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Ann Thorac Surg 2010;90:1922-1929. doi:10.1016/j.athoracsur.2010.06.116
© 2010 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Mitral Valve Morphology Assessment: Three-Dimensional Transesophageal Echocardiography Versus Computed Tomography

Miriam Shanks, MDa, Victoria Delgado, MDa, Arnold C.T. Ng, MBBSa, Frank van der Kley, MDa, Joanne D. Schuijf, PhDa, Eric Boersma, PhDc, Nico R.L. van de Veire, MD, PhDa, Gaetano Nucifora, MDa, Matteo Bertini, MDa, Albert de Roos, MD, PhDb, Lucia Kroft, MD, PhDb, Martin J. Schalij, MD, PhDa, Jeroen J. Bax, MD, PhDa,*

a Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
b Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
c Department of Epidemiology and Statistics, Erasmus University, Rotterdam, the Netherlands

Accepted for publication June 29, 2010.

* Address correspondence to Dr Bax, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333 ZA, the Netherlands (Email: j.j.bax{at}lumc.nl).


Dr Schalij discloses that he has a financial relationship with Boston Scientific, Biotronik, and Medtronic; Dr Bax with St. Jude Medical, Medtronic, GE Healthcare, BMS, Biotronik, Edwards Lifesciences, and Boston Scientific.

 

   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Advances in the minimally invasive mitral valve repair techniques increase the demands on accurate and reliable morphologic assessment of the mitral valve using three-dimensional imaging modalities. The present study compared mitral valve geometry measurements obtained by three-dimensional transesophageal echocardiography (TEE) to those obtained with multidetector row computed tomography (MDCT) used as a standard reference.

Methods: Clinical preoperative MDCT and intraoperative three-dimensional TEE were performed in 43 patients (mean age 81.0 ± 7.7 years) considered for transcatheter valve implantation procedure. Various measurements of mitral valve geometry were obtained from three-dimensional TEE datasets using mitral valve quantification software, and compared with those obtained from MDCT images using multiplanar reformation planes.

Results: Moderate and severe mitral regurgitation was present in 48.9% of patients. There was good agreement in mitral valve geometry measurements between three-dimensional TEE and MDCT without significant overestimation or underestimation and tight 95% limits of agreement. For linear dimensions, angles and areas, the 95% limits of agreement were less than 1 cm, less than 15 degrees, and less than 2 cm2, respectively. In addition, the intraclass correlation coefficients were more than 0.8 for all parameters. Finally, the measurements were highly reproducible, with low intraobserver and interobserver variability (nonsignificant overestimation or underestimation and narrow 95% limits of agreement).

Conclusions: The present study demonstrates the accuracy and clinical feasibility of the assessment of the mitral valve geometry with three-dimensional TEE that is comparable to the MDCT measurements. Three-dimensional TEE and MDCT provide accurate and complementary information in the evaluation of patients with mitral valve disease. Its potential incremental clinical value in the field of transcatheter mitral repair procedures needs further assessment in the future studies.

Advances in the percutaneous and surgical options for mitral valve repair have increased the demands on accurate and reliable morphologic assessment of the mitral valve. Two-dimensional echocardiography is the most commonly used imaging modality for the assessment of the valvular heart disease. However, the mitral valve has a complex saddle-shaped configuration, and its assessment by two-dimensional imaging techniques may be challenging [1]. Significant advances in ultrasound technology have allowed for on-line display of three-dimensional images of the mitral valve, contributing to a better understanding of the anatomy and geometry of the mitral valve apparatus and the spatial relationships with the surrounding cardiac structures. Particularly, the use of newly developed matrix array transesophageal transducers in three-dimensional transesophageal echocardiography (TEE) has enabled accurate noninvasive imaging of the complex mitral valve anatomy in real time and from unique orientations previously available only to surgeons [2]. Three-dimensional TEE has been shown to be superior to two-dimensional TEE in the evaluation of mitral valve anatomy [3]. Multidetector row computed tomography (MDCT) is also increasingly used for noninvasive coronary angiography, and also provides high image quality to visualize other cardiac structures [4]. Hence, MDCT may provide additional information on the valvular anatomy during the noninvasive evaluation of the coronary vessels [5, 6]. Recent studies demonstrated that MDCT provides information of the mitral valve anatomy and surrounding structures (coronary sinus and circumflex coronary artery) crucial to anticipate the feasibility of percutaneous mitral valve repair techniques [5–8].

Compared with MDCT, three-dimensional TEE can provide complementary information on the valvular structure and function before, during, and immediately after mitral valve repair procedures [9, 10]. Therefore, three-dimensional TEE in combination with MDCT may become the imaging modalities of choice for perioperative planning for mitral valve disease.

To date, agreements between the three-dimensional TEE and MDCT derived measurements of the mitral valve morphology are unknown. Therefore, the aim of the present study was to compare the geometry measurements of the mitral valve obtained with three-dimensional TEE versus those obtained with MDCT. Off-line analysis of the three-dimensional TEE images was performed using novel postprocessing Mitral Valve Quantification (MVQ) software (QLAB Cardiac 3DQ; Philips Medical Systems, Andover, MA).


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patient Population
A total of 43 patients considered for transcatheter valve implantation procedure were prospectively included in the present study. Patients with history of mitral valve repair or replacement were excluded. All patients underwent a routine preoperative two-dimensional transthoracic echocardiography (TTE) to assess left ventricular and valvular function. The MDCT was performed to evaluate aortic and mitral valve anatomy before the intervention. In addition, TEE was performed routinely during the procedure and three-dimensional TEE images of the mitral valve were acquired. The median time interval between the MDCT and the three-dimensional TEE was 7 days.

Mitral valve geometry was evaluated on three-dimensional TEE and MDCT datasets. Mitral valve geometry determinants were derived during off-line analysis of the three-dimensional TEE images and compared with MDCT measurements. The accuracy of the novel MVQ software to assess mitral valve geometry was evaluated using MDCT as a reference method.

The study was conducted with the approval of the Leiden University Medical Center Institutional Review Board with specific waiver of the need for individual patient consent.

Two-Dimensional TTE
Standard two-dimensional TTE was performed with the subjects at rest in the left lateral decubitus position with a commercially available ultrasound transducer and equipment (M3S Probe, Vivid 7; GE-Vingmed, Horten, Norway). All images were digitally stored for off-line analysis (EchoPac, version 108.1.5; GE-Vingmed). Complete two-dimensional, color, pulsed- and continuous-wave Doppler images were acquired according to standard techniques [11, 12]. Left ventricular end-systolic volume index and end-diastolic volume index were calculated using Simpson's biplane method of disks and indexed to body surface area [13]. Left ventricular ejection fraction was subsequently derived and expressed as a percentage. Mitral regurgitation severity was determined quantitatively from color Doppler images obtained from the apical four-chamber views using proximal isovelocity surface area method for determining the effective regurgitant orifice areas and regurgitant volumes, as previously described [14].

Real-Time Three-Dimensional TEE Data Acquisition and Analysis
Transesophageal echocardiography was performed using the iE33 ultrasound imaging system (Philips Medical Systems) equipped with the fully sampled matrix-array TEE transducer (X7-2t) capable of acquiring images in both two and three dimensions. The probe was positioned at the midesophageal level at a 120-degree tilt. Full-volume datasets were obtained using electrocardiographic gating over seven consecutive heart beats to combine seven small real-time subvolumes into a larger pyramidal volume. The scan volume included the mitral apparatus, the aortic valve, and proximal ascending aorta. To avoid stitch artifacts, the images were acquired during a brief suspension of breathing, and special care was taken to stabilize the probe during data acquisition.

All images were digitally stored for off-line analysis with the MVQ software. The MVQ software allows precise three-dimensional quantification of the mitral valve geometry and associated structures based on acquired three-dimensional TEE data. This software helps to build a three-dimensional model, step by step, of the mitral valve annulus, anterior and posterior leaflets, leaflet segmentation, coaptation line and potential coaptation defects, as well as mitral valve spatial relationship with the aortic valve. First, three-dimensional images are displayed in end systole using the multiplanar reformation planes, which allows the operator to crop three-dimensional echocardiographic data sets into infinite planes, and to review the moving image in three simultaneous orthogonal planes. Subsequently, reference points are manually placed on the multiplanar reformation planes. By identifying three-dimensional landmarks on multiplanar reformation planes, MVQ builds a three-dimensional model of the mitral valve and the surrounding structures (Fig 1A). The MVQ three-dimensional model can be manipulated in the three-dimensional space and overlaid on the anatomical three-dimensional view of the mitral valve. A user-defined three-dimensional measurement set as well as a comprehensive report is generated and displayed. Each measurement can also be displayed on the three-dimensional model (Fig 1B).


Figure 1
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  		Fig 1. Real time three-dimensional transesophageal echocardiography technique for assessment of mitral valve geometry. (A) Using the multiplanar reformation planes, the Mitral Valve Quantification software identifies the landmarks points of the mitral valve apparatus. The anterior, posterior, anterolateral, and posteromedial points of the mitral annulus are identified onto the two- and three-chamber views. The en face view provides the cross-sectional area of the mitral annulus, and simultaneously, the three-dimensional full volume of the mitral valve can be visualized. (B) The software generates a model of the mitral valve and the various measurements can be taken semiautomatically. (A = anterior; AL = anterolateral; Ao = aorta; LA = left atrium; LV = left ventricle; P = posterior; PM = posteromedial.)

 
The measurements of the mitral valve apparatus performed with the MVQ software included the intercommissural and anteroposterior annular diameters and the mitral annular area, the length, angle, and area of the anterior and posterior leaflet, the tenting height and the coaptation leaflet angle, and the angle between the mitral annulus and the aortic annulus. Three-dimensional TEE data were analyzed by one experienced observer who was blinded to the results of MDCT data analysis. The three-dimensional TEE measurements were then compared with the measurements obtained from MDCT images (Fig 2).


Figure 2
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  		Fig 2. Examples of the mitral valve geometry determinants obtained by multidetector row computed tomography. From the three-chamber views, the following measurements were obtained: (A) anterior mitral leaflet angle; (B) posterior leaflet angle; (C) mitral leaflet tenting height (arrow) and coaptation angle; and (D) aortomitral annulus angle. In addition, proper alignment of the multiplanar reformation planes along the mitral leaftlets permits visualization of (E) the sagittal view (three-chamber view) and (F) the short-axis view at the level of the posterior mitral leaflet. (G) The length of the posterior mitral leaflet can be measured, and (H) the posterior mitral leaflet area can be quantified by planimetry. (AML = anterior mitral leaflet; Ao = aorta; LA = left atrium; LV = left ventricle; PMLA = posterior mitral leaflet area; PMLL = posterior mitral leaflet length.)

 
Multidetector Row Computed Tomography Data Acquisition and Analysis
In addition, all patients underwent clinically indicated MDCT using 64-detector row or 320-detector row CT scanners (Aquilion64 or Aquilion ONE, respectively; Toshiba Medical Systems, Otawara, Japan). Accordingly, data were acquired with a collimation of either 64 x 0.5 mm or 320 x 0.5 mm and a gantry rotation time of 400 ms or 350 ms, respectively. For the Acquilion64, the tube current was 300 mA to 400 mA, and the tube voltage was 120 kV or 135 kV as determined by patients' body mass indexes. Similarly, for the AcquilionONE, the tube current was 400 mA to 580 mA, and tube voltage was 100 kV, 120 kV, or 135 kV as determined by patients' body mass indexes. The patient's heart rate and blood pressure were monitored before each scan. Beta-blockers (50 mg to 100 mg metoprolol orally) were administered in the absence of contraindications if the heart rate exceeded 65 beats per minute.

All scans were performed during midinspiratory breath-hold, and 80 mL to 90 mL of nonionic contrast (Iomeron 400; Bracco, Milan, Italy) was injected into the antecubital vein. With a 64-detector row CT scanner, data acquisition was performed gated to the electrocardiogram to allow retrospective gating and reconstruction of the data at desired phases of the cardiac cycle (at each 10% of R-R interval and at 75% to 85% for diastole and 30% to 35% for systole). In contrast, with a 320-detector row CT scanner, prospective electrocardiography triggered dose modulation was applied, scanning an entire cardiac cycle and attaining maximal tube current at 75% (when stable heart rate was less than 60 beats per minute) or 65% to 85% (when heart rate was 60 or more beats per minute) of R-R interval. When prospective dose modulation was used, the tube current outside of the predefined interval was 25% of the maximal tube current. Subsequently, data sets were reconstructed, and off-line postprocessing of MDCT images was performed on dedicated workstations (Vitrea2; Vital Images, Minneapolis, MN).

Cardiac MDCT images were analyzed by experienced reviewers blinded to the echocardiographic results. End-systolic images of the mitral valve, confirmed by visual inspection of the mitral leaflet motion and minimum left ventricular systolic volume, were selected. Using the three multiplanar reformation planes, long-axis images analogous to the 120-degree long-axis view on TEE were obtained (Fig 2). In a manner similar to the three-dimensional TEE image analysis, two orthogonal multiplanar reformation planes bisect the long axis of the left ventricle in parallel. The third transverse plane bisects the mitral annulus at the insertion points of the mitral leaflets to obtain the short-axis mitral annular view. From the long-axis multiplanar reformation plane, tenting height, defined as the distance between the leaflet coaptation and mitral annulus plane [15], as well as the aortomitral and the leaflet angles were obtained (Fig 2). From the short-axis multiplanar reformation plane, the planimetered area of the mitral annulus, the anteroposterior, and the intercommisural diameters were obtained. The short-axis plane was then moved parallel to the anterior, and subsequently posterior mitral leaflets, to obtain en face views of the leaflets in which leaflet areas and maximal leaflet lengths were measured (Fig 2).

Statistical Analysis
Continuous variables are presented as mean with standard deviation unless stated otherwise. Categorical data are summarized as frequencies and percentages. Bland-Altman plots and calculation of intraclass correlation coefficients were used for agreement analysis between three-dimensional TEE and MDCT derived mitral valvular geometry measurements [16]. Good correlation was defined as intraclass correlation coefficients greater than 0.8. A two-tailed p value less than 0.05 was considered significant. Similarly, the intraobserver and interobserver agreement for three-dimensional TEE and MDCT measurements were evaluated by Bland-Altman analysis. All statistical analyses were performed using SPSS for Windows, version 16 (SPSS, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
In all, 43 patients (mean age 81.0 ± 7.7 years; 60% men) were evaluated. Clinical and two-dimensional TTE characteristics of the patients are described in Table 1. Mean height, weight, and body mass index were 170.8 ± 7.6 cm, 75.1 ± 10.7 kg, and 25.7 ± 3.4 kg/m2, respectively.


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  		Table 1 Baseline Clinical and Echocardiographic Characteristics of the Patient Population
 
Variable degrees of mitral regurgitation were present in 88.4% of patients, with 48.9% of the patients showing moderate or severe mitral regurgitation (Table 1). The average heart rate during TEE was 66.7 ± 13.3 beats per minute. All patients had good quality three-dimensional TEE and MDCT images suitable for off-line quantification of the mitral valve geometry. The mean values of the measurements describing mitral valve geometry obtained from three-dimensional TEE and MDCT images are shown in Table 2. There was a good agreement in the mitral valve geometry measurements between three-dimensional TEE and MDCT, as demonstrated using Bland-Altman plots (Figs 3 to 6) Go Go Go and further confirmed by intraclass correlation coefficients greater than 0.8 for all the variables (Table 2; Figs 3 to 6). No significant overestimations or underestimations were observed, and the 95% limits of agreement were narrow, being within less than 1 cm for distances, less than 2 cm2 for areas, and less than 15 degrees for angles.


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  		Table 2 Agreements in Mitral Valve Geometry Measurements Obtained With Three-Dimensional Transesophageal Echocardiography (MVQ Software) and Multidetector Row Computed Tomography
 

Figure 3
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  		Fig 3. Comparison between three-dimensional transesophageal echocardiography (3D TEE) and multidetector row computed tomography (MDCT) to measure the mitral valve annular geometry. Intraclass correlation (ICC) analysis and Bland-Altman plots demonstrating good agreement in the measurements of the mitral valve annular measurements (intercommissural and anteroposterior diameters and mitral valve annular area) were obtained using three-dimensional TEE and MDCT. (A) Intercommissural annular diameter. (B) Anteroposterior annular diameter. (C) Mitral annular area.

 

Figure 4
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  		Fig 4. Comparison between three-dimensional transesophageal echocardiography (3D TEE) and multidetector row computed tomography (MDCT) to measure the mitral anterior leaflet geometry. Intraclass correlation (ICC) analysis and Bland-Altman plots demonstrating good agreement in the measurements of the length, area, and angle of the anterior mitral leaflet were obtained using three-dimensional TEE and MDCT. (A) Anterior leaflet length. (B) Anterior leaflet angle. (C) Anterior leaflet area.

 

Figure 5
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  		Fig 5. Comparison between three-dimensional transesophageal echocardiography (3D TEE) and multidetector row computed tomography (MDCT) to measure the mitral posterior leaflet geometry. Intraclass correlation (ICC) analysis and Bland-Altman plots demonstrating good agreement in the measurements of the length, area, and angle of the posterior mitral leaflet were obtained using three-dimensional TEE and MDCT. (A) Posterior leaflet length. (B) Posterior leaflet angle. (C) Posterior leaflet area.

 

Figure 6
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  		Fig 6. Comparison between three-dimensional transesophageal echocardiography (3D TEE) and multidetector row computed tomography (MDCT) to measure the tenting height, leaflet coaptation, and aortomitral annular angle. Intraclass correlation (ICC) analysis and Bland-Altman plots demonstrate good agreement using three-dimensional TEE and MDCT. (A) Tenting height. (B) Leaflet coaptation angle. (C) Aortoannulus angle.

 
Finally, reproducibility of the measurements was assessed in 10 randomly selected patients. Good intraobserver and interobserver agreements for mitral valve geometry measurements obtained with three-dimensional TEE and MDCT were observed (Table 3). As assessed with Bland-Altman analysis, there was a good intraobserver and interobserver reproducibility for all the variables evaluated without significant overestimation or underestimation and narrow 95% limits of agreement (Table 3).


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  		Table 3 Intraobserver and Interobserver Agreements for Three-Dimensional Transesophageal Echocardiography (MVQ Software) and Multidetector Row Computed Tomography (MDCT)
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The present study demonstrates that three-dimensional TEE allows for an accurate analysis of the mitral valve geometry as compared with the anatomical reference standard MDCT. In addition, three-dimensional TEE derived measurements were highly reproducible with good intraobserver and interobserver agreements. These findings indicate that three-dimensional TEE and MDCT may be complementary imaging tools to evaluate the mitral valve anatomy and geometry.

Three-Dimensional Analysis of Mitral Valve Anatomy and Geometry
Over the last decade, the major advances in the surgical and percutaneous mitral valve repair techniques have led to an increasing dependence on the exact morphologic and functional characterization of the mitral valve as part of preoperative planning. Two-dimensional echocardiography remains as the mainstay imaging technique to evaluate the geometry and function of the mitral valve. However, three-dimensional imaging techniques provide superior accuracy to assess the dimensions of the mitral valve annulus and mitral leaflet morphology [1, 5, 17–19]. Thus, MDCT offers the possibility of three-dimensional acquisition of the entire heart throughout the cardiac cycle and multiple plane reconstructions. The correct alignment of the orthogonal mutliplanar reformation planes permits accurate evaluation of the mitral valve anatomy and geometry. Recent studies demonstrated the usefulness of MDCT for the assessment of the mitral valve morphology and geometry both in healthy subjects and in heart failure patients with and without functional mitral regurgitation [5]. In addition, in a recent series of 112 patients, MDCT demonstrated high sensitivity and specificity to diagnose mitral valve prolapse (96% and 93%, respectively) [20]. Finally, the anatomical relationship of the mitral valve apparatus and the surrounding structures such as the circumflex coronary artery and the coronary sinus can be accurately evaluated with MDCT [6]. Therefore, MDCT permits comprehensive evaluation of patients with mitral valve disease and provides accurate information on mitral valve anatomy and geometry.

The assessment of mitral valve function is also crucial for the clinical decision making of patients with mitral valve disease. In this regard, three-dimensional TEE may be a good complementary imaging tool to MDCT. Several studies have demonstrated that three-dimensional echocardiography has superior accuracy than two-dimensional echocardiography to quantify the severity of mitral valve regurgitation [21, 22]. In addition, three-dimensional TEE has demonstrated superior accuracy to localize the prolapsed mitral valve scallops as compared with two-dimensional TEE [3, 18]. Recently, dedicated software has been developed that enabled advanced three-dimensional rendering of the echocardiographic images of the valves, permitting quantitative off-line analysis of the mitral apparatus geometry [17, 19, 23, 24].

Initial studies have compared the accuracy of MDCT and two-dimensional TEE to measure the mitral valve annulus [1]. However, no studies have performed a direct comparison of the measurements obtained by MDCT with those obtained by three-dimensional echocardiography using this novel postprocessing software. The present study was designed to compare the mitral valve geometry measurements obtained prospectively with MDCT and three-dimensional TEE using MVQ software. There was a good agreement between the two imaging techniques in all the parameters studied with the results being highly reproducible for both methods.

Clinical Implications
These technical advances in three-dimensional imaging technology may constitute an important step forward to support the development of new therapeutic approaches for the mitral valve disease. Particularly, the recently introduced minimally invasive surgery or percutaneous mitral valve repair techniques offer a promising therapeutic option for high risk patients with mitral regurgitation who have favorable mitral valve anatomy. These new therapeutic approaches are strongly dependent on accurate assessment of the mitral valve anatomy and function and its spatial relationships. For example, MDCT permits exact location of the coronary sinus relative to the mitral annulus, crucial to determine the feasibility of percutaneous mitral valve annuloplasty [6]. In addition, three-dimensional TEE and MDCT identify the prolapsed scallop of the mitral leaflets, key issue before percutaneous edge-to-edge mitral valve repair technique [3]. Therefore, three-dimensional TEE and MDCT may be good complementary imaging modalities to accurately assess mitral valve anatomy, geometry and function. Particularly, three-dimensional TEE permits accurate visualization of the mitral valve apparatus before, during, and after the procedure and enables accurate selection of the therapeutic strategy, procedural guidance, and evaluation of the immediate results. This may improve the procedural success rate and minimize the number of complications of these novel therapeutic options [25]. During the procedure, fluoroscopy remains as the mainstay imaging technique to guide the intervention. However, the poor soft-tissue contrast resolution of fluoroscopy does not permit accurate visualization of the entire mitral valvular apparatus. Therefore, the dissemination of these procedures will increase the demand for three-dimensional assessment of the mitral valve. Combination of three-dimensional echocardiography and MDCT assessments may provide the most accurate evaluation of patients with mitral valve disease who are potential candidates to these novel therapies.

Study Limitations
Some limitations should be acknowledged. First, transcatheter or surgical mitral valve repair was not performed in the present population. Therefore, additional studies are warranted to confirm the clinical implications of the current results. Second, MDCT was performed before intervention, whereas three-dimensional TEE was performed during the intervention.

In conclusion, the present study demonstrates the accuracy and clinical feasibility of the assessment of the mitral valve geometry by three-dimensional TEE that is comparable to the MDCT measurements. Both imaging modalities, three-dimensional TEE and MDCT, provide accurate and complementary information in the evaluation of patients with mitral valve disease. Its potential incremental clinical value in the field of transcatheter mitral repair procedures needs further assessment in the future studies.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Foster GP, Dunn AK, Abraham S, Ahmadi N, Sarraf G. Accurate measurement of mitral annular dimensions by echocardiography: importance of correctly aligned imaging planes and anatomic landmarks J Am Soc Echocardiogr 2009;22:458-463.[Medline]
  2. Sugeng L, Shernan SK, Salgo IS, Weinert L, Shook D, Raman J, et al. Live three-dimensional transesophageal echocardiography initial experience using the fully-sampled matrix array probe J Am Coll Cardiol 2008;52:446-449.[Medline]
  3. De CS, Salandin V, Cartoni D, et al. Qualitative and quantitative evaluation of mitral valve morphology by intraoperative volume-rendered three-dimensional echocardiography J Heart Valve Dis 2002;11:173-180.[Medline]
  4. Manghat NE, Rachapalli V, Van LR, Veitch AM, Roobottom CA, Morgan-Hughes GJ. Imaging the heart valves using ECG-gated 64-detector row cardiac CT Br J Radiol 2008;81:275-290.[Abstract/Free Full Text]
  5. Delgado V, Tops LF, Schuijf JD, et al. Assessment of mitral valve anatomy and geometry with multislice computed tomography J Am Coll Cardiol Img 2009;2:556-565.[Medline]
  6. Tops LF, Van de Veire NR, Schuijf JD, et al. Noninvasive evaluation of coronary sinus anatomy and its relation to the mitral valve annulus: implications for percutaneous mitral annuloplasty Circulation 2007;115:1426-1432.[Abstract/Free Full Text]
  7. Alkadhi H, Bettex D, Wildermuth S, et al. Dynamic cine imaging of the mitral valve with 16-MDCT: a feasibility study AJR Am J Roentgenol 2005;185:636-646.[Abstract/Free Full Text]
  8. Messika-Zeitoun D, Serfaty JM, Laissy JP, et al. Assessment of the mitral valve area in patients with mitral stenosis by multislice computed tomography J Am Coll Cardiol 2006;48:411-413.[Medline]
  9. Feldman T, Wasserman HS, Herrmann HC, et al. Percutaneous mitral valve repair using the edge-to-edge technique: six-month results of the EVEREST phase I clinical trial J Am Coll Cardiol 2005;46:2134-2140.[Medline]
  10. Langerveld J, Valocik G, Plokker HW, et al. Additional value of three-dimensional transesophageal echocardiography for patients with mitral valve stenosis undergoing balloon valvuloplasty J Am Soc Echocardiogr 2003;16:841-849.[Medline]
  11. Nishimura RA, Miller FA, Callahan MJ, Benassi RC, Seward JB, Tajik AJ. Doppler echocardiography: theory, instrumentation, technique, and application Mayo Clin Proc 1985;60:321-343.[Medline]
  12. Tajik AJ, Seward JB, Hagler DJ, Mair DD, Lie JT. Two-dimensional real-time ultrasonic imaging of the heart and great vessels. Technique, image orientation, structure identification, and validation. Mayo Clin Proc 1978;53:271-303.[Medline]
  13. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography's Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology J Am Soc Echocardiogr 2005;18:1440-1463.[Medline]
  14. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography J Am Soc Echocardiogr 2003;16:777-802.[Medline]
  15. Kwan J, Shiota T, Agler DA, et al. Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation: real-time three-dimensional echocardiography study Circulation 2003;107:1135-1140.[Abstract/Free Full Text]
  16. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement Lancet 1986;1:307-310.[Medline]
  17. Veronesi F, Corsi C, Sugeng L, et al. Quantification of mitral apparatus dynamics in functional and ischemic mitral regurgitation using real-time three-dimensional echocardiography J Am Soc Echocardiogr 2008;21:347-354.[Medline]
  18. Grewal J, Mankad S, Freeman WK, et al. Real-time three-dimensional transesophageal echocardiography in the intraoperative assessment of mitral valve disease J Am Soc Echocardiogr 2009;22:34-41.[Medline]
  19. Veronesi F, Corsi C, Sugeng L, et al. A study of functional anatomy of aortic-mitral valve coupling using 3D matrix transesophageal echocardiography Circ Cardiovasc Imaging 2009;2:24-31.[Abstract/Free Full Text]
  20. Feuchtner GM, Alkadhi H, Karlo C, et al. Cardiac CT angiography for the diagnosis of mitral valve prolapse: comparison with echocardiography Radiology 2010;254:374-383.[Abstract/Free Full Text]
  21. Little SH, Pirat B, Kumar R, et al. Three-dimensional color Doppler echocardiography for direct measurement of vena contracta area in mitral regurgitation: in vitro validation and clinical experience J Am Coll Cardiol Img 2008;1:695-704.[Medline]
  22. Marsan NA, Westenberg JJ, Ypenburg C, et al. Quantification of functional mitral regurgitation by real-time 3D echocardiography: comparison with 3D velocity-encoded cardiac magnetic resonance J Am Coll Cardiol Img 2009;2:1245-1252.
  23. Ahmad RM, Gillinov AM, McCarthy PM, et al. Annular geometry and motion in human ischemic mitral regurgitation: novel assessment with three-dimensional echocardiography and computer reconstruction Ann Thorac Surg 2004;78:2063-2068.[Abstract/Free Full Text]
  24. Daimon M, Saracino G, Gillinov AM, et al. Local dysfunction and asymmetrical deformation of mitral annular geometry in ischemic mitral regurgitation: a novel computerized 3D echocardiographic analysis Echocardiography 2008;25:414-423.[Medline]
  25. Swaans MJ, Van den Branden BJ, Van der Heyden JA, et al. Three-dimensional transoesophageal echocardiography in a patient undergoing percutaneous mitral valve repair using the edge-to-edge clip technique Eur J Echocardiogr 2009;10:982-983.[Abstract/Free Full Text]



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