Insights From Three-dimensional Echocardiographic Laser Stereolithography

Gilon, Dan; Cape, Edward G.; Handschumacher, Mark D.; Jiang, Leng; Sears, Charles; Solheim, Joan; Morris, Eleanor; Strobel, John T.; Miller-Jones, Stockton M.; Weyman, Arthur E.; Levine, Robert A.

doi:10.1161/01.cir.94.3.452

Cited by 37 publications

(6 citation statements)

References 40 publications

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“…An alteration of the inflow angulation during exercise, caused by a conformational change in the subvalvular apparatus, is known to increase the coefficient of contraction (26). Thus, any exercise-induced increase in leaflet angulation will result in both an increase in geometric orifice area and an increase in the coefficient of contraction, which compounds the effect on EOA.…”

Section: Discussionmentioning

confidence: 99%

Mitral Valve Area During Exercise After Restrictive Mitral Valve Annuloplasty

Bertrand

Verbrugge

Verhaert

et al. 2015

Journal of the American College of Cardiology

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BACKGROUND Restrictive mitral valve annuloplasty (RMA) for secondary mitral regurgitation might cause functional mitral stenosis, yet its clinical impact and underlying pathophysiological mechanisms remain debated. OBJECTIVES The purpose of our study was to assess the hemodynamic and clinical impact of effective orifice area (EOA) after RMA and its relationship with diastolic anterior leaflet (AL) tethering at rest and during exercise. METHODS Consecutive RMA patients (n = 39) underwent a symptom-limited supine bicycle exercise test with Doppler echocardiography and respiratory gas analysis. EOA, transmitral flow rate, mean transmitral gradient, and systolic pulmonary arterial pressure were assessed at different stages of exercise. AL opening angles were measured at rest and peak exercise. Mortality and heart failure readmission data were collected for at least 20 months after surgery. RESULTS EOA and AL opening angle were 1.5 ± 0.4 cm2 and 68 ± 10°, respectively, at rest (r = 0.4; p = 0.014). EOA increased significantly to 2.0 ± 0.5 cm2 at peak exercise (p < 0.001), showing an improved correlation with AL opening angle (r = 0.6; p < 0.001). Indexed EOA (EOAi) at peak exercise was an independent predictor of exercise capacity (maximal oxygen uptake, p = 0.004) and was independently associated with freedom from all-cause mortality or hospital admission for heart failure (p = 0.034). Patients with exercise EOAi <0.9 cm2/m2 (n = 14) compared with ≥0.9 cm2/m2 (n = 25) had a significantly worse outcome (p = 0.048). In multivariate analysis, AL opening angle at peak exercise (p = 0.037) was the strongest predictor of exercise EOAi. CONCLUSIONS In RMA patients, EOA increases during exercise despite fixed annular size. Diastolic AL tethering plays a key role in this dynamic process, with increasing AL opening during exercise being associated with higher exercise EOA. EOAi at peak exercise is a strong and independent predictor of exercise capacity and is associated with clinical outcome. Our findings stress the importance of maximizing AL opening by targeting the subvalvular apparatus in future repair algorithms for secondary mitral regurgitation.

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Section: Discussionmentioning

confidence: 99%

Mitral Valve Area During Exercise After Restrictive Mitral Valve Annuloplasty

Bertrand

Verbrugge

Verhaert

et al. 2015

Journal of the American College of Cardiology

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“…38 RT3DE has revealed that valve shape, not just the size of the orifice, has a potential effect on the flow dynamics across a valve. 39 The coefficient of contraction (=effective/anatomic orifice area) and the related net pressure loss are importantly affected by leaflet geometry in patients with MS. With the use of 3DE and stereolitography, Gilon et al confirmed that variations in the 3D geometry of the MV led to varying pressure gradients that were up to 40% higher for the flattest valves for the same anatomic area and flow rate compared with "funnel"-shaped valves. 39 Their findings suggested that morphological quantification could address uniquely 3D questions to provide insight into relations between cardiac structure, pressure, and flow.…”

Section: Rheumatic MV Diseasementioning

confidence: 99%

Quantification of Mitral Valve Morphology With Three-Dimensional Echocardiography

Lee

Fang

Jin

et al. 2014

Circ J

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Circulation Journal Official Journal of the Japanese Circulation Society http://www. j-circ.or.jp ysis yields faster and more reproducible results; and (4) a variety of users (eg, cardiac anesthetists) wants to use the repeatable methodology offered by quantitative methods. Image-processing tools provide characterization of the complex 3D morphology and motion of the MV. Combined with the properties of the imaging modality and knowledge of anatomy, this yields quantitative descriptions that are useful in diagnostic and therapeutic decision-making. This review summarizes the current development and applications of quantitative analysis of the MV morphology using RT3DE. Anatomic Consideration MV LeafletsThe anterior leaflet (AL) is in fibrous continuity with the aortic valve and guards one-third of the anterior mitral annulus. Fine demarcations divide the AL into 3 smaller scallops. The posterior leaflet (PL) is crescent-shaped and spans the posterior n the past 5 years, advances in real-time 3-dimensional echocardiography (RT3DE) have revolutionized the imaging of the mitral valve (MV). Many studies have consistently shown the superiority of 3D transesophageal echocardiography (TEE) over 2D TEE for visualizing MV morphology. 1 RT3DE has become the imaging modality of choice for guiding MV surgery and catheter-based intervention. Currently, RT3D imaging of the MV involves mainly visualization and qualitative interpretation of volume-rendered images. This "qualitative" approach typically involves few quantitative measurements of MV morphology, and is prone to subjectivity that introduces bias, low reproducibility, and high dependency on imaging expertise.Quantitative cardiac imaging has growing importance for several reasons: (1) as imaging becomes more digital, the opportunity will create the need; (2) automated approaches to intervention and surgery design and planning are emerging from the laboratory and entering the clinic; (3) algorithm-driven anal- The mitral valve (MV) has complex 3-dimensional (3D) morphology and motion. Advance in real-time 3D echocardiography (RT3DE) has revolutionized clinical imaging of the MV by providing clinicians with realistic visualization of the valve. Thus far, RT3DE of the MV structure and dynamics has adopted an approach that depends largely on subjective and qualitative interpretation of the 3D images of the valve, rather than objective and reproducible measurement. RT3DE combined with image-processing computer techniques provides precise segmentation and reliable quantification of the complex 3D morphology and rapid motion of the MV. This new approach to imaging may provide additional quantitative descriptions that are useful in diagnostic and therapeutic decision-making. Quantitative analysis of the MV using RT3DE has increased our understanding of the pathologic mechanism of degenerative, ischemic, functional, and rheumatic MV disease. Most recently, 3D morphologic quantification has entered into clinical use to provide more accurate diagnosis of MV disease and for plannin...

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“…A more conical and funnel-like valve produces a lower pressure gradient than an immobile valve with flat geometry. These variations can cause differences of up to 40% in the pressure drop for any given anatomic area [27]. In order to quantify the mobility and three-dimensional geometry of the mitral valve, we measured the doming volume, i.e., the volume subtended by the mitral valve leaflets and annular cut plane.…”

Section: Discussionmentioning

confidence: 99%

New quantitative three-dimensional echocardiographic indices of mitral valve stenosis

Valočík

Kamp

Mannaerts

et al. 2007

Int J Cardiovasc Imaging

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Only moderate correlations between 3DE and Doppler-derived MVA's were observed. Measurement of the doming volume allows quantification of the 3DE geometry of the mitral apparatus. Patients with conical or funnel-like geometry are more likely to have sinus rhythm, whereas, patients with flat geometry are likely to have atrial fibrillation. Mitral valve volume can be used for the evaluation of mitral stenosis severity. These new 3DE indices might be used for selection of patients for balloon valvuloplasty.

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Insights From Three-dimensional Echocardiographic Laser Stereolithography

Cited by 37 publications

References 40 publications

Mitral Valve Area During Exercise After Restrictive Mitral Valve Annuloplasty

Mitral Valve Area During Exercise After Restrictive Mitral Valve Annuloplasty

Quantification of Mitral Valve Morphology With Three-Dimensional Echocardiography

New quantitative three-dimensional echocardiographic indices of mitral valve stenosis

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