3D Echocardiography in Mitral Valve Heart Disease – Is It the New Gold Standard?
more focused approach with the acquisition of two 3D images (a realtime 3D image and a full-volume data set) can reduce these times further. Pepi et al.9
found similar diagnostic accuracies for 2D TEE
versus 3D TTE (87 and 90%, respectively; p=NS). Others have found similar comparable diagnostic data between 2D TEE and 3D TTE.5,10,11
Transoesophageal 3D Echocardiography in the Assessment of Mitral Valve Morphology
With the huge step up in image resolution offered by 3D TEE, an authentic depiction of mitral valve anatomy can now be viewed in vivo and in realtime. New levels of understanding of valve morphology are now possible.
Surgical View of the Mitral Valve
Since the closest cardiac structure to the probe in TEE is the left atrium, replicating the surgical view is rapid and straightforward. Using clear 2D image quality as the guide and choosing the image plane where the mitral valve lies as perpendicularly to the plane as possible, the surgical view is easily obtained in live 3D zoom mode. Figure 2 shows examples of posterior mitral leaflet prolapse on 3D TEE and illustrates how this allows appreciation of differences between them. The huge advantage of this technique is its ability to produce excellent image quality irrespective of heart rhythm. Additional information can be gained by 3D colour full volume imaging (but image quality may be reduced in the setting of arrythmias), and with complex lesions can aid in better understanding of the mechanism of valve failure.12
Not only
can the location of a primary regurgitant jet be identified, but additional smaller jets along the coaptation line and commissures may be seen. These can play an important role in residual regurgitation post-repair and may help draw the surgeon’s attention to areas of the mitral leaflet coaptation requiring attention.
Segmental Analysis of the Mitral Valve
The same approach described for 3D TTE segmental analysis can be applied to 3D TEE. Since the image resolution is superior, this form of analysis can be performed on the same live 3D zoom mode data set acquired for the surgical view. Very little extra time is needed to obtain this 3D view and this can easily be incorporated into the routine 2D TEE study (aquisition time 60±18 seconds).13
Macnab et al. compared 2D and 3D TEE assessment of the mitral valve against the gold standard of surgical findings, and reported that 3D TEE is more accurate at identifying the location and extent of leaflet prolapse, and was more so at the most medial and lateral portions of the valve.14
More recently, Grewal et al. performed a similar study and also found superior performance of 3D TEE, particularly in identifying complex disease involving multiple segments or both leaflets.13
3D TEE
is superior to 2D TEE and 3D TTE in its diagnostic accuracy of localisation of leaflet prolapse (96.5, 87 and 90%, respectively; pFigure 3) as the site of regurgitation, are being understood.
Mitral Valve Quantification Software
Mitral valve quantification has the potential to provide new insights into mitral pathophysiology concepts and may help to refine repair strategies. A recent study by Grewal et al.15
using realtime 3D TEE found that the normal mitral annulus reduction in size (mitral orifice EUROPEAN CARDIOLOGY
No prolapse is seen. The mitral regurgitant jet originates from a deep cleft within P2 segment, which was only appreciated on 3D imaging.
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Image 1: Prolapse of the lateral portion of P2 and part of P1, with chordal rupture in that region. Image 2: Central portion of P2 is flail with chordal rupture. The regurgitant jet tracks over A2, where a deep ridge is visible. Image 3: Lateral portion of P2 prolapse with chordal rupture. There is a deep ‘cleft’ in the P2 segment, extending back to the annulus, on the right of the prolapse. Image 4: Central P2 segment prolapse with several points of chordal rupture.
Figure 3: 3D Transoesophageal Echocardiography Surgical View of a Mitral Valve with Severe Mitral Regurgitation
3 4
Transthoracic full-volume 3D data set taken from the parasternal long-axis window. Using a multiplanar reconstruction format, long- and short-axis views are displayed at three levels. The level of each segment is confirmed in the short axis and then assessed during systole in the long axis. The images show P2 flail segment with additional prolapse of P3 and A3.
Figure 2: Surgical View of the Mitral Valve on Transoesophageal Echocardiography Showing Four Examples of P2 Segment Prolapse
Figure 1: Segmental Analysis of the Mitral Valve
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