Clinical Investigations
Transesophageal Echocardiographic Imaging of the Mitral Valve
Diagnostic Accuracy of Transesophageal Echocardiographic Commissural-Biplane Approach in Identifying Mitral Valve Anatomy

https://doi.org/10.1016/j.echo.2023.04.008Get rights and content

Highlights

  • CBA and the MPA have very good diagnostic accuracy in determining MV anatomy.

  • CBA has a higher sensitivity than MPA in diagnosing commissural prolapse.

  • Comprehensive TEE using CBA and MPA is recommended for better MV assessment.

Background

Transesophageal echocardiography (TEE) conventional multiplane approach (MPA) and the newly proposed commissural-biplane approach (CBA) are the recommended algorithms for identifying the affected mitral valve (MV) segments in the setting of mitral regurgitation. To date, there are no reports to address the diagnostic performance of CBA. In this study we aim to analyze the diagnostic accuracy of CBA and MPA in comparison with three-dimensional echocardiographic findings in patients with severe mitral regurgitation.

Methods

We prospectively enrolled 102 patients with severe mitral regurgitation. All patients underwent systematic TEE assessment of MV before surgical intervention to define the affected MV segments/scallops. The standard MPA includes 4-chamber, 2-chamber, long-axis, and commissural views; CBA was performed by obtaining the bicommissural view and simultaneous biplane imaging of the medial, middle, and lateral MV aspects. The findings of both TEE approaches were compared with three-dimensional TEE data to assess the diagnostic accuracy of MPA and CBA.

Results

The mean patient age was (65 ± 11) years, and 37 (36.3%) were female. We found that CBA had an overall diagnostic accuracy between 88% and 97% in identifying the abnormal MV scallops; in contrast, MPA accuracy ranged between 82% and 95%. The CBA and MPA were the least accurate in identifying the P3 scallop—88% and 82% respectively; however, both were the most accurate in assessing the A2 segment—95% and 97%, respectively. The sensitivity of identifying commissural abnormalities was 80% with CBA and 30% with MPA. Three-dimensional TEE was found to have a strong agreement with CBA (averaged kappa of 0.81, P < .0001) and a modest agreement with MPA (averaged kappa of 0.61, P < .0001) in identifying abnormal anterior or posterior segments. On the other hand, three-dimensional TEE had a weak agreement with CBA (kappa of 0.43, P < .0001) and no agreement with MPA (kappa of 0.14, P = .153) in the assessment of commissural involvements.

Conclusion

The CBA is more accurate than the MPA in the assessment of MV commissural involvement. Given the accuracy differences of the 2 approaches for specific leaflet/scallops, a comprehensive evaluation using both approaches is recommended for all MV scallop assessments.

Introduction

Mitral regurgitation (MR) is the most common valvular disorder encountered in clinical practice, and the second most prevalent valvular disorder to require percutaneous or surgical intervention.1,2 Mitral regurgitation is classified into primary, resulting from structural abnormalities of the mitral valve (MV) components, and secondary, due to left ventricular (LV; or atrial) dilation without significant MV structural defects.3 Three-dimensional (3D) transesophageal echocardiography (TEE) imaging complemented by surgical exploration of the MV anatomy is the reference standard in determining MR etiology and identifying the involved segments.4, 5, 6 Surgical MV intervention, including repair and replacement, is recommended for symptomatic significant primary MR and asymptomatic severe MR with left ventricle dysfunction.7

Surgical intervention of the MV is considered the procedure of choice in treating MR of all etiologies.8,9 Different surgical techniques are used in MV intervention based on valve morphology; thus, detailed information about the anatomy and extent of leaflet involvement is a critical presurgical requisite to plan suitability for surgical repair versus replacement.10,11

Transesophageal echocardiography is considered the imaging modality of choice for the evaluation of MV structure, assessment of the involved leaflet/scallops, and MR severity before surgery.12 The multiplane TEE imaging algorithm (i.e., the multiplane approach [MPA]) is the approach recommended by the American Society of Echocardiography.11, 12, 13, 14 The multiplane approach has an excellent overall diagnostic accuracy in identifying the affected posterior MV scallops (lateral, P1; middle, P2; and medial, P3) and anterior (lateral, A1; middle, A2; and medial, A3) segments. With this approach, the accuracy varies among different MV scallops/segments, which range between 97% with the P2 scallop and 90% with the A3 segment;11 however, a proper assessment of commissural involvement is still a limitation.

More recently, Hahn et al.15,16 have proposed a new commissural-biplane approach (CBA) for assessing MV abnormalities using the bicommissural view and simultaneous biplane sweep over the lateral (A1/P1), middle (A2/P2), and medial aspects (A3/P3) of the MV leaflets. This approach, which avails itself of newer echocardiographic technology recently introduced in commercially available platforms, has not been fully validated. In this study, we aimed to determine the diagnostic accuracy of the TEE multiplane and CBA approaches when compared with findings from 3D-TEE as the standard method.

Section snippets

Methods

We prospectively enrolled patients with moderate and severe MR on transthoracic echocardiography who were referred for TEE between January 2019 and December 2020 to assess the etiology and severity of MR. Patients who subsequently underwent surgical MV intervention were enrolled in the final analysis. Individuals with severe MR who underwent MV clip or declined surgical intervention were excluded. The study protocol was approved by the local ethics committee. All patients signed informed

Results

One hundred two consecutive patients with severe MR underwent surgical intervention. The mean age at the time of the surgery was (65 ± 11) years (range, 19-86 years), and 37 (36.3%) were female. The indications for surgery were symptoms of heart failure in 82 (80.4%) and reduced LVEF or LV chamber dilatation in 9 (8.8%); the remaining 11 (10.8%) were due to symptoms as well as reduced LVEF. Other baseline characteristics are shown in Table 1.

Preoperative LVEF was normal in 80.4% of the

Discussion

In this study we investigated the diagnostic performance of TEE conventional multiplane and bicommissural approaches compared with 3D-TEE with intraoperative surgical findings in identifying MV abnormalities. We found that both approaches have an excellent diagnostic accuracy in defining the affected MV segments/scallops. However, the bicommissural method was significantly more accurate in diagnosing commissural defects.

Multiple TEE imaging protocols have been proposed to identify the affected

Conclusion

The new commissural TEE approach has a higher sensitivity and diagnostic accuracy than the conventional approach in evaluating MV commissures when compared with the intraoperative findings, and it may have a role complementary to other TEE approaches in the assessment of MV abnormalities.

References (25)

Cited by (2)

Conflicts of Interest: None.

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