The comparative value of transesophageal and transthoracic echocardiography before and after percutaneous mitral balloon valvotomy: A prospective study

doi:10.1016/0002-8703(93)90119-T

American Heart Journal

Volume 125, Issue 4, April 1993, Pages 1094-1105

https://doi.org/10.1016/0002-8703(93)90119-T Get rights and content

Abstract

Transthoracic (TTE) and transesophageal echocardiography (TEE) were performed prospectively on 53 consecutive patients (mean age 59 ± 14 years) immediately before and within 24 hours of mitral balloon valvotomy to compare the relative value of the two techniques. Biplane TEE was used in 38 patients and single-plane imaging was done in 11. All patients underwent left and right cardiac catheterization, left ventriculography, and coronary angiography. While TEE provided excellent images of the mitral valve in all patients, imaging planes were more limited than by TTE. Mitral valve morphology could be assessed satisfactorily by either technique. Echo scores derived from each showed good correlation (r = 0.90, p < 0.001). TEE transgastric longitudinal scanning provided superior detail of the subvalvar apparatus but only in 20 (53%) of 38 patients. Patients with good transgastric views had significantly smaller left atrial volumes than those without (58 ± 22 vs 106 ± 41 cm³, p < 0.001). Mitral valve orifice and the commissures were better assessed by TTE. Before valvotomy, mitral regurgitation (MR) graded by TEE and TTE color flow mapping was concordant with angiography in 80% and 81%, respectively. After valvotomy, TTE color flow mapping failed to detect MR in two of the three patients who developed severe MR. Two of these patients were examined by TEE, which demonstrated both the MR jets as well as leaflet tears. Thrombus was diagnosed in the left atrium in eight patients by TEE and in only one patient by TTE. Biplane TEE was required for accurate thrombus localization and for assessing its size and extent. Five patients with thrombus underwent balloon valvotomy without complications. Left-to-right atrial shunting was detected by TEE and TTE in 95% and 48% of patients, respectively. Flow convergence regions, from which quantitative flow information can be derived, were imaged by TEE only. TTE and TEE have complementary roles. However, TEE is essential for excluding thrombus in the left atrium before balloon valvotomy. After the procedure, TEE is recommended for the evaluation of patients with severe mitral regurgitation.

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Cited by (22)

Assessment of mitral valve commissural morphology by transoesophageal echocardiography predicts outcome after balloon mitral valvotomy
2013, Indian Heart Journal
Citation Excerpt :
Left atrial thrombus cannot be reliably excluded by TTE because of its inability to visualize the left atrial appendage fully in all patients,12–14 and many centers now routinely perform TOE before BMV for this reason. The longitudinal transgastric plane, when available, also allows more detailed visualization of the chordae and papillary muscles than does TTE.15 TOE also has a role after BMV, since it is more accurate in determining the severity and mechanism of MR and in evaluating the degree of any residual left to right shunting across the interatrial septum.12,15
Balloon mitral valvotomy (BMV) is a safe and an effective treatment in patients with symptomatic rheumatic mitral stenosis. This study was conducted to validate the importance of assessing the morphology of mitral valve commissures by transoesophageal echocardiography and thereby predicting the outcome after balloon mitral valvotomy [BMV].
Study consisted of 100 patients with symptomatic mitral stenosis undergoing BMV. The Commissural Morphology and Wilkins score were assessed by transoesophageal echocardiography. Both the commissures (anterolateral and posteromedial) were scored individually according to whether non-calcified fusion was absent (0), partial (1), or extensive (2) and calcification (score 0) and combined giving an overall commissural score of 0–4. Outcome of BMV was correlated with commissural score and Wilkins score.
The commissural score and outcome after BMV correlated significantly. 66 of 70 patients (94%) with a commissural score of 3–4 obtained a good outcome compared with only six (20%) patients of 30 with a commissural score of 0–2 (positive and negative predictive accuracy 94% and 80%, respectively, p < 0.001). Increase in 2DMVA post BMV was more in patients with higher commissural score (score of 3–4). Wilkins score <8 usually predicts a good outcome but even in patients with Wilkins score >8 a commissural score >2 predicts a 50% chance of a good result.
A higher commissural score predicts a good outcome after BMV hence it can be concluded that along with Wilkins score, commissural morphology and score should be assessed with TOE in patients undergoing BMV.
Echocardiographic assessment of mitral stenosis. Echocardiographic features of rheumatic mitral stenosis
2013, Cardiology Clinics
Citation Excerpt :
Atrial fibrillation, spontaneous echo contrast, and an enlarged left atrium are associated with high thromboembolic risk.96,97 During the PBMV, 2D and 3D TEE can provide navigational guidance for transseptal puncture and balloon placement, and evaluate for procedural success and complications such as new or worsening mitral regurgitation, interatrial shunting, or, rarely, pericardial effusion.98–100 It can be done expeditiously, reliably, and with minimal complications.
Mitral balloon valvuloplasty
2010, Journal of the Saudi Heart Association
Percutaneous mitral balloon valvuloplasty (MBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, MBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of MBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0–0.5%), cerebral accident (1–2%), mitral regurgitation (MR) requiring surgery (1.6–3%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with MBV and surgical commissurotomy. Restenosis after MBV ranges from 4% to 70% depending on the patient selection, valve morphology, and duration of follow-up. Restenosis was encountered in 31% of the author’s series at mean follow-up 9 ± 5.2 years (range 1.5–19 years) and the 10, 15, and 19 years restenosis-free survival rates were (78 ± 2%) (52 ± 3%) and (26 ± 4%), respectively, and were significantly higher for patients with favorable mitral morphology (MES ⩽ 8) at 88 ± 2%, 67 ± 4% and 40 ± 6%), respectively (P < 0.0001). The 10, 15, and 19 years event-free survival rates were (88 ± 2%, 60 ± 4% and 28 ± 7%, respectively, and were significantly higher for patients with favorable mitral morphology (92 ± 2%, 70 ± 4% and 42 ± 7%, respectively (P < 0.0001). The effect of MBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation are addressed in this review. In addition, the application of MBV in specific clinical situations such as in children, during pregnancy and for restenosis is discussed.
The advantages of on-line transesophageal echocardiography guide during percutaneous balloon mitral valvuloplasty
2000, Journal of the American Society of Echocardiography
Citation Excerpt :
Hung et al16 reported that patients with left atrial thrombi were safely treated with balloon valvuloplasty after thrombi was successfully resolved with several months of anticoagulation. However, several cases of uneventful balloon valvuloplasty have been reported in patients with left atrial appendage thrombi.18,19 Five patients with left atrial appendage thrombi in group 2 underwent balloon valvuloplasty without embolic event (Figure 3).
The purpose of this study was to evaluate the potential advantages of on-line transesophageal echocardiography during percutaneous balloon mitral valvuloplasty (PBMV). One hundred thirty-four consecutive patients who underwent PBMV were included in this study. Group 1 included 64 patients who underwent PBMV under fluoroscopy guide only, and group 2 included 70 patients who underwent PBMV under on-line transesophageal echocardiography guide. Inoue balloons were used in all cases. The mitral valve area after valvuloplasty was comparable between the 2 groups. The procedure time was significantly shorter in group 2 (99 ± 48 min vs 64 ± 22 min, P <.0001 ), and the average fluoroscopy time was shorter in group 2 without statistical significance (30 ± 17 min vs 19 ± 15 min, P =.25 ). Five (7.8%) patients in group 1 and 2 (2.8%) patients in group 2 underwent surgery because of procedure-related complications. The limitation of this study was the learning curve of the operator, because the 2 groups were treated serially. In conclusion, transesophageal echocardiography can be used effectively during balloon mitral valvuloplasty, and it may help to reduce the rate of complications resulting from trans-septal catheterization and balloon valvuloplasty and to reduce procedure time and fluoroscopy time. (J Am Soc Echocardiogr 2000;13:26-34.)
Comparative evaluation of transthoracic and transoesophageal echocardiography in detection of left atrial thrombus before percutaneous transvenous mitral commissurotomy. Do all patients need transoesophageal examination?
1997, International Journal of Cardiology
We postulated that the sensitivity of transthoracic echocardiography in detection of left atrial cavity or appendage thrombi is better in south-east asian patients with rheumatic mitral stenosis. This was considering that these patients are generally younger, have lesser body weight and thinner chest walls resulting in better transthoracic echogenecity than their western counterparts. We prospectively performed transthoracic and transoesophageal echocardiography in 150 consecutive Indian patients (mean age 28.8±7.2 years; 78 men) being evaluated for percutaneous transvenous mitral commissurotomy. The overall sensitivity of transthoracic echocardiography was 74% (95% C.I. 59–88%). This was significantly higher than the pooled estimate from five western reports which evaluated similar patients (overall sensitivity 12%; 95% C.I. 0–25%; P<0.0001). The sensitivity rose to 83% when patients with poor echogenecity were excluded. Amongst patients with good echogenecity (81% patients) the diagnosis of left atrial thrombi was correctly made or suspected on transthoracic examination in all patients subsequently shown to have thrombi on transoesophageal echocardiography. Significant savings in cost may be safely achieved by limiting transoesophageal echocardiography to patients in whom left atrial cavity or appendage is not adequately visualized on transthoracic examination due to poor echogenecity, or in whom there are shadows suggestive but not diagnostic of thrombi.
Can an echocardiographic score predict who will benefit clinically from balloon dilation of the mitral valve?
1995, International Journal of Cardiology
Deciding whether a patient with sub-optimal mitral valve anatomy will benefit from percutaneous mitral valvotomy remains a demanding clinical problem. We assessed the ability of an established echo score applied to transoesophageal images to predict absolute increases in mitral valve area and improvement in exercise capacity. Twenty five consecutive patients undergoing routine percutaneous mitral valvotomy were studied. Changes in exercise tolerance were measured by serial cardiorespiratory treadmill exercise testing. Before the procedure, exercise duration was directly related to mitral valve area (r_s = 0.44, P < 0.05). Following percutaneous mitral valvotomy there was an increase in valve area (0.9 ± 0.2 to 1.4 ± 0.3 cm², P < 0.0001) and repeat exercise testing demonstrated increases in exercise duration (470 ± 220 to 610 ± 240 s, P < 0.001) and peak VO₂ (12.6 ± 4.2 to 15.1 ± 4.5 ml/kg/min, P < 0.01). There was an inverse correlation between the echo score and the increase in valve area (r_s = −0.52, P < 0.05) but no relationship between the echo score and the increase in exercise duration or peak minute oxygen consumption (V_O₂). These data demonstrate that a score applied to transoesophageal images echocardiographic images can predict changes in mitral valve area but that the score fails to predict functional improvement for an individual patient. This suggests, therefore, that patients without contraindications to valvotomy whose valves have a high echo score should still be considered for valvotomy as they may benefit considerably from the procedure.

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The comparative value of transesophageal and transthoracic echocardiography before and after percutaneous mitral balloon valvotomy: A prospective study

Abstract

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Clin Radiol

Am J Cardiol

Ann Thorac Surg

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation

Br Heart J

Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study

Circulation