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      Two and three dimensional echocardiography for pre-operative assessment of mitral valve regurgitation

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      Author(s): ,
      Publication date (Electronic):
      Journal: Cardiovascular Ultrasound
      Publisher: BioMed Central
      Keywords: Mitral valve, 3D echo

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          Abstract

          Mitral regurgitation may develop when the leaflets or any other portion of the apparatus becomes abnormal. As the repair techniques for mitral valve disease evolved, so has the need for detailed and accurate imaging of the mitral valve prior to surgery in order to better define the mechanism of valve dysfunction and the severity of regurgitation. In patients with significant mitral valve disease who require surgical intervention, multiplane transesophageal echocardiogram (TEE) is invaluable for surgical planning. However, a comprehensive TEE in a patient with complex mitral valve disease requires great experience and skill. There is evidence to suggest that 3D echocardiography can overcome some of the limitations of 2D multiplane TEE and thus is crucial in evaluation of patients undergoing mitral valve surgery. In the following sections, we review some of the crucial 2D and 3D echo images necessary for evaluation of MR based on the Carpentier classification.

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          The "physio-ring": an advanced concept in mitral valve annuloplasty.

          Alain F Carpentier, Arrigo Lessana, John Y.M. Relland … (1995)
          A new annuloplasty ring has been developed with the aim of adding flexibility to the remodeling annuloplasty concept. Here we report its clinical use with special emphasis on segmental valve analysis and valve sizing. From October 1992 through June 1994, 137 patients aged 4 to 76 years (mean age, 49.1 years) were operated on. The main causes of mitral valve insufficiency were degenerative, 90; bacterial endocarditis, 15; and rheumatic, 13. The indication for operation was based on the severity of the mitral valve insufficiency (90 patients were in grade III or IV) rather than on functional class (60 patients were in class III or IV). At echocardiography 6 patients had normal leaflet motion (type I), 119 leaflet prolapse (type II), and 12 restricted leaflet motion (type III). Surgical repair was carried out using Carpentier techniques of valve reconstruction. In 3 patients, inadequate ring sizing was responsible for systolic anterior motion of the anterior leaflet diagnosed by intraoperative echo. The valve was replaced in 2 patients. There were three hospital deaths, no late deaths, one reoperation for recurrent mitral valve insufficiency due to chordal rupture 1 month after repair, one reoperation for atrial thrombus formation 5 months after repair, one anticoagulant-related hemorrhage, and one thromboembolic episode. Mid-term follow-up between 6 and 18 months was available in 94 patients. Echocardiography showed trivial or no regurgitation in 93.2% of the patients and minimal regurgitation in 6.8%. The average transmitral diastolic gradient was 3.55 +/- 1.93 mm Hg. Left ventricular end-systolic diameter and volume decreased postoperatively, demonstrating an improved left ventricular function. This preliminary experience has provided promising results and allowed us to define the indications of the Physio-Ring versus the classic ring. It has also shown that valve sizing and proper ring selection are of primary importance.
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            Predicting systolic anterior motion after mitral valve reconstruction: using intraoperative transoesophageal echocardiography to identify those at greatest risk.

            David Adams, S Itagaki, Robin Varghese … (2013)
            We set out to determine if intraoperative pre-bypass transoesophageal echocardiography could assist in predicting which patients are at greatest risk for systolic anterior motion (SAM) after mitral valve repair (MVR). Three hundred and seventy-five consecutive patients who underwent reconstructive MVR surgery for degenerative disease were included. Data were collected using intraoperative echocardiographic images taken prior to the initiation of cardiopulmonary bypass. Based on the physiology of SAM, we postulated that 11 parameters could be potential risk factors for SAM: left ventricular ejection fraction (LVEF), left ventricular end-systolic dimension, left ventricular end-diastolic dimension (LVEDD), basal septal diameter (basal-interventricular septal diameter in diastole (IVDd)), mid-ventricular septal diameter (mid-IVDd), coaptation-septal distance (c-sept), anterior leaflet height, posterior leaflet height, aorto-mitral angle, mitral annular diameter and left atrial diameter. These parameters were measured and recorded by a blinded single operator. Independent predictors of SAM were identified using multiple logistic regression analysis. Of the 375 patients, 345 (92%) did not develop SAM (No-SAM group), while 30 (8%) developed intraoperative or postoperative SAM (SAM group). The mean age was 56.8 ± 12.8 and 56.7 ± 13.8 in the No-SAM and SAM groups, respectively. The incidence of fibroelastic deficiency, forme fruste and Barlow's disease was similar in both groups. All patients received a complete annuloplasty ring as part of the repair. There was no statistical difference in the mean ring size used in each group. EF was similar in the No-SAM (56.2% ± 8.1) and SAM (57.0% ± 9.2) P = 0.63) groups. Independent predictors of developing SAM after valve repair were: EDD 15 mm (OR 3.80; P = 0.012) and basal septal diameter ≥ 15 mm (OR 3.63; P = 0.039). The risk for SAM can be predicted using intraoperative transoesophageal echocardiography. The combination of a smaller left ventricle, tall posterior leaflet, narrow aorto-mitral angle and enlarged basal septum significantly increases the risk for SAM. Knowing these parameters prior to valve repair can assist the surgeon in adjusting their repair technique to minimize the risk.
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              Tricuspid regurgitation secondary to mitral valve disease: tricuspid annulus function as guide to tricuspid valve repair.

              E Vitali, Remo C Russo, S Agati … (2001)
              A prospective analysis was performed on 50 patients (pts) with rheumatic mitral disease and associate secondary tricuspid insufficiency who underwent mitral valve replacement from January 1995 to December 1998. Surgical indication to tricuspid annuloplasty was considered in patients with echocardiographic tricuspid annulus diameter > 21 mm/m2, regardless semiquantitative evaluation of tricuspid insufficiency. De Vega annuloplasty was performed in 33 out of 50 patients. Hospital mortality was 2.0% (CL 0.3-3.6). The follow up of the discharged patients ranged from 3 to 48 months (mean 25 +/- 15.9). Three late deaths occurred (6.1% CL 2.8-9.2). Forty-two patients out of the 46 followed up (91.3% CL 84.9-93.8) were in I or II NYHA class. In eight patients (16.3% of discharged patients) the obtained result has been considered as 'negative late results': persisting moderate (three cases) or moderate-severe (five cases) TrI, together with congestive heart failure requiring a furosemide intake of > 25 mg/day. No patients had severe TrI at follow up. The statistics analysis demonstrated the 'preoperative fraction shortening of the tricuspid annulus' (P = 0.038) as factor predictive of late negative result. The incidence of late negative result was 57.1% among patients with fractional shortening lower than 25% and 0% among those patients with fractional shortening greater than 25% (P = 0.0001). The choice to treat the tricuspid insufficiency according to indexed tricuspid annulus dimension (> 21 mm/m2) has been effective in terms of clinical efficacy and of late functional result. Fractional shortening of the tricuspid annulus, expression of right ventricular cardiomyopathy in patients with poorest prognosis, affects the postoperative evolution of tricuspid insufficiency.
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                Author and article information

                Contributors
                Nishath Quader: nquader007@gmail.com
                Vera H Rigolin: vrigolin@nmff.org
                Journal
                Journal ID (nlm-ta): Cardiovasc Ultrasound
                Journal ID (iso-abbrev): Cardiovasc Ultrasound
                Title: Cardiovascular Ultrasound
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1476-7120
                Publication date (Electronic): 25 October 2014
                Publication date PMC-release: 25 October 2014
                Publication date Collection: 2014
                Volume: 12
                Issue: 1
                Electronic Location Identifier: 42
                Affiliations
                [ ]Northwestern University Feinberg School of Medicine, Chicago, IL USA
                [ ]Northwestern Medicine, 675 N St Claire, Suite 19-100, Chicago, IL 60611 USA
                Article
                Publisher ID: 537
                DOI: 10.1186/1476-7120-12-42
                PMC ID: 4219041
                PubMed ID: 25344779
                SO-VID: 13381b0c-fd8f-4650-9491-54fd8ac7cc43
                Copyright © © Quader and Rigolin; licensee BioMed Central Ltd. 2014
                License:

                This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                Date received : 14 August 2014
                Date accepted : 17 October 2014
                Categories
                Subject: How I do it article
                Custom metadata
                issue-copyright-statement © The Author(s) 2014

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: mitral valve,3d echo
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: mitral valve, 3d echo

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