The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

Navigating the Dynamic Nature of Mitral Regurgitation With the Use of Multimodality Imaging in a Young Woman

The mechanism and severity of mitral valve (MV) regurgitation (MR) play a critical role in guiding treatment decisions. Transthoracic echocardiography (TTE) is the primary diagnostic modality for evaluating MV disease. Discordant findings on TTE can be further quantified through transesophageal echocardiography (TEE). We describe the case of a young woman with worsening exertional dyspnea who was found to have restricted posterior MV leaflet and moderate to severe eccentric MR on TTE. TEE was subsequently performed to determine the exact mechanism of MR revealing the prolapse of the A2 segment of the MV. However, TEE significantly underestimated MR severity, downgrading it to visually mild to moderate MR and quantitatively moderate MR. This discrepancy highlights the potential for significant variation in MR severity assessment under general anesthesia, emphasizing the impact of hemodynamic loading conditions. In our case, intravenous sedatives may have altered the loading conditions reducing MR severity on TEE compared to TTE. Given her symptom severity, MV pathology, left ventricular dilatation, and the higher MR severity observed on TTE, she underwent surgical MV repair, in alignment with the Class I recommendation by the American College of Cardiology/American Heart Association (ACC/AHA) valvular heart disease guidelines. Postoperatively, she experienced significant improvement in symptoms and quality of life.

Echocardiographic assessment of atrial, ventricular, and valvular function in patients with atrial fibrillation-an expert proposal by the german working group of cardiovascular ultrasound

Echocardiography in patients with atrial fibrillation is challenging due to the varying heart rate. Thus, the topic of this expert proposal focuses on an obvious gap in the current recommendations about diagnosis and treatment of atrial fibrillation (AF)-the peculiarities and difficulties of echocardiographic imaging. The assessment of systolic and diastolic function-especially in combination with valvular heart diseases-by echocardiography can basically be done by averaging the results of echocardiographic measurements of the respective parameters or by the index beat approach, which uses a representative cardiac cycle for measurement. Therefore, a distinction must be made between the functionally relevant status, which is characterized by the averaging method, and the best possible hemodynamic status, which is achieved with the most optimal left ventricular (LV) filling according to the index beat method with longer previous RR intervals. This proposal focuses on left atrial and left ventricular function and deliberately excludes problems of echocardiography when assessing left atrial appendage in terms of its complexity. Echocardiography of the left atrial appendage is therefore reserved for its own expert proposal.

EasyPISA: Automatic Integrated PISA Measurements of Mitral Regurgitation From 2-D Color-Doppler Using Deep Learning

OBJECTIVE

The proximal isovelocity surface area (PISA) method is a well-established approach for mitral regurgitation (MR) quantification. However, it exhibits high inter-observer variability and inaccuracies in cases of non-hemispherical flow convergence and non-holosystolic MR. To address this, we present EasyPISA, a framework for automated integrated PISA measurements taken directly from 2-D color-Doppler sequences.

METHODS

We trained convolutional neural networks (UNet/Attention UNet) on 1171 images from 196 recordings (54 patients) to detect and segment flow convergence zones in 2-D color-Doppler images. Different preprocessing schemes and model architectures were compared. Flow convergence surface areas were estimated, accounting for non-hemispherical convergence, and regurgitant volume (RVol) was computed by integrating the flow rate over time. EasyPISA was retrospectively applied to 26 MR patient examinations, comparing results with reference PISA RVol measurements, severity grades, and cMRI RVol measurements for 13 patients.

RESULTS

The UNet trained on duplex images achieved the best results (precision: 0.63, recall: 0.95, dice: 0.58, flow rate error: 10.4 ml/s). Mitigation of false-positive segmentation on the atrial side of the mitral valve was achieved through integration with a mitral valve segmentation network. The intraclass correlation coefficient was 0.83 between EasyPISA and PISA, and 0.66 between EasyPISA and cMRI. Relative standard deviations were 46% and 53%, respectively. Receiver operator characteristics demonstrated a mean area under the curve between 0.90 and 0.97 for EasyPISA RVol estimates and reference severity grades.

CONCLUSION

EasyPISA demonstrates promising results for fully automated integrated PISA measurements in MR, offering potential benefits in workload reduction and mitigating inter-observer variability in MR assessment.

Validation of Yeo's index in assessing severity of rheumatic mitral stenosis in mixed valve lesions

Introduction

Yeo's Index, product of the mitral leaflet separation index and dimensionless index, is a novel measure of the severity of rheumatic mitral stenosis (MS). We assess Yeo's index in patients with rheumatic MS with or without mixed valve disease.

Methods

In a retrospective cohort study, Yeo's index was measured in 237 cases of rheumatic MS - 124 in a transthoracic echocardiography validation cohort using mitral valve area (MVA) by pressure half-time and planimetry as comparator and 113 in a transesophageal echocardiography (TEE) validation cohort using TEE three-dimensional MVA as comparator. Patients were considered to have mixed valve disease if they had MS and concomitant mitral regurgitation or aortic valve disease.

Results

There were 113 patients with isolated MS and 124 patients with mixed valve disease. Overall, Yeo's index ≤ 0.26 cm showed 93.0 % sensitivity and 87.5 % specificity for identifying severe MS (MVA ≤ 1.5 cm2). In isolated MS, Yeo's index ≤ 0.26 cm showed sensitivity of 94.6 % and specificity of 90.0 % for identifying severe MS, while in mixed valve disease sensitivity was 90.6 % and specificity 86.7 %. Overall, Yeo's index ≤ 0.15 cm showed 83.6 % sensitivity and 94.3 % specificity for very severe MS (MVA ≤ 1.0 cm2). In isolated MS, the threshold of ≤0.15 cm showed sensitivity of 84.4 % and specificity of 92.6 % for very severe MS, while in mixed valve disease sensitivity was 81.3 % and specificity 95.3 %. The presence of atrial fibrillation did not influence the performance of Yeo's index.

Conclusion

Yeo's Index accurately differentiates severity of rheumatic MS with or without mixed valve disease.

Practical guidance and clinical applications of transoesophageal echocardiography. A position paper of the working group of echocardiography of the Hellenic Society of Cardiology

Transoesophageal echocardiography (TOE) is a well-established imaging modality, providing more accurate and of higher quality information than transthoracic echocardiography (TTE) for a wide spectrum cardiac and extra-cardiac diseases. The present paper represents an effort by the Echocardiography Working Group (WG) of the Hellenic Cardiology Society to state the essential steps of the typical TOE exam performed in echo lab. This is an educational text, describing the minimal requirements and the preparation of a meticulous TOE examination. Most importantly, it gives practical instructions to obtain and optimize TOE views and analyses the implementation of a combined two-and multi-dimensional protocol for the imaging of the most common cardiac structures during a TOE. In the second part of the article a comprehensive review of the contemporary use of TOE in a wide spectrum of valvular and non-valvular cardiac diseases is provided, based on the current guidelines and the experience of the WG members.

Impact of Net Atrioventricular Compliance on Mitral Valve Area Assessment-A Perspective Considering Three-Dimensional Mitral Valve Area by Transesophageal Echocardiography

BACKGROUND

Net atrioventricular compliance (Cn) can affect the accuracy of mitral valve area (MVA) assessment. We assessed how different methods of MVA assessment are affected by Cn, and if patients with abnormal Cn may be identified by clinical and/or echocardiographic parameters.

METHODS

We studied 244 patients with rheumatic MS. The concordance between mitral valve area (MVA) by 2D planimetry, pressure half-time (PHT), continuity equation (CE), Yeo's index, and 3-dimensional mitral valve area assessed by transesophageal echocardiography (TEE 3DMVA) in patients with normal and abnormal Cn (Cn ≤ 4 mL/mmHg) were evaluated in the 110 patients with both transesophageal echocardiogram (TEE) and transthoracic echocardiogram (TTE). Variables that were associated with abnormal Cn were validated in the remaining 134 patients with only TTE.

RESULTS

Except for MVA by CE, concordance with TEE 3DMVA was poorer for all other methods of MVA assessment in patients with abnormal Cn. But, the difference in concordance was only statistically significant for MVA by PHT. Patients with MVA ≤ 1.5 cm2 by 2D planimetry and PHT ≤ 130 ms were likely to have an abnormal Cn. (specificity 98.5%). This finding was validated in the remaining 134 patients (specificity 93%).

CONCLUSIONS

MVA assessment by PHT is significantly affected by Cn. Abnormal Cn should be suspected when 2D planimetry MVA is ≤1.5 cm2 together with an inappropriately short PHT that is ≤130 ms. In this scenario, MVA by PHT is inaccurate.

Combining 2D Planimetry and Yeo's Index Can Help Accurately Identify Patients with Severe Rheumatic Mitral Stenosis-A Perspective from a 3D Assessment Using Transoesophageal Echocardiography

BACKGROUND

Yeo's index is a novel measure of the severity of rheumatic mitral valve stenosis (MS). It is derived from the product of the mitral leaflet separation index and dimensionless index. This study aims to validate Yeo's index using a transesophageal echocardiogram (TEE) three-dimensional (3D) mitral valve area (MVA) as a comparator and to compare the concordance of existing echocardiographic measures of the MVA with TEE 3DMVA.

METHODS AND RESULTS

We studied 111 patients with rheumatic MS who underwent both transthoracic echocardiography (TTE) and a TEE assessment of MS severity. Yeo's index, the MVA determined by 2D planimetry, pressure half-time (PHT) and continuity equation (CE) measured on TTE were compared with the TEE 3DMVA. With a linear correlation, Yeo's index showed the best correlation with TEE 3DMVA (r2 = 0.775), followed by 2D planimetry (r2 = 0.687), CE (r2 = 0.598) and PHT (r2 = 0.363). Using TEE 3DMVA as comparator, Yeo's index (ρc = 0.739) demonstrated the best concordance, followed by 2D planimetry (ρc = 0.632), CE (ρc = 0.464) and PHT (ρc = 0.366). When both Yeo's index and 2D planimetry suggested significant MS, the positive predictive value was high (an AUC of 0.966 and a PPV of 100.00% for severe MS, and an AUC of 0.864 and a PPV of 85.71% for very severe MS). When both measures suggested the absence of significant MS, the negative predictive value was also high (an AUC of 0.940 and an NPV of 88.90% for severe MS, and an AUC of 0.831 and an NPV of 88.71% for very severe MS).

CONCLUSIONS

Yeo's index performed well in identifying severe MS when compared with TEE 3DMVA and may be a useful adjunct to existing methods of measuring MS severity. Combining it with 2D planimetry could further enhance its accuracy.

Embedding Tasks Into the Latent Space: Cross-Space Consistency for Multi-Dimensional Analysis in Echocardiography

Multi-dimensional analysis in echocardiography has attracted attention due to its potential for clinical indices quantification and computer-aided diagnosis. It can utilize various information to provide the estimation of multiple cardiac indices. However, it still has the challenge of inter-task conflict. This is owing to regional confusion, global abnormalities, and time-accumulated errors. Task mapping methods have the potential to address inter-task conflict. However, they may overlook the inherent differences between tasks, especially for multi-level tasks (e.g., pixel-level, image-level, and sequence-level tasks). This may lead to inappropriate local and spurious task constraints. We propose cross-space consistency (CSC) to overcome the challenge. The CSC embeds multi-level tasks to the same-level to reduce inherent task differences. This allows multi-level task features to be consistent in a unified latent space. The latent space extracts task-common features and constrains the distance in these features. This constrains the task weight region that satisfies multiple task conditions. Extensive experiments compare the CSC with fifteen state-of-the-art echocardiographic analysis methods on five datasets (10,908 patients). The result shows that the CSC can provide left ventricular (LV) segmentation, (DSC = 0.932), keypoint detection (MAE = 3.06mm), and keyframe identification (accuracy = 0.943). These results demonstrate that our method can provide a multi-dimensional analysis of cardiac function and is robust in large-scale datasets.

Left Atrium: A New Prognostic Marker and Therapeutic Target in Secondary Mitral Regurgitation?

Mitral regurgitation (MR) is one of the most common valvular abnormalities worldwide and can be subdivided into primary and secondary causes. Atrial MR consists of a novel type of secondary MR (SMR), most often observed in patients with AF and heart failure with preserved ejection fraction. The main pathophysiological mechanism of atrial MR is mitral valve annular dilatation. Recently published studies have highlighted the clinical significance of left atrium (LA) evaluation in the early diagnosis and prognosis of patients with primary MR. However, there are little data regarding the role of the LA in SMR. The present literature review aims to elucidate the use of the echocardiographic parameters regarding LA evaluation in the prognosis prediction and therapeutic strategy of patients with SMR.

Clinical Impact of the Volumetric Quantification of Ventricular Secondary Mitral Regurgitation by Three-Dimensional Echocardiography

BACKGROUND

The assessment of ventricular secondary mitral regurgitation (v-SMR) severity through effective regurgitant orifice area (EROA) and regurgitant volume (RegVol) calculations using the proximal isovelocity surface area (PISA) method and the two-dimensional echocardiography volumetric method (2DEVM) is prone to underestimation. Accordingly, we sought to investigate the accuracy of the three-dimensional echocardiography volumetric method (3DEVM) and its association with outcomes in v-SMR patients.

METHODS

We included 229 patients (70 ± 13 years, 74% men) with v-SMR. We compared EROA and RegVol calculated by the 3DEVM, 2DEVM, and PISA methods. The end point was a composite of heart failure hospitalization and death for any cause.

RESULTS

After a mean follow-up of 20 ±11 months, 98 patients (43%) reached the end point. Regurgitant volume and EROA calculated by 3DEVM were larger than those calculated by 2DEVM and PISA. Using receiver operating characteristic curve analysis, both EROA (area under the curve, 0.75; 95% CI, 0.68-0.81; P = .008) and RegVol (AUC, 0.75; 95% CI, 0.68-0.82; P = .02) measured by 3DEVM showed the highest association with the outcome at 2 years compared to PISA and 2DEVM (P < .05 for all). Kaplan-Meier analysis demonstrated a significantly higher rate of events in patients with EROA ≥ 0.3 cm2 (cumulative survival at 2 years: 28% ± 7% vs 32% ± 10% vs 30% ± 11%) and RegVol ≥ 45 mL (cumulative survival at 2 years: 21% ± 7% vs 24% ± 13% vs 22% ± 10%) by 3DEVM compared to those by PISA and 2DEVM, respectively. In Cox multivariable analysis, 3DEVM EROA remained independently associated with the end point (hazard ratio, 1.02, 95% CI, 1.00-1.05; P = .02). The model including EROA by 3DEVM provided significant incremental value to predict the combined end point compared to those using 2DEVM (net reclassification index = 0.51, P = .003; integrated discrimination index = 0.04, P = .014) and PISA (net reclassification index = 0.80, P < .001; integrated discrimination index = 0.06, P < .001).

CONCLUSIONS

Effective regurgitant orifice area and RegVol calculated by 3DEVM were independently associated with the end point, improving the risk stratification of patients with v-SMR compared to the 2DEVM and PISA methods.

Hypertrophic cardiomyopathy with anteriorly directed mitral regurgitation is a red flag for concomitant pathology: a case report

Background

Hypertrophic cardiomyopathy (HCM) is often linked to systolic anterior motion (SAM) of the mitral valve, typically resulting in a posteriorly directed mitral regurgitation (MR) jet. An anteriorly directed MR jet suggests additional mitral valve pathology that may not be resolved by myectomy alone.

Case summary

A 58-year-old construction worker with no significant medical history experienced a syncopal event and was admitted to the emergency department with acute pulmonary oedema. A systolic murmur was investigated with a trans-thoracic echocardiogram that revealed severe MR with an unusual anteriorly directed MR jet and a possible flail segment of the posterior leaflet. This finding was further characterized with a trans-oesophageal echocardiogram that revealed severe asymmetric septal hypertrophy with SAM of the mitral valve, severe mitral regurgitation into a dilated left atrium with pulmonary vein flow reversal not caused by HCM-associated SAM, and a markedly abnormal mitral valve with flail and prolapse. The patient underwent successful cardiac surgery, including mitral valve repair and septal myectomy. The patient's recovery was uneventful, allowing for a return to work within a month post-surgery.

Discussion

The anteriorly directed MR jet served as a red flag, leading to the discovery of an independent mitral valve pathology that required surgical intervention beyond the expected treatment for SAM-associated HCM. This case highlights the complexity of assessing MR in patients with HCM and underscores the importance of characterizing MR jet direction in diagnosing additional mitral valve diseases.

Mitral valve surgery assisted by virtual and augmented reality: Cardiac surgery at the front of innovation

BACKGROUND

Given the variety in mitral valve (MV) pathology and associated surgical techniques, extended reality (XR) holds great potential to assist MV surgeons. This review aims to systematically evaluate the currently available evidence investigating the use of XR and associated technologies in MV surgery.

METHODS

A systematic database search was conducted of original articles and case reports that explored the use of XR and MV surgery in EMBASE, MEDLINE, Cochrane database and Google Scholar, from inception to February 2022.

RESULTS

Our search yielded 171 articles, of which 15 studies were included in this review, featuring 328 patients. Two main areas of application were identified: (i) pre-operative planning and (ii) predicting post-operative outcomes. The articles reporting outcomes relating to pre-operative planning were further categorised as exploring themes relevant to (i) mitral annular assessment; (ii) training; (iii) evaluation of surgical technique; (iv) surgical approach or plan and (v) selecting ring size or type. Preoperatively, XR has been shown to evaluate mitral annular pathology more accurately than echocardiography, informing the surgeon about the optimal surgical technique, approach and plan for a particular patient's MV pathology. Furthermore, XR could simulate and aid ring size/type selection for MV annuloplasty, creating a personalized surgical plan. Additionally, XR could estimate the postoperative MV biomechanical and physiological characteristics, predicting and pre-empting post-operative complications.

CONCLUSION

XR demonstrated promising applications for assisting MV surgery, enhancing outcomes and patient-centred care, nevertheless, there remain the need for randomized studies to ascertain its feasibility, safety, and validity in clinical practice.

Echocardiographic quantification of mitral apparatus morphology and dynamics in patients with dilated cardiomyopathy

Mitral regurgitation is among the most common valvular heart diseases. Mitral regurgitation in patients with dilated cardiomyopathy is a complex pathology involving annular dilatation, papillary muscle displacement, systolic leaflet tethering, and left ventricular remodeling. Quantification of mitral apparatus damage in these patients is essential for successful interventional and surgical therapy. Mitral regurgitation in the presence of dilated cardiomyopathy is classified as Carpentier type IIIB, with restricted leaflet mobility as a standard feature. Echocardiography allows accurate evaluation of the complex anatomy and function of the mitral apparatus. Updated guidelines recommend two-dimensional followed by systematic three-dimensional echocardiographic evaluation in patients with mitral regurgitation. New three-dimensional echocardiographic software packages provide many parameters that help identify the precise morphology and function of the various components of the mitral apparatus, helping to determine the etiology of mitral regurgitation and evaluate disease severity. This review provides the first point-by-point approach to the assessment of all old and new echocardiographic methods, from the simplest to the most complex, used to examine the components of the mitral valve apparatus in patients with dilated cardiomyopathy. Although these parameters are still under research, this information will be helpful for establishing therapeutic procedures in a disease with a poor prognosis.

Yeo's index: A novel index that combines anatomic and haemodynamic assessment of the severity of mitral stenosis

BACKGROUND

A mitral leaflet separation index (MLSI), measuring the anatomical separation of the mitral valve (MV) leaflet tips in diastole, was previously described as an accurate method of assessing mitral stenosis (MS). We propose a novel modification of the MLSI by including a hemodynamic assessment which we term Yeo's index that may improve its diagnostic performance.

METHODS AND RESULTS

We retrospectively studied 174 patients with varying severity of MS without significant mitral regurgitation, aortic valve disease or ventricular septal defect. MLSI was measured in 2 orthogonal views on transthoracic echocardiography as previously described. MV dimensionless index (DI) was calculated by dividing the left ventricular outflow tract pulsed-wave Doppler time velocity integral (TVI) by the MV continuous-wave Doppler TVI. We defined Yeo's index as the product of MLSI and DI. With linear correlation, Yeo's index demonstrated good correlation against MVA by planimetry (r = 0.728), pressure half-time (r = 0.677), and continuity equation (r = 0.829), with improved performance over the MLSI. Using ROC analysis, Yeo's index demonstrated good ability to correctly classify MS as severe (MVA ≤1.5cm2) (AUC 0.874, 95% CI 0.816-0.920). Yeo's index ≤0.260 cm correctly classified severe MS with sensitivity of 82% and specificity of 80%. Presence of AF did not affect the performance of Yeo's index. Yeo's index ≤0.147 cm also identified very severe MS (MVA ≤ 1.0 cm2) with specificity of 94% and sensitivity of 78%.

CONCLUSION

Yeo's index performed well in identifying severe MS and may be a useful adjunct to existing measures of MS severity.

Diagnostic yield of a heart failure referral pathway using N-terminal pro-brain natriuretic peptide

OBJECTIVE

To determine the diagnostic yield of a 'high' N-terminal pro-brain natriuretic peptide (NT-proBNP) in patients with suspected heart failure (HF) referred from primary to secondary care.

METHODS

In this retrospective study, cardiac diagnoses were quantified in consecutive patients with an NT-proBNP>400 ng/L referred from primary care centres to a specialist HF service.

RESULTS

Among 654 consecutive patients (age: 78.5±9.72 years; 45.9% men; left ventricular ejection fraction (LVEF): 55.4±12.5% (mean±SD)), the primary diagnoses were: valvular disease (39.4%), HF (29.2%; 13.3% with LVEF<40%) and atrial fibrillation (AF; 17.3%). In terms of primary or secondary diagnoses, 68% of patients had valve disease, 46.9% had AF and 29.2% had HF. A cardiac diagnosis was made in 85.9%. In multivariable analyses, NT-proBNP predicted HF with LVEF<40% (OR: 10.2, 95% CI: 5.63 to 18.3) and HF with any LVEF (OR: 6.13, 95% CI: 3.79 to 9.93). In canonical linear discriminant analyses, NT-proBNP correctly identified 54.5% of patients with HF. The remainder were misclassified as valvular disease, AF or no cardiac diagnosis.

CONCLUSION

Among patients with an NT-proBNP>400 ng/L referred through a primary care HF pathway, most patients had valve disease or AF rather than HF. NT-proBNP cannot discriminate among HF, valve disease and AF. On this basis, NT-proBNP may be best employed in detecting cardiac disease in general rather than HF per se.

Diagnostic Accuracy of Transesophageal Echocardiographic Commissural-Biplane Approach in Identifying Mitral Valve Anatomy

BACKGROUND

Transesophageal echocardiography (TEE) conventional multiplane approach (MPA) and the newly proposed commissural-biplane approach (CBA) are the recommended algorithms for identifying the affected mitral valve (MV) segments in the setting of mitral regurgitation. To date, there are no reports to address the diagnostic performance of CBA. In this study we aim to analyze the diagnostic accuracy of CBA and MPA in comparison with three-dimensional echocardiographic findings in patients with severe mitral regurgitation.

METHODS

We prospectively enrolled 102 patients with severe mitral regurgitation. All patients underwent systematic TEE assessment of MV before surgical intervention to define the affected MV segments/scallops. The standard MPA includes 4-chamber, 2-chamber, long-axis, and commissural views; CBA was performed by obtaining the bicommissural view and simultaneous biplane imaging of the medial, middle, and lateral MV aspects. The findings of both TEE approaches were compared with three-dimensional TEE data to assess the diagnostic accuracy of MPA and CBA.

RESULTS

The mean patient age was (65 ± 11) years, and 37 (36.3%) were female. We found that CBA had an overall diagnostic accuracy between 88% and 97% in identifying the abnormal MV scallops; in contrast, MPA accuracy ranged between 82% and 95%. The CBA and MPA were the least accurate in identifying the P3 scallop-88% and 82% respectively; however, both were the most accurate in assessing the A2 segment-95% and 97%, respectively. The sensitivity of identifying commissural abnormalities was 80% with CBA and 30% with MPA. Three-dimensional TEE was found to have a strong agreement with CBA (averaged kappa of 0.81, P < .0001) and a modest agreement with MPA (averaged kappa of 0.61, P < .0001) in identifying abnormal anterior or posterior segments. On the other hand, three-dimensional TEE had a weak agreement with CBA (kappa of 0.43, P < .0001) and no agreement with MPA (kappa of 0.14, P = .153) in the assessment of commissural involvements.

CONCLUSION

The CBA is more accurate than the MPA in the assessment of MV commissural involvement. Given the accuracy differences of the 2 approaches for specific leaflet/scallops, a comprehensive evaluation using both approaches is recommended for all MV scallop assessments.

Computational Modeling of the Subject-Specific Effects of Annuloplasty Ring Sizing on the Mitral Valve to Repair Functional Mitral Regurgitation

Surgical repair of functional mitral regurgitation (FMR) that occurs in nearly 60% of heart failure (HF) patients is currently performed with undersizing mitral annuloplasty (UMA), which lacks short- and long-term durability. Heterogeneity in valve geometry makes tailoring this repair to each patient challenging, and predictive models that can help with planning this surgery are lacking. In this study, we present a 3D echo-derived computational model, to enable subject-specific, pre-surgical planning of the repair. Three computational models of the mitral valve were created from 3D echo data obtained in three pigs with HF and FMR. An annuloplasty ring model in seven sizes was created, each ring was deployed, and post-repair valve closure was simulated. The results indicate that large annuloplasty rings (> 32 mm) were not effective in eliminating regurgitant gaps nor in restoring leaflet coaptation or reducing leaflet stresses and chordal tension. Smaller rings (≤ 32 mm) restored better systolic valve closure in all investigated cases,but excessive valve tethering and restricted motion of the leaflets were still present. This computational study demonstrates that for effective correction of FMR, the extent of annular reduction differs between subjects, and overly reducing the annulus has deleterious effects on the valve.

Mitral regurgitation in the critically ill: the devil is in the detail

Mitral regurgitation (MR) is common in the critically unwell and encompasses a heterogenous group of conditions with diverging therapeutic strategies. MR may present acutely with haemodynamic instability or more insidiously with failure to wean from mechanical ventilation. Critical illness is associated with marked physiological stress and haemodynamic changes that dynamically influence the severity and implication of MR. The expanding role of critical care echocardiography uniquely positions the intensivist to apply advanced bedside valvular assessment to recognise haemodynanically significant MR, manipulate and optimise cardiopulmonary physiology and identify patients requiring urgent cardiology and surgical referral. This review will consider common clinical scenarios, therapeutic strategies and the pearls and pitfalls of echocardiographic assessment and quantification in the critically unwell.

Mitral valve geometrical echocardiographic analysis and 3D computational modeling of a normal mitral valve

Aim: This research aims to develop a consistent computational model of a normal mitral valve (MV) and describe mitral regurgitation (MR) geometry based on Carpentier's classification. Materials & methods: MV geometry was assessed by 2D transthoracic echocardiogram in 100 individuals. A 3D parametric geometric model of the MV was developed. A computational model of a normal MV was performed. Results: The simulation of the valve function was successfully accomplished and its kinematics was analyzed. Differences in geometry were revealed between normal and type III MR. Conclusion: 3D computational models of the normal MV can be constructed relying on standard measurements performed by 2D echocardiography. Certain geometrical differences exist among the normal and the most severe type of MR.

Transthoracic Echocardiographic Assessment of the Heart in Pregnancy-a position statement on behalf of the British Society of Echocardiography and the United Kingdom Maternal Cardiology Society

Pregnancy is a dynamic process associated with profound hormonally mediated haemodynamic changes which result in structural and functional adaptations in the cardiovascular system. An understanding of the myocardial adaptations is important for echocardiographers and clinicians undertaking or interpreting echocardiograms on pregnant and post-partum women. This guideline, on behalf of the British Society of Echocardiography and United Kingdom Maternal Cardiology Society, reviews the expected echocardiographic findings in normal pregnancy and in different cardiac disease states, as well as echocardiographic signs of decompensation. It aims to lay out a structure for echocardiographic scanning and surveillance during and after pregnancy as well as suggesting practical advice on scanning pregnant women.

Clinical Utility of Three-Dimensional Echocardiography in the Evaluation of Mitral Valve Disease: Tips and Tricks

Although real-time 3D echocardiography (RT3DE) has only been introduced in the last decades, its use still needs to be improved since it is a time-consuming and operator-dependent technique and acquiring a good quality data can be difficult. Moreover, the additive value of this important diagnostic tool still needs to be wholly appreciated in clinical practice. This review aims at explaining how, why, and when performing RT3DE is useful in clinical practice.

Multimodality Imaging in Valvular Structural Interventions

Structural valvular interventions have skyrocketed in the past decade with new devices becoming available and indications for patients who would previously have been deemed inoperable. Furthermore, while echocardiography is the main imaging tool and the first line for patient screening, cardiac magnetic resonance and CT are now essential tools in pre-planning and post-procedural follow-up. This review aims to address imaging modalities and their scope in aortic, mitral and tricuspid structural valvular interventions, including multimodality imaging. Pulmonary valve procedures, which are mostly carried out in patients with congenital problems, are discussed. This article presents a guide on individualised imaging approcahes on each of the available interventional procedures.

A practical guideline for performing a comprehensive transthoracic echocardiogram in the congenital heart disease patient: consensus recommendations from the British Society of Echocardiography

Transthoracic echocardiography is an essential tool in the diagnosis, assessment, and management of paediatric and adult populations with suspected or confirmed congenital heart disease. Congenital echocardiography is highly operator-dependent, requiring advanced technical acquisition and interpretative skill levels. This document is designed to complement previous congenital echocardiography literature by providing detailed practical echocardiography imaging guidance on sequential segmental analysis, and is intended for implementation predominantly, but not exclusively, within adult congenital heart disease settings. It encompasses the recommended dataset to be performed and is structured in the preferred order for a complete anatomical and functional sequential segmental congenital echocardiogram. It is recommended that this level of study be performed at least once on all patients being assessed by a specialist congenital cardiology service. This document will be supplemented by a series of practical pathology specific congenital echocardiography guidelines. Collectively, these will provide structure and standardisation to image acquisition and reporting, to ensure that all important information is collected and interpreted appropriately.

Multimodality imaging for the management of patients with primary mitral regurgitation

Advanced cardiac imaging (ACI), including myocardial deformation imaging, 3D echocardiography and cardiac magnetic resonance, overcomes the limitations of conventional echocardiography in the assessment of patients with primary mitral regurgitation (MR). They enable a more precise MR quantification and reveal early changes before advanced and irreversible remodeling with depressed heart function occurs. ACI permits a thorough analysis of mitral valvular anatomy and MR mechanisms (important for planning and guiding percutaneous and surgical procedures) and helps to identify structural and functional changes coupled with a high arrhythmogenic potential, especially the occurrence of atrial fibrillation and heart failure development. The key question is how the data provided by ACI can improve the current management of primary MR.

Practical Echocardiographic Approach of the Regurgitant Mitral Valve Assessment

Mitral regurgitation is the second-most frequent valvular heart disease in Europe after degenerative aortic stenosis. It is associated with significant morbidity and mortality, and its prevalence is expected to increase with population aging. Echocardiography is the first diagnostic approach to assess its severity, constituting a challenging process in which a multimodality evaluation, integrating quantitative, semiquantitative and qualitative methods, as well as a detailed evaluation of the morphology and function of both left ventricle and atria is the key. In this review, we would like to provide a practical diagnosis approach on the mitral valve regurgitation mechanism, severity quantification, and planning of future therapeutic options.

Clinical indications and triaging for adult transthoracic echocardiography: a consensus statement by the British Society of Echocardiography in collaboration with British Heart Valve Society

Transthoracic echocardiography (TTE) is widely utilised within many aspects of clinical practice, as such the demand placed on echocardiography services is ever increasing. In an attempt to provide incremental value for patients and standardise patient care, the British Society of Echocardiography in collaboration with the British Heart Valve Society have devised updated guidance for the indications and triaging of adult TTE requests for TTE services to implement into clinical practice.

Multi-modality imaging assessment of native valvular regurgitation: an EACVI and ESC council of valvular heart disease position paper

Valvular regurgitation represents an important cause of cardiovascular morbidity and mortality. Imaging is pivotal in the evaluation of native valve regurgitation and echocardiography is the primary imaging modality for this purpose. The imaging assessment of valvular regurgitation should integrate quantification of the regurgitation, assessment of the valve anatomy and function, and the consequences of valvular disease on cardiac chambers. In clinical practice, the management of patients with valvular regurgitation largely relies on the results of imaging. It is crucial to provide standards that aim at establishing a baseline list of measurements to be performed when assessing native valve regurgitation. The present document aims to present clinical guidance for the multi-modality imaging assessment of native valvular regurgitation.

Valvular Cardiomyopathy: The Value of Cardiovascular Magnetic Resonance Imaging

Cardiovascular magnetic resonance (CMR) imaging has had a vast impact on the understanding of a wide range of disease processes and pathophysiological mechanisms. More recently, it has contributed significantly to the diagnosis and risk stratification of patients with valvular heart disease. With its increasing use, CMR allows for a detailed, reproducible, qualitative, and quantitative evaluation of left ventricular volumes and mass, thereby enabling assessment of the haemodynamic impact of a valvular lesion upon the myocardium. Postprocessing of the routinely acquired images with feature tracking CMR methodology can give invaluable information about myocardial deformation and strain parameters that suggest subclinical ventricular impairment that remains undetected by conventional measures such as the ejection fraction (EF). T1 mapping and late gadolinium enhancement (LGE) imaging provide deep myocardial tissue characterisation that is changing the approach towards risk stratification of patients as an increasing body of evidence suggests that the presence of fibrosis is related to adverse events and prognosis. This review summarises the current evidence regarding the utility of CMR in the left ventricular assessment of patients with aortic stenosis or mitral regurgitation and its value in diagnosis, risk stratification, and management.