectives by imaging modalities for an old illness: Rheumatic mitral stenosis

Mitral stenosis (MS) is a progressive and devastating disease and most often occurs among young women. Given its considerable prevalence in Mediterranean and Eastern European countries according to the Euro Heart Survey, new imaging modalities are warranted to improve the management of patients with this condition. A wide spectrum of abnormalities occurs involving all parts of this complex structure and causing different grades of MS and/or regurgitation as a consequence of rheumatic affection. Novel imaging modalities significantly improved the assessment of several aspects of this rheumatic destructive process including the morphological alterations of the mitral valve (MV) apparatus, left atrial (LA) function, LA appendage, right and left ventricular (LV) functions, and complications, namely, atrial fibrillation and thromboembolic events. Furthermore, new imaging modalities improved the prediction of outcome of patients who underwent percutaneous balloon mitral comissurotomy and changed the paradigm of patient selection for intervention and risk stratification. The present review aimed to summarize the role of new multimodality, multiparametric imaging approaches to assess the morphological characteristics of the rheumatic MS and its associated complications, and to guide patient management.

Additive value of 3D-echo in prediction of immediate outcome after percutaneous balloon mitral valvuloplasty

Background

Results of percutaneous balloon mitral valvuloplasty (BMV) are basically dependent on suitable patient selection. Currently used two-dimensional (2D) echocardiography (2DE) scores have many limitations. Three-dimensional (3D) echocardiography (3DE)-based scores were developed for better patient selection and outcome prediction. We aimed to compare between 3D-Anwar and 2D-Wilkins scores in mitral assessment for BMV, and investigate the additive value of 3DE in prediction of immediate post-procedural outcome. Fifty patients with rheumatic mitral stenosis and candidates for BMV were included. Patients were subjected to 2D- and real-time 3D-transthoracic echocardiography (TTE) before and immediately after BMV for assessing MV area (MVA), 2D-Wilkins and 3D-Anwar score, commissural splitting, and mitral regurgitation (MR). Transesophageal echocardiography (TEE) was also undertaken immediately before and intra-procedural. Percutaneous BMV was performed by either multi-track or Inoue balloon technique.

Results

The 2DE underestimated post-procedural MVA than 3DE (p = 0.008). Patients with post-procedural suboptimal MVA or significant MR had higher 3D-Anwar score compared to 2D-Wilkins score (p = 0.008 and p = 0.03 respectively). The 3D-Anwar score showed a negative correlation with post-procedural MVA (r = − 0.48, p = 0.001). Receiver operating characteristic (ROC) curve analysis for both scores revealed superior prediction of suboptimal results by 3D-Anwar score (p < 0.0001). The 3DE showed better post-procedural posterior-commissural splitting than 2DE (p = 0.004). Results of both multi-track and Inoue balloon were comparable except for favorable posterior-commissural splitting by multi-track balloon (p = 0.04).

Conclusion

The 3DE gave valuable additive data before BMV that may predict immediate post-procedural outcome and suboptimal results.

Electronic supplementary material

The online version of this article (10.1186/s43044-019-0019-x) contains supplementary material, which is available to authorized users.

A Novel 3-Dimensional Approach for the Echocardiographic Evaluation of Mitral Valve Area After Repair for Degenerative Disease

BACKGROUND

Currently available 2-dimensional (2D) echocardiographic methods for accurately assessing the mitral valve orifice area (MVA) after mitral valve repair (MVr) are limited due to its complex 3-dimensional (3D) geometry. We compared repaired MVAs obtained with commonly used 2D and 3D echocardiographic methods to a 3D orifice area (3DOA), which is a novel echocardiographic measurement and independent of geometric assumptions.

METHODS

Intraoperative 2D and 3D transesophageal echocardiography (TEE) images from 20 adult cardiac surgery patients who underwent MVr for mitral regurgitation obtained immediately after repair were retrospectively reviewed. MVAs obtained by pressure half-time (PHT), 2D planimetry (2DP), and 3D planimetry (3DP) were compared to those derived by 3DOA.

RESULTS

MVAs (mean value ± standard deviation [SD]) after MVr were obtained by PHT (3 ± 0.6 cm), 2DP (3.58 ± 0.75 cm), 3D planimetry (3DP; 2.78 ± 0.74 cm), and 3DOA (2.32 ± 0.76 cm). MVAs obtained by the 3DOA method were significantly smaller compared to those obtained by PHT (mean difference, 0.68 cm; P = .0003), 2DP (mean difference, 1.26 cm; P < .0001), and 3DP (mean difference, 0.46 cm; P = .003). In addition, MVA defined as an area ≤1.5 cm was identified by 3DOA in 2 patients and by 3DP in 1 patient.

CONCLUSIONS

Post-MVr MVAs obtained using the novel 3DOA method were significantly smaller than those obtained by conventional echocardiographic methods and may be consistent with a higher incidence of MVA reduction when compared to 2D techniques. Further studies are still needed to establish the clinical significance of 3D echocardiographic techniques used to measure MVA after MVr.

Comparison of 2D vena contracta area with 3D planimetric mitral valve area in rheumatoid mitral valve disease

Rheumatoid valve disease is a general health problem of developing countries, and it mainly affects after the age of 40. Assessment of the correct mitral valve area (MVA) is important for the treatment of rheumatoid valve disease. However, there are contradictions between the three-dimensional (3D) and two-dimensional (2D) methods. A measurement with 3D echocardiography is a more accurate method to measure the MVA. However, in centers without 3D echocardiography, there are some difficulties in the accurate measurement of the MVA. The aim of this study was to assess the value of 2D transesophageal echocardiography (TEE) mitral valve vena contracta area (VCA) in predicting the severity of rheumatoid mitral stenosis (RMS) by comparing 3D planimetry. A total of 24 patients (10 females and 14 males) who were diagnosed with mild/moderate/severe RMS with using pressure half time, mean transmitral gradient, and planimetry methods were included in this study. 3D images were acquired using the 3D zoom and full volume. 2D TEE VCA was measured at an angle of 140° and 60°, which was perpendicular to the former, with color Doppler and the VCA was measured with an ellipsoid area using mathematical formula. There was statistically significant relationship between the measurements of 2D VCA and 3D zoom mode MVA planimetry and MVA full measurements (MVA full volume) (p < 0.01). Calculation of the valvular area after measuring the mitral valve VCA with 2D TEE is a reliable method that is usable in centers without 3D echocardiography.

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.

Level of agreement in three-dimensional planimetric measurement of mitral valve area between transthoracic and transesophageal echocardiography

BACKGROUND

Echocardiographic measurement of mitral valve area (MVA) is critical prior to percutaneous transmitral commissurotomy (PTMC). This study aimed to compare the agreement between transthoracic (TTE) and transesophageal echocardiography (TEE) in three-dimensional (3D) planimetric measurement of the MVA among patients with severe mitral stenosis.

METHODS

MVA was measured with planimetry in 105 patients before undergoing PTMC. 3D reconstruction was applied to both TTE and TEE examinations. The MVA values from four different methods of 3D reconstruction were compared to the average values of 3D methods in TEE as the gold standard measurement method for the MVA in this study. The agreement levels between the two examinations were evaluated and analyzed for various reconstruction methods.

RESULTS

The mean age was 49 ± 12 years for 28 men and 77 women who were enrolled. The image quality was graded as "excellent" in 57% of 3D images obtained by TTE, while it was graded as "excellent" in 81% of 3D images obtained by TEE. The ventricular zooming method in TTE with a bias of -0.006 ± 0.065 cm² (P < 0.0001) had the highest agreement with the 3D-MVA in TEE. While 2D-TTE and 3D-TEE measurements of the MVA (R = 0.91; P < 0.0001) were significantly correlated, 2D-TTE overestimated the MVA by 0.19 cm² .

CONCLUSION

Although the quality of 3D images was significantly better in TEE than those in TTE, a good agreement existed between the measured 3D-TTE and 3D-TEE studies. We also demonstrated that 2D-TTE overestimated the MVA compare to 3D-TEE.

Impact of 3D echocardiography on grading of mitral stenosis and prediction of clinical events

Background

The mitral valve orifice area (MVOA) is difficult to assess accurately by 2D echocardiography because of geometric assumptions; therefore, 3D planimetry may offer advantages. We studied the differences in MVOA measurements between the most frequently used methods, to determine if 3D planimetry would result in the re-grading of severity in any cases, and whether it was a more accurate predictor of clinical outcomes.

Methods

This was a head-to-head comparison of the three most commonly used techniques to grade mitral stenosis (MS) by orifice area and to assess their impact on clinical outcomes. 2D measurements (pressure half-time (PHT), planimetry) and 3D planimetry were performed retrospectively on patients with at least mild MS. The clinical primary endpoint was defined as a composite of MV balloon valvotomy, mitral valve repair or replacement (MVR) and/or acute heart failure (HF) admissions.

Results

Forty-one consecutive patients were included; the majority were female (35; 85.4%), average age 55 (17) years. Mean and peak MV gradients were 9.4 (4) mmHg and 19 (6) mmHg, respectively. 2D and 3D measures of MVOA differed significantly; mean 2D planimetry MVOA was 1.28 (0.40) cm², mean 3D planimetry MVOA 1.15 (0.29) cm² (P = 0.003). Mean PHT MVOA was 1.43 (0.44) cm² (P = 0.046 and P < 0.001 in comparison to 2D and 3D planimetry methods, respectively). 3D planimetry reclassified 7 (17%) patients from mild-to-moderate MS, and 1 (2.4%) from moderate to severe. Overall, differences between the two methods were significant (X², P < 0.001). Only cases graded as severe by 3D predicted the primary outcome measure compared with mild or moderate cases (odds ratio 5.7).

Conclusion

3D planimetry in MS returns significantly smaller measurements, which in some cases results in the reclassification of severity. Routine use of 3D may significantly influence the management of MS, with a degree of prediction of clinical outcomes.

Recent technological advancements in cardiac ultrasound imaging

About 92.1 million Americans suffer from at least one type of cardiovascular disease. Worldwide, cardiovascular diseases are the number one cause of death (about 31% of all global deaths). Recent technological advancements in cardiac ultrasound imaging are expected to aid in the clinical diagnosis of many cardiovascular diseases. This article provides an overview of such recent technological advancements, specifically focusing on tissue Doppler imaging, strain imaging, contrast echocardiography, 3D echocardiography, point-of-care echocardiography, 3D volumetric flow assessments, and elastography. With these advancements ultrasound imaging is rapidly changing the domain of cardiac imaging. The advantages offered by ultrasound imaging include real-time imaging, imaging at patient bed-side, cost-effectiveness and ionizing-radiation-free imaging. Along with these advantages, the steps taken towards standardization of ultrasound based quantitative markers, reviewed here, will play a major role in addressing the healthcare burden associated with cardiovascular diseases.

Echocardiographic 3D-guided 2D planimetry in quantifying left-sided valvular heart disease

Echocardiographic 3D-guided 2D planimetry can improve the accuracy of valvular disease assessment. Acquisition of 3D pyramidal dataset allows subsequent multiplanar reconstruction with accurate orthogonal plane alignment to obtain the correct borders of an anatomic orifice or flow area. Studies examining the 3D-guided 2D planimetry approach in left-sided valvular heart disease were identified and reviewed. The strongest evidence exists for estimating mitral valve area in patients with rheumatic mitral valve stenosis and vena contracta area in patients with mitral regurgitation (both primary and secondary). 3D-guided approach showed excellent feasibility and reproducibility in most studies, as well as time efficiency and good correlation with reference and comparator methods. Therefore, 3D-guided 2D planimetry can be used as an important clinical tool in quantifying left-sided valvular heart disease, especially mitral valve disorders.

A novel method to measure mitral valve area in patients with rheumatic mitral stenosis using three-dimensional transesophageal echocardiography: Feasibility and validation

AIMS

Neither two- nor three-dimensional (3D) planimetry of the mitral valve (MV) orifice takes the mitral commissures into account. Thus, if the commissures are not completely fused, the MV orifice will not be planar, and MV area (MVA) will be underestimated. The study aimed to validate a novel method for measurement of the MVA using a software that traces the MV orifice including the commissures.

METHODS AND RESULTS

The study included 30 patients undergoing percutaneous balloon mitral valvuloplasty for severe rheumatic mitral stenosis. All performed 3D transesophageal echocardiography (TEE) immediately before the procedure. MVA was measured using the mitral valve navigation (MVN) software of the Philips Q-Lab 10.2 in a diastolic frame with maximum diastolic opening of the MV. Regular 3D planimetry of the MV orifice was also performed. Before balloon dilation, the MVA was calculated invasively using the Gorlin's formula. No significant difference was detected between MVN-derived MVA and Gorlin-derived MVA (0.98 cm² vs. 1.0 cm² , P = .33). A statistically significant difference was detected between Planimetry-derived MVA and Gorlin-derived MVA (0.8 cm² vs. 1.0 cm² , P < .001). There were significant linear correlations between MVN-derived MVA and Gorlin-derived MVA (r = .84, P < .001). Using Bland-Altman analysis, Gorlin-derived MVA showed better and relatively narrower limits of agreement with MVN-derived MVA than planimetry-derived MVA.

CONCLUSION

Measurement of the MVA using the MVN method is feasible and is more correlated to the invasively measured MVA than the 3D planimetry method. This is the most accurate method of measuring the MVA that takes MV commissures into account.

Effect of Percutaneous Edge-to-Edge Repair on Mitral Valve Area and Its Association With Pulmonary Hypertension and Outcomes

Percutaneous edge-to-edge repair using the MitraClip system causes reduction in mitral valve area (MVA). However, its clinical impact is not fully elucidated. This study assessed the impact of postprocedural MVA reduction on pulmonary hypertension and outcomes. A total of 92 patients with grades 3 to 4 + mitral regurgitation (MR) who underwent MitraClip therapy were retrospectively reviewed. Using intraprocedural, 3-dimensional transesophageal echocardiography, postprocedural MVA was obtained by 2 optimized planes through the medial and lateral orifices of the repaired valve. MVA was reduced by 60.1% immediately after MitraClip procedure (p <0.001). Postprocedural MVA correlated moderately with mean transmitral pressure gradient (TMPG) in the majority of patients (r = -0.56, p <0.001), but discordance of MVA and TMPG was observed in 40% of patients. In multivariable linear regression analysis, postprocedural MVA ≤1.94 cm² was independently associated with a blunted decrease in systolic pulmonary artery pressure at 1-month follow-up (β-estimate -4.63, 95% confidence interval -9.71 to -0.15, p = 0.042). Postprocedural MVA ≤1.94 cm² was an independent predictor of all-cause mortality and heart failure hospitalization after MitraClip (hazard ratio 4.28, 95% confidence interval 1.56 to 11.7, p = 0.005) even after adjustment for age, gender, atrial fibrillation, cause of MR, left ventricular systolic function, pre-existing pulmonary hypertension, and residual MR. After further adjustment for TMPG ≥5 mm Hg, postprocedural MVA ≤1.94 cm² remained predictive for adverse outcomes (p = 0.048). In conclusion, the intraprocedural assessment of MVA by 3-dimensional transesophageal echocardiography can predict hemodynamic response and postprocedural prognosis after MitraClip therapy.

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.

Echocardiographic Assessment of Mitral Stenosis Orifice Area: A Comparison of a Novel Three-Dimensional Method Versus Conventional Techniques

BACKGROUND

A comprehensive evaluation of mitral stenosis (MS) severity commonly utilizes two-dimensional (2D) echocardiography techniques. However, the complex three-dimensional (3D) structure of the mitral valve (MV) poses challenges to accurate measurements of its orifice area by 2D imaging modalities. We aimed to assess MS severity by comparing measurements of the MV orifice area using conventional echocardiography methods to 3D orifice area (3DOA), a novel echocardiographic technique which minimizes geometric assumptions.

METHODS

Routine 2D and 3D intraoperative transesophageal echocardiographic images from 26 adult cardiac surgery patients with at least moderate rheumatic MS were retrospectively reviewed. Measurements of the MV orifice area obtained by pressure half-time (PHT), proximal isovelocity surface area (PISA), continuity equation, and 3D planimetry were compared to those acquired using 3DOA.

RESULTS

MV areas derived by PHT, PISA, continuity equation, 3D planimetry, and 3DOA (mean value ± standard deviation) were 1.12 ± 0.27, 1.03 ± 0.27, 1.16 ± 0.35, 0.97 ± 0.25, and 0.76 ± 0.21 cm, respectively. Areas obtained from the 3DOA method were significantly smaller than areas derived from PHT (mean difference 0.35 cm, P < .0001), PISA (mean difference: 0.28 cm, P = .0002), continuity equation (mean difference: 0.43 cm, P = .0015), and 3D planimetry (mean difference: 0.19 cm, P < .0001). MV 3DOAs also identified a significantly greater percentage of patients with severe MS (88%) compared to PHT (31%, P = .006), PISA (42%, P = .01), and continuity equation (39%, P = .017) but not in comparison to 3D planimetry (62%, P = .165).

CONCLUSIONS

Novel measures of the stenotic MV 3DOA in patients with rheumatic heart disease are significantly smaller than calculated values obtained by conventional methods and may be consistent with a higher incidence of severe MS compared to 2D techniques. Further investigation is warranted to determine the clinical relevance of 3D echocardiographic techniques used to measure MV area.

Three-dimensional proximal flow convergence automatic calculation for determining mitral valve area in rheumatic mitral stenosis

PURPOSE

Management of patients with mitral stenosis (MS) depends heavily on the accurate quantification of mitral valve area (MVA) using echocardiography. All currently used two-dimensional (2D) methods have limitations. Estimation of MVA using the proximal isovelocity surface area (PISA) method with real time three-dimensional (3D) echocardiography may circumvent those limitations. We aimed to evaluate the accuracy of 3D direct measurement of PISA in the estimation of MVA.

METHODS

Twenty-seven consecutive patients (median age of 63 years; 77.8% females) with rheumatic MS were prospectively studied. Transthoracic and transesophageal echocardiography with 2D and 3D acquisitions were performed on the same day. The reference method for MVA quantification was valve planimetry after 3D-volume multiplanar reconstruction. A semi-automated software was used to calculate the 3D flow convergence volume.

RESULTS

Compared to MVA estimation using 3D planimetry, 3D PISA showed the best correlation (rho=0.78, P<.0001), followed by pressure half-time (PHT: rho=0.66, P<.001), continuity equation (CE: rho=0.61, P=.003), and 2D PISA (rho=0.26, P=.203). Bland-Altman analysis revealed a good agreement for MVA estimation with 3D PISA (mean difference -0.03 cm² ; limits of agreement (LOA) -0.40-0.35), in contrast to wider LOA for 2D methods: CE (mean difference 0.02 cm² , LOA -0.56-0.60); PHT (mean difference 0.31 cm² , LOA -0.32-0.95); 2D PISA (mean difference -0.03 cm² , LOA -0.92-0.86).

CONCLUSIONS

MVA estimation using 3D PISA was feasible and more accurate than 2D methods. Its introduction in daily clinical practice seems possible and may overcome technical limitations of 2D methods.

Pathophysiology and management of multivalvular disease

Multivalvular disease (MVD) is common among patients with valvular disease, and has a complex pathophysiology dependent on the specific combination of valve lesions. Diagnosis is challenging because several echocardiographic methods commonly used for the assessment of stenosis or regurgitation have been validated only in patients with single-valve disease. Decisions about the timing and type of treatment should be made by a multidisciplinary heart valve team, on a case-by-case basis. Several factors should be considered, including the severity and consequences of the MVD, the patient's life expectancy and comorbidities, the surgical risk associated with combined valve procedures, the long-term risk of morbidity and mortality associated with multiple valve prostheses, and the likelihood and risk of reoperation. The introduction of transcatheter valve therapies into clinical practice has provided new treatment options for patients with MVD, and decision-making algorithms on how to combine surgical and percutaneous treatment options are evolving rapidly. In this Review, we discuss the pathophysiology, diagnosis, and treatment of MVD, focusing on the combinations of valve pathologies that are most often encountered in clinical practice.

Update on percutaneous mitral commissurotomy

Percutaneous mitral commissurotomy (PMC) is the first-line therapy for managing rheumatic mitral stenosis. Over the past two decades, the indications of the procedure have expanded to include patients with unfavourable valve anatomy as a consequence of epidemiological changes in patient population. The procedure is increasingly being performed in patients with increased age, more deformed valves and associated comorbidities. Echocardiography plays a crucial role in patient selection and to guide a more efficient procedure. The main echocardiographic predictors of immediate results after PMC are mitral valve area, subvalvular thickening and valve calcification, especially at the commissural level. However, procedural success rate is not only dependent on valve anatomy, but a number of other factors including patient characteristics, interventional management strategies and operator expertise. Severe mitral regurgitation continues to be the most common immediate procedural complication with unchanged incidence rates over time. The long-term outcome after PMC is mainly determined by the immediate procedural results. Postprocedural parameters associated with late adverse events include mitral valve area, mitral regurgitation severity, mean gradient and pulmonary artery pressure. Mitral restenosis is an important predictor of event-free survival rates after successful PMC, and repeat procedure can be considered in cases with commissural refusion. PMC can be performed in special situations, which include high-risk patients, during pregnancy and in the presence of left atrial thrombus, especially in centres with specialised expertise. Therefore, procedural decision-making should take into account the several determinant factors of PMC outcomes. This paper provides an overview and update of PMC techniques, complications, immediate and long-term results over time, and assessment of suitability for the procedure.

Recent advances in echocardiography for valvular heart disease

Echocardiography is the imaging modality of choice for the assessment of patients with valvular heart disease. Echocardiographic advancements may have particular impact on the assessment and management of patients with valvular heart disease. This review will summarize the current literature on advancements, such as three-dimensional echocardiography, strain imaging, intracardiac echocardiography, and fusion imaging, in this patient population.

Catheter interventions for mitral stenosis in children: results and perspectives

Stenosis of the mitral valve most often occurs as a result of chronic rheumatic heart disease, causing thickening and fibrosis of the mitral valve apparatus. Rheumatic heart disease continues to be a major public health problem in several developing countries and mitral stenosis is also common in these regions. According to the reports from India and Africa, the disease tends to follow a rapidly progressive course in children. The treatment of choice is balloon dilatation of the mitral valve. Echocardiography is indispensable for this procedure. Before planning the procedure, it is essential to assess the suitability of balloon dilatation. Echocardiography performed during the procedure helps to decide whether the size of the balloon needs to be increased in case of inadequate relief of stenosis. Most published series have reported an immediate success rate of over 90% with balloon dilatation in children and young adults. With an increase in mitral valve area and improvement in functional class, the left atrial pressure and the transmitral gradients fall. These gratifying results are also reported from very young children of less than 12 years of age. It is recommended to start with a smaller balloon size and increase its size in a stepwise fashion to minimize complications. The complications, seen in about 1% to 2% of cases, include development of significant mitral regurgitation and hemopericardium, secondary to cardiac chamber perforation. The long-term results indicate slightly higher restenosis rates in children than in adults. Most children with restenosis can undergo successful repeat dilatation.

Libman-Sacks Endocarditis: Detection, Characterization, and Clinical Correlates by Three-Dimensional Transesophageal Echocardiography

BACKGROUND

Libman-Sacks endocarditis, characterized by Libman-Sacks vegetations, is common in patients with systemic lupus erythematosus and is commonly complicated with embolic cerebrovascular disease. Thus, accurate detection of Libman-Sacks vegetations may lead to early therapy and prevention of their associated complications. Although two-dimensional (2D) transesophageal echocardiography (TEE) has high diagnostic value for detection of Libman-Sacks vegetations, three-dimensional (3D) TEE may allow improved detection, characterization, and clinical correlations of Libman-Sacks vegetations.

METHODS

Twenty-nine patients with systemic lupus erythematosus (27 women; mean age, 34 ± 12 years) prospectively underwent 40 paired 3D and 2D transesophageal echocardiographic studies and assessment of cerebrovascular disease manifested as acute clinical neurologic syndromes, neurocognitive dysfunction, or focal brain injury on magnetic resonance imaging. Initial and repeat studies in patients were intermixed in a blinded manner with paired studies from healthy controls, deidentified, coded, and independently interpreted by experienced observers unaware of patients' clinical and imaging data.

RESULTS

The results of 3D TEE compared with 2D TEE were more often positive for mitral or aortic valve vegetations, and 3D TEE detected more vegetations per study and determined larger sizes of vegetations (P ≤ .03 for all). Also, 3D TEE detected more vegetations on the anterior mitral leaflet, anterolateral and posteromedial scallops, and ventricular side or both atrial and ventricular sides of the leaflets (P < .05 for all). In addition, 3D TEE detected more vegetations on the aortic valve left and noncoronary cusps, coronary cusps' tips and margins, and aortic side or both aortic and ventricular sides of the cusps (P ≤ .01 for all). Furthermore, 3D TEE more often detected associated mitral or aortic valve commissural fusion (P = .002). Finally, 3D TEE detected more vegetations in patients with cerebrovascular disease (P = .01).

CONCLUSIONS

Three-dimensional TEE provides clinically relevant additive information that complements 2D TEE for the detection, characterization, and association with cerebrovascular disease of Libman-Sacks endocarditis.

Role of modern 3D echocardiography in valvular heart disease

Three-dimensional (3D) echocardiography has been conceived as one of the most promising methods for the diagnosis of valvular heart disease, and recently has become an integral clinical tool thanks to the development of high quality real-time transesophageal echocardiography (TEE). In particular, for mitral valve diseases, this new approach has proven to be the most unique, powerful, and convincing method for understanding the complicated anatomy of the mitral valve and its dynamism. The method has been useful for surgical management, including robotic mitral valve repair. Moreover, this method has become indispensable for nonsurgical mitral procedures such as edge to edge mitral repair and transcatheter closure of paravaluvular leaks. In addition, color Doppler 3D echo has been valuable to identify the location of the regurgitant orifice and the severity of the mitral regurgitation. For aortic and tricuspid valve diseases, this method may not be quite as valuable as for the mitral valve. However, the necessity of 3D echo is recognized for certain situations even for these valves, such as for evaluating the aortic annulus for transcatheter aortic valve implantation. It is now clear that this method, especially with the continued development of real-time 3D TEE technology, will enhance the diagnosis and management of patients with these valvular heart diseases.

Incremental value of 3-D transesophageal echocardiographic imaging of the mitral valve

Transesophageal echocardiography provides excellent visualization of the posteriorly located mitral valve. Over the last decade, 3-dimensional transesophageal echocardiography (3D TEE) has emerged as an exciting imaging modality, particularly of the mitral valve. The current generation matrix array technology allows the operator to perform 2D and 3D imaging with a single transducer. 3D TEE affords the unique ability to view the mitral valve and its surrounding structures "en face" in real time (RT), and provide contextual anatomical guidance during surgical and transcatheter interventions. Additionally, offline quantification has made significant contributions to our mechanistic understanding of the normal and diseased mitral valve, and alterations induced by therapeutic intervention such as surgical repair. This review will address recent advances in the incremental role of 3D TEE in mitral valve imaging.

3-dimensional echocardiography and its role in preoperative mitral valve evaluation

Echocardiography plays a key role in the preoperative evaluation of mitral valve disease. 3-dimensional echocardiography is a relatively new development that is being used more and more frequently in the evaluation of these patients. This article reviews the available literature comparing the use of this new technology to classic techniques in the assessment of mitral valve pathology. The authors also review some of the novel insights learned from 3-dimensional echocardiography and how they may be used in surgical decision making and planning.