Accurate Localization of Mitral Regurgitant Defects Using Multiplane Transesophageal Echocardiography

doi:10.1016/S0003-4975(98)00084-8

The Annals of Thoracic Surgery

Volume 65, Issue 4, April 1998, Pages 1025-1031

https://doi.org/10.1016/S0003-4975(98)00084-8 Get rights and content

Abstract

Background. Appropriate patient selection for surgical repair of the mitral valve depends on the specific location and mechanism of regurgitation, which, in turn, has necessitated a more detailed method to accurately describe mitral pathology. This study tests a strategy of using multiplane transesophageal echocardiography to systematically localize mitral regurgitant defects and compares these results with the surgical findings.

Methods. Fifty patients with mitral regurgitation underwent intraoperative transesophageal echocardiography for the evaluation of mitral pathology and potential repair. Mitral regurgitant defects were localized using a systematic strategy and a simple nomenclature that divides each mitral valve into six sections (three sections per leaflet) and each prosthetic sewing ring into six sections (60 radial degrees = one section).

Results. Thirty-nine patients with native mitral valves were studied, for a total of 234 sections evaluated. Eighty-seven of these sections contained regurgitant defects by transesophageal echocardiography (mean number of regurgitant defects per valve, 2.2; range, 1 through 6). There was agreement between the transesophageal echocardiographic and surgical localizations in 96% (224/234; p < 0.0001) of the sections. Eleven patients with prosthetic mitral valves were studied, for a total of 66 sections evaluated. Twenty-three of these sections contained paravalvular leaks by transesophageal echocardiography (mean number of leaks per prosthesis, 2.1; range, 1 through 6). There was agreement between the transesophageal echocardiographic and surgical localizations in 88% (58/66; p < 0.001) of the sections.

Conclusions. This transesophageal echocardiographic strategy provides a systematic method to accurately localize mitral regurgitant lesions and has the potential to improve the preoperative assessment of patients with significant mitral regurgitation.

Section snippets

Patient Selection

All patients with significant mitral regurgitation undergoing intraoperative transesophageal echocardiography in conjunction with valve repair or replacement from 1993 through 1996 at Massachusetts General Hospital were evaluated for inclusion in the study. The patients had either native or prosthetic mitral valve disease. Patients were excluded from the study if any of the following variables was present: they had major concomitant mitral stenosis, the transesophageal examination was performed

Native Mitral Regurgitant Defects

A total of 39 patients with native mitral valves were studied to localize mitral pathology and regurgitant defects. As each mitral valve had six sections, a total of 234 mitral sections were evaluated. Of these 234 sections, 82 were found by transesophageal echocardiography to have regurgitant defects. In all 39 patients, mitral regurgitation was the result of prolapsing or flail leaflet segments. A mean of 2.2 regurgitant defects per valve (range, 1 through 6) were identified. The majority of

Comment

This study demonstrates the use of a strategy to localize mitral regurgitant defects using multiplane transesophageal echocardiography. This approach is shown to be accurate for both native and prosthetic mitral regurgitant defects when compared with the surgical findings.

An improved understanding of the underlying pathophysiology of mitral regurgitation has led to advances in surgical therapies 12, 13. Specifically, in selected patients, surgical repair has become the treatment of choice [14].

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2024, International Journal of Cardiology
Worsening mitral regurgitation (MR) is a complication of intervention for atrial septal defect (ASD). Little is known about mitral valve (MV) characteristics associated with worsening MR. We aimed to elucidate MR outcomes and predictors of worsening MR after transcatheter ASD closure.
We analyzed changes in MR from prior to transcatheter ASD closure to 6 months after the procedure and predictors of worsening MR via baseline transthoracic echocardiography in 238 patients (64.7% females; mean age, 53 ± 22 years).
Worsening MR was defined as worsening to moderate in patients with less than or equal to mild MR at baseline or vena contracta width increasing of ≥2 mm by 6-month follow-up in patients with moderate MR. Worsening MR was observed in 29 patients (12.2%). The associated echocardiographic findings were pseudoprolapse, hamstringing, stiffness, and anteroposterior and intercommissural mitral annulus diameter in the univariable logistic regression analysis (all P < 0.05). Multivariable analysis after adjusting for age; long-standing persistent atrial fibrillation; and ASD size showed that models combining MV leaflet findings such as pseudoprolapse or hamstringing, or anterior leaflet stiffness with the ratio of the sum of anterior and posterior leaflet lengths to intercommissural mitral annulus diameter were statistically significant for predicting worsening MR (R² = 0.393, P < 0.001 and R² = 0.385, P < 0.001, respectively).
Worsening MR after transcatheter ASD closure might depend on MV leaflet findings and annulus size in patients with long-standing persistent atrial fibrillation.
Diagnostic Accuracy of Transesophageal Echocardiographic Commissural-Biplane Approach in Identifying Mitral Valve Anatomy
2023, Journal of the American Society of Echocardiography
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.
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.
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.
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.
The Mitral Coaptation to Ventricular Septal Space: Two- and Three-Dimensional Transesophageal Echocardiographic Assessment
2021, Journal of Cardiothoracic and Vascular Anesthesia
Objectives: To assess the dimensions and changes in the CSEPT (space between the ventricular septum and mitral coaptation point) before and after cardiopulmonary bypass (CPB) and to compare patients with and without aortic valve stenosis (AS) undergoing cardiac surgery.
Design: Retrospective review of intraoperative transesophageal echocardiographic examinations.
Setting: Single academic medical center.
Participants: The study comprised 91 elective cardiac surgical patients—30 with AS scheduled for aortic valve replacement and 61 without AS (non-AS).
Interventions: Two- and 3-dimensional (2D and 3D) analysis of the CSEPT before and after CPB.
Measurements and Main Results: Assessment of the CSEPT distances and areas was performed using 2D and 3D imaging before and after CPB. Two-dimensional measures of CSEPT distances were performed using midesophageal 5-chamber and long-axis windows. Three-dimensional measures were performed offline using multiplanar reconstruction. The CSEPT space was smaller after CPB (p < 0.01). Before and after CPB, the midesophageal 5-chamber and long-axis windows were similar to each other, and both were larger than the pre-CPB 3D CSEPT distance. Patients with AS had smaller before and after CPB distances and areas compared with non-AS patients (p < 0.05). The change in CSEPT area in AS patients was 24%.
Conclusions: The CSEPT space is smaller after CPB and more so for patients with AS undergoing aortic valve replacement. Two-dimensional CEPT distances vary compared with 3D CSEPT distances. Additional study using Doppler analysis will elucidate the added value of 3D assessment of the CSEPT space.
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Intraoperative transesophageal echocardiography is a mature imaging modality and critical component of contemporary heart surgery, in which it plays a key role in surgical planning, determination of cardiac chamber filling and function early after cardiopulmonary bypass, and timely assessment of surgical interventions. Intraoperative transesophageal echocardiography affords the unique opportunity to correct suboptimal surgical results before leaving the operating room. Herein, the authors provide a comprehensive review of their institution's experience with intraoperative transesophageal echocardiography, emphasizing a practical assessment of commonly encountered noncongenital surgical heart lesions in adults, anticipation of potential surgical complications, and imaging approaches to facilitate timely surgical correction of unsatisfactory results.
Practice Pattern Variation in the Use of Transesophageal Echocardiography for Open Valve Cardiac Surgery
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Citation Excerpt :
Claims for TEE at the time of surgery were more common in the MV (or combined MV-AV) subgroup where only 1 in 7 patients lacked an intraoperative TEE claim. This observation may be due to the unique role TEE has in surgical planning in MV procedures, particularly MV repair.5,6,10,22-24, 45-47 Nonetheless, even in this context, claims for intraoperative TEE were well below 100%.
The authors sought to assess for the presence of practice variation in the use of intraoperative transesophageal echocardiography (TEE) for open cardiac valve surgery.
This study was a retrospective cohort analysis.
The administrative claims data used for this investigation were multi-institutional and a representative sample of commercially insured patients in the United States between 2010 and 2015.
The cohort consisted of adult patients, aged 18 years or older, undergoing open mitral valve (MV) or aortic valve (AV) surgery.
This was an observational analysis without interventions.
Of 19,386 valve surgeries, 12,313 (64%) underwent AV replacement, 6,192 (32%) underwent MV repair or replacement, and 881 (<5%) underwent both MV and AV surgery. The overall rate of intraoperative TEE was 82% (95% confidence interval [CI]: 81%-82%), less frequently observed in AV procedures compared to MV or combined MV-AV procedures (80% v 85%, p < 0.001). Rates of intraoperative TEE claims varied markedly across U.S. states. After adjustment, the relative odds of an intraoperative TEE claim ranged across states from 0.26 (Louisiana, 95% CI: 0.18-0.36; p < 0.001) to 2.10 (North Carolina, 95% CI: 1.57-2.82; p < 0.001).
Among adult patients undergoing open AV or MV surgery in the United States, 82% had a claim for an intraoperative TEE with marked variability across U.S. states. Increasing adherence to intraoperative TEE guidelines for valve surgery may represent an unrecognized opportunity to improve the quality of cardiac surgical care.
Imaging for Mitral Interventions: Methods and Efficacy
2018, JACC: Cardiovascular Imaging
The mitral valve (MV) is a complex and intricate structure. With the development of transesophageal echocardiography in the 1990s, it became possible to evaluate MV anatomy and function in real time during surgical procedures. Subsequently, new surgical and percutaneous techniques for MV repair as well as replacement have evolved. Development of 3-dimensional and intracardiac echocardiography, as well as computed tomography, cardiac resonance imaging, and most recently fusion imaging, have paved the way for a more comprehensive evaluation of the MV as well as for the planning of percutaneous MV procedures such as balloon valvuloplasty, paravalvular mitral leak closure, percutaneous edge-to-edge repair, transcatheter MV annuloplasty, artificial chord implantation, and transcatheter MV replacement. The applicability and use of the various imaging modalities for the assessment and guidance of therapy for MV disorders is discussed in this paper.

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Original ArticlesAccurate Localization of Mitral Regurgitant Defects Using Multiplane Transesophageal Echocardiography

Abstract

Section snippets

Patient Selection

Native Mitral Regurgitant Defects

Comment

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

Am J Cardiol

J Am Soc Echocardiogr

Mayo Clinic Proc

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

Am J Cardiol

J Am Soc Echocardiogr

Original Articles
Accurate Localization of Mitral Regurgitant Defects Using Multiplane Transesophageal Echocardiography