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Assessment of mitral regurgitation: it is not only the valve

Non-Invasive Imaging

This was a beautiful session, starting with a talk by L. Badano (Padua, IT) on 3D anatomy and function of the mitral annulus. It is now possible to assess mitral annulus shape and function using transthoracic real time 3D echocardiography.
It can be done in less than 4 minutes and seems to provide really relevant information, given that our current way of assessing the mitral annulus is based on the too-simple (and actually wrong) measurement of the diameter in the parasternal long axis view (normal diameter < 35mm). Very easily, it becomes (based on real time 3D images) easy to get the height of the annulus, the antero-posterior, the anterolateral –posteromedial diameters, the area… Normal values are different according to gender. Badano and co-workers were able to define normal values in 245 healthy volunteers. The intra- and inter-observer variability was good.
There are now huge perspectives for assessing the mitral apparatus using transthoracic echocardiography in diseased patients in the hope of helping the decision-making process for treatment (interventional or surgical).
Professor Vannan (Columbus, USA) demonstrated beautifully that real time 3D colour Doppler is very promising in best, not ideally, defining the severity of the mitral regurgitation. The single beat 3D PISA method allows a measurement of 3D PISA at the peak but also (which seems essential for Barlow disease) based on an integrative measurement of the 3D PISA over the images recorded in systole. It is also possible to use the 3D automatic stroke volume approach to diminish the risk of error in assessing the degree of regurgitation. It is feasible in about 80% of the patients explored consecutively in clinical practice, and it has been shown to be valid in animal studies and versus Cardiac MR.
As regards the importance of the left ventricle, we all deal with LV diameters and LV ejection fraction according to the guidelines, but we now have concordant data pushing us to assess longitudinal strain or at least, to conduct prospective studies in larges series to confirm the additive value of this new parameter in predicting the risk of post-operative LV dysfunction and to best define the prognosis of an asymptomatic patient with severe mitral regurgitation.

Thus, although much work remains to be done, but we saw very exciting perspectives for better assessment of mitral valve regurgitation using transthoracic echocardiography.




Assessment of mitral regurgitation: it is not only the valve

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.