Three-dimensional Echocardiography Is Essential for Intraoperative Assessment of Mitral Regurgitation

Abstract

Since its introduction, 3-dimensional (3D) transesophageal echocardiography (TEE) has become widely adopted in operating rooms and cardiac catheterization laboratories worldwide. This is because the matrix-array 3D TEE probe allows acquisition of high-quality 3D images in real time with relatively little training. The rapid adoption of this technology has proven that this innovative imaging modality provides additional clinical information beyond that obtained from 2-dimensional (2D) TEE images. These developments have enabled medical centers to create integrated valve programs in which surgeons, interventionalists, and echocardiographers discuss cases and surgical approaches. Response by McCarthy on p 652In particular, 3D TEE has been proven to be superior to 2D TEE in the assessment of both mitral valve anatomy and mitral regurgitation, promoting its use in the operating room (Table 1). [1][2][3] One reason for this superiority is that 3D TEE allows the mitral valve to be displayed en face in an orientation identical to the surgeon's view of the mitral valve intraoperatively. This surgeon's view greatly facilitates communication with cardiac surgeons because they can easily interpret these images.Here, we argue that the widespread acceptance and use of 3D TEE are attributable to the pivotal role this modality plays in the intraoperative assessment of mitral regurgitation. We believe that 3D TEE of the mitral valve is invaluable not only because of the realistic images it provides but also because it improves: 1) lesion localization, 2) identification of the mechanisms causing mitral regurgitation, 3) quantification of the severity of mitral regurgitation, 4) selection of surgical intervention, 5) the choice of the surgeon whose expertise is best suited to perform the operation, 6) guidance of percutaneous mitral valve procedures, and 7) postoperative assessment. 3D Echocardiography of the Mitral ValveAccurate preoperative assessment of the mitral valve is critical in the surgical management of patients with severe mitral regurgitation. This information determines whether the patient should undergo valve repair or replacement, which has implications in terms of timing of surgery and long-term morbidity and mortality. 4 Traditionally, 2D TEE has been used to evaluate mitral valve anatomy. However, 2D TEE requires manual manipulation of the transducer in the esophagus and various degrees of flexion or anteflexion of the probe to acquire the standard mid-esophageal views and to examine all leaflet scallops. Since 2D TEE only provides single plane images, the entire mitral annulus and leaflets are not displayed in a single en face view, making it difficult to identify specific scallops with precision. As well, because the mitral annulus is saddle shaped, distortions of mitral valve anatomy, mitral annular dilatation, or aortic root enlargement may change the orientation of the ultrasound plane in relation to mitral valve apparatus, resulting in scallop misidentification.

What Does 3D Echocardiography Add to 2D Echocardiography in the Assessment of Mitral Regurgitation?

“…Unlike 2D techniques, which require multiple tomographic views to examine the different parts of the mitral valve leaflets, real-time 3D echocardiography provides a comprehensive assessment of the mitral valve in only one view, the "en face" view from the left atrium (surgeon's view, Fig. 3) or the LV, leading to more effective communication with cardiac surgeons [23]. Several studies have demonstrated, at the time of surgery (surgical inspection), the superiority of 3D over 2D echocardiography [24,25].…”

Multimodality Imaging in Transcatheter Mitral Interventions

“…7,8 Since that time, the role of 3D-TEE in detailed imaging assessment of not only mitral regurgitant severity but also complex mitral anatomic details has become indisputable. 9 As we enter the next phase of transcatheter mitral valve interventions of new repair and replacement devices as well as standardization of transcatheter paravalvular leak (PVL) closure, the role of imaging is evolving. MDCT and 3D-TEE are currently being used to screen patients anatomically for transcatheter mitral valve replacement.…”

Transoesophageal echocardiography: what the general cardiologist needs to know

“…Three-dimensional TOE of the MV is superior to 2D TOE in identifying the precise location and extent of leaflet prolapse and presence of deep clefts, for assessing geometry of the MV annulus and for quantifying MR severity when there are multiple or eccentric jets 18 19. Three-dimensional TOE is now the preferred method for quantifying mitral stenosis, since 3D planimetry accurately defines the MV orifice; measurements are reproducible, with close correlation with invasive and surgical measurements of MV area;20 long-term outcome data using 3D TOE data are awaited.…”