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Mitral valve echo assessment

ESC Congress Report

  • Transthoracic 2D echocardiographic continues to play a pivotal role in mitral valve disease
  • Transesophageal echocardiography is important as an evaluation tool when transthoracic evaluation is technically limited and, because of its superior spatial resolution, plays an important role  delineating anatomy and physiology (particularly in patients with degenerative mitral regurgitation).
  • Three dimensional transesophageal echocardiography is essential for surgical mitral repair and replacement as well as catheter- based interventions including mitral repair, paravalvular leak closure and valve-in-valve  or valve-in-ring replacement for prosthetic dysfunction.

View the Slides from this session in ESC Congress 365

In addressing the question “ Is 2D enough?”, Dr. Jean Louis Vanoeuverschelde (Brussels, BE) led off with a reminder that 2D transthoracic echocardiography ( 2D-TTE)with both imaging and Doppler applications remains the mainstay of the echocardiographic evaluation of the patient with mitral disease. It has been shown to adequately delineate anatomy and function in most patients providing sufficient information, in many cases,to predict valve repairability and suitability for mitral balloon valvuloplasty. Dr.  Vanoeuverschelde noted also the important role that TTE plays in assessing left ventricular and  left atrial size and in measuring left ventricular function. He stressed the importance of an integrated quantitative approach to using imaging and Doppler information, warning against a determination of mitral regurgitation (MR) severity based exclusively on jet dimensions. Making reference to the EACVI guidelines, he noted the limitations of PISA and its tendency to overestimate severity of MR with posterior leaflet prolapse/flail. An approach that uses complementary methods of calculating stroke volume, regurgitant volume and regurgitant fraction was recommended. This is particularly important in the patient with non-holosystolic mitral regurgitation as may be encountered with degenerative and functional MR. A key point was the observation that chronic severe MR should be accompanied by LV dilatation.

In addressing the question “Should transesophageal echocardiography be recommended?”, Dr. Sara Fernandez Santos (Madrid, ES) confirmed the importance of 2D TTE but noted situations in which 2DTTE may be suboptimal and those in which 2DTTE is impractical (intra-operatively and peri-procedurally). In such instances TEE is essential. TEE may be required for pre-surgical planning particularly in patients with degenerative mitral regurgitation suspected to involve other than the P2 scallop.  The predictability of repair is an important element of deciding when to intervene, particularly in patients with degenerative MR. Being able to predict the likelihood of repair in turn mandates detailed understanding of mitral anatomy with isolated P2 prolapse/flail  being more likely to be repairable than anterior leaflet, commissural or  extensive multi-scallop disease.

Dr Roberto Lang (Chicago, US) spoke to the question “Is 3D echo mandatory?” He noted the advances in transthoracic 3D imaging as well as increasingly sophisticated semi-automated quantitative tools for the analysis of 3D TEE datasets. In aggregate, using a number of illustrations, he argued that 3D is superior to 2D for delineating mitral anatomy, localizing lesions, identifying the mechanism and severity of both mitral stenosis and regurgitation, and guidance of procedures. The ability of 3D echo to generate the enface surgical view of the mitral valve has been important in the introduction of 3D echo into the clinical mainstream. Specific examples provided including distinguishing between localized fibro-elastic deficiency and generalized Barlow’s disease and clefts versus indentations. He also underscored the importance of 3D for optimizing PISA calculations of severity in the many patients in whom PISA shells are non-hemispherical and in the direct planimetry of regurgitant orifices that are non-circular, a common situations in patients with functional MR.

Dr. Alain Berrebi (Issy-les-Moulineauux, France) spoke to the pivotal role played by the interventional echocardiographer who provides critical input into surgical mitral repair and replacement as well as transcatheter approaches to mitral repair (Mitra-Clip) and replacement (valve-in-valve or valve-in-ring). Echocardiography (TEE, typically a combination of 3D and 2D) is important intra-procedurally, prior to, during and following valve intervention. He noted that the initial outcome of approximately 7% of mitral repairs is suboptimal, requiring a second pump run, with intra-operative echocardiography identifying the need for revision in most cases. He noted that transcatheter interventions including paravalvular leak closure, Mitra-Clip placement and newer valve-in valve procedures are all done with echocardiographic guidance. The advent of newer devices and transcatheter valve replacement for native mitral disease are expected to expand the role of the interventional echocardiographer. Communication between the echocardiographer and surgeon/interventionalist using a common clock-face referenced to the aortic valve, is imperative. Fusion imaging which allows an overlay of the 3D echo image on the fluoroscopy may be a valuable adjunct to current TEE approaches.

Additional concepts that emerged from the discussion included that intracardiac echocardiography, while helpful for balloon mitral valvuloplasty for mitral stenosis, does not yet have the technical ability to support other mitral procedures (limited 3D field of view). However, the development of small 3D probes that can be passed trans-nasally may meet the dual needs of providing detailed images and avoiding general anesthesia as is frequently required when prolonged TEE imaging is undertaken.




Mitral valve echo assessment

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.