Head-to-head comparison of two- and three-dimensional transthoracic and transesophageal echocardiography in the localization of mitral valve prolapse

Multi-modality imaging for pre-procedural planning of transcatheter mitral valve interventions

Transcatheter mitral valve interventions (TMVI), either repair or replacement, are established alternative options for patients with mitral regurgitation (MR) deemed not suitable for conventional open-heart surgery. Multi-modality imaging plays a pivotal role in the selection of patients, gaining insights into the anatomy of the mitral valve the mechanism and the severity of MR, which are essential to predict the success of these procedures. The aim of this review is to provide an overview on the role of multi-modality imaging in the patient selection and pre-procedural planning of TMVI.

Clinical Utility of Three-Dimensional Echocardiography in the Evaluation of Mitral Valve Disease: Tips and Tricks

Although real-time 3D echocardiography (RT3DE) has only been introduced in the last decades, its use still needs to be improved since it is a time-consuming and operator-dependent technique and acquiring a good quality data can be difficult. Moreover, the additive value of this important diagnostic tool still needs to be wholly appreciated in clinical practice. This review aims at explaining how, why, and when performing RT3DE is useful in clinical practice.

Balloon mitral valvuloplasty: a re-emerging technique enhanced with real-time, three-dimensional transoesophageal cardiac ultrasound/echocardiography (3D-TOE)

We describe the case of a woman in her 60s with mitral stenosis, rate-controlled atrial fibrillation and a history of childhood rheumatic fever. She successfully underwent elective percutaneous transvenous mitral commissurotomy (PTMC), also described as balloon mitral valvuloplasty, for severe, symptomatic mitral stenosis. This was completed via right femoral vein access, trans-septal puncture and commissural separation guided by real-time three-dimensional (3D) transoesophageal echocardiography under general anaesthesia.Balloon mitral valvuloplasty is being completed more frequently in the UK due to the population having a higher incidence of mitral valve disease as a result of migration and as a palliative measure in those considered too high risk for mitral valve replacement cardiothoracic surgery.Rheumatic mitral stenosis is known to be a disease prevalent in countries of low and middle income and with increased migration to the UK, resulting in an increased prevalence of rheumatic mitral valve disease in the UK. It is estimated that within the UK, one in seven persons are migrants, and as such, we believe it is important to pay attention to diseases which affect the evolving population of the UK.Technological advancements, including availability and use of 3D transoesophageal cardiac ultrasound/echocardiography, have made PTMC much safer and more effective than previously. Additionally, the multidisciplinary team approach to PTMC is very important to its success. The procedure was completed successfully, with no complications.

3D echocardiography in mitral valve prolapse

Mitral valve prolapse (MVP) is the leading cause of mitral valve surgery. Echocardiography is the principal imaging modality used to diagnose MVP, assess the mitral valve morphology and mitral annulus dynamics, and quantify mitral regurgitation. Three-dimensional (3D) echocardiographic (3DE) imaging represents a consistent innovation in cardiovascular ultrasound in the last decades, and it has been implemented in routine clinical practice for the evaluation of mitral valve diseases. The focus of this review is the role and the advantages of 3DE in the comprehensive evaluation of MVP, intraoperative and intraprocedural monitoring.

Mitral Valve Prolapse-The Role of Cardiac Imaging Modalities

Mitral valve prolapse (MVP) is the most common nonischemic mitral regurgitation etiology and mitral abnormality requiring surgery in the Western world. There is an increasing awareness that pathological findings in MVP are not confined to the valve tissue; rather, it is a complex disease, involving the mitral valve apparatus, cardiac hemodynamics, and cardiac structure. Imaging has played a fundamental role in the understanding of the diagnosis, prevalence, and consequences of MVP. The diagnosis of MVP by imaging is based upon demonstrating valve leaflets ascending into the left atrium through the saddle-shaped annulus. Transthoracic and transesophageal echocardiography are the primary modalities in the diagnosis and assessment of MVP patients and must include careful assessment of the leaflets, annulus, chords, and papillary muscles. High-spatial-resolution imaging modalities such as cardiac magnetic resonance images and cardiac computed tomography play a secondary role in this regard and can demonstrate the anatomical relation between the mitral valve annulus and leaflet excursion for appropriate diagnosis. Ongoing development of new methods of cardiac imaging can help us to accurately understand the mechanism, diagnose the disease, develop an appropriate treatment plan, and estimate the risk for sudden death. Recently, several new observations with respect to prolapse have been derived from cardiac imaging including three-dimensional echocardiography and tissue-Doppler imaging. The aim of this article is to present these new imaging-derived insights for the diagnosis, risk assessment, treatment, and follow-up of patients with MVP.

Mitral valve prolapse in patients with atrial septal defect: A quantitative three-dimensional echocardiographic analysis

INTRODUCTION AND OBJECTIVES

Mitral valve (MV) prolapse is highly prevalent in patients with atrial septal defect (ASD). Abnormal left ventricular geometry has been proposed as the main mechanism of MV prolapse in ASD, however, the changes in the morphology of the MV apparatus remain to be clarified. Our aim was to assess the MV geometry in patients with ASD and MV prolapse.

METHODS

We evaluated 99 patients (73% female, median age 40 years) with ASD who underwent a three-dimensional transesophageal echocardiogram. Three-dimensional analysis of the MV was done using dedicated automated software. Transthoracic echocardiographic parameters were assessed post ASD closure in 28 patients.

RESULTS

MV prolapse was found in 39% of patients. Although smaller left ventricular dimensions and greater interatrial shunt were found in patients with MV prolapse compared with those without prolapse, there was no difference in the subvalvular parameters. MV prolapse was associated with larger mitral anterior-posterior diameter, anterolateral-posteromedial diameter, anterior perimeter, posterior perimeter, total perimeter, and anterior leaflet area (all p < 0.05). Mitral regurgitation was more frequent in patients with MV prolapse (80 vs. 48%, p = 0.002).

CONCLUSIONS

In patients with ASD, the main mechanism of MV prolapse is the presence of an organic primary process of the MV apparatus (excessive anterior mitral leaflet tissue and mitral annular enlargement).

Three-Dimensional Echocardiography Assessment of Right Ventricular Volumes and Function: Technological Perspective and Clinical Application

Right ventricular (RV) function has important prognostic value in a variety of cardiovascular diseases. Due to complex anatomy and mode of contractility, conventional two-dimensional echocardiography does not provide sufficient and accurate RV function assessment. Currently, three-dimensional echocardiography (3DE) allows for an excellent and reproducible assessment of RV function owing to overcoming these limitations of traditional echocardiography. This review focused on 3DE and discussed the following points: (i) acquisition of RV dataset for 3DE images, (ii) reliability, feasibility, and reproducibility of RV volumes and function measured by 3DE with different modalities, (iii) the clinical application of 3DE for RV function quantification.

Cavernous haemangioma of anterior mitral valve leaflet: diagnostic utility of 3D echocardiography

Mitral valve (MV) haemangiomas are rare primary cardiac tumours which may cause progressive cardiac failure as well as sudden death. We present a case of a 44-year-old woman referred for surgical correction of symptomatic severe mitral regurgitation. Preoperative two-dimensional transthoracic and transoesophageal echocardiography (TOE) were reported as demonstrating complex bi-leaflet prolapse causing severe mitral regurgitation. The patient was listed for MV surgery. Only on preoperative CT coronary angiogram was a filling defect noted, leading to suspicion of a cardiac tumour. Prior to skin incision, three-dimensional (3D) TOE revealed a 2×3 cm mass attached to the anterior leaflet of the MV. The tumour was subsequently resected, and the MV replaced. Postoperative histopathology confirmed a large cavernous haemangioma of the anterior MV leaflet. This case highlights a rare cause of severe mitral regurgitation and demonstrates the utility of 3D TOE as an adjunctive modality in confirming the suspected diagnosis of a cardiac tumour.

The role of three dimensional transesophageal echocardiography in predicting the effect of cardiac resynchronization therapy on mitral regurgitation in patients with low ejection fraction heart failure

PURPOSE

Cardiac resynchronization therapy (CRT) positively affects the improvement of functional mitral regurgitation (MR) in patients with heart failure with reduced ejection fraction (HFrEF). However, geometric changes in the mitral valve apparatus, subvalvular structures and their contribution to improving mitral regurgitation after CRT have not been clearly defined. Our study aimed to evaluate the geometric parameters of mitral valve apparatus measured with three-dimensional (3D) transesophageal echocardiography (TEE) before CRT implantation and to determine the parameters predicting the improvement of MR after CRT.

METHODS

In this prospective study, we included thirty patients with moderate or severe MR and HFrEF planned for CRT implantation who had an indication for TEE. Before CRT implantation, effective regurgitant orifice (ERO) and regurgitant volume (RV) measurements were performed. Detailed quantitative measurements of the mitral valve were done from recorded images by 3D TEE. ERO and RV measurements were repeated to evaluate MR at the end of the third month.

RESULTS

There were no significant changes in left ventricular EF and left ventricular diameters at third-month follow-up, whereas ERO and RV values were decreased. The posterior leaflet angle was higher in the non-responder group than the responder group (28.93 ± 8.41 vs 41.25 ± 10.90, p = 0.006). The posterior leaflet angle was an independent predictor of decreased RV and ERO.

CONCLUSION

Among HFrEF patients with moderate or severe functional MR who underwent CRT implantation had a lower posterior leaflet angle, which was measured by 3D TEE, in the patient group whose MR improved after CRT.

Diagnosis of Mitral Valve Prolapse: Much More than Simple Prolapse. Multimodality Approach to Risk Stratification and Therapeutic Management

Mitral valve prolapse (MVP) is the most common valvular disease with a prevalence of 2%. It has generally a benign course; however, recent findings suggested an association between MVP and complex arrhythmias and eventually cardiac arrest and for this reason, it is also called arrhythmogenic MVP. Subjects who experience this complication are in general young women, with thickened mitral leaflets or bileaflet prolapse not necessarily associated with severe mitral regurgitation (MR). The nature of the relation between MVP and cardiac arrest is not clearly understood. Actually, the challenging task is to find the cluster of prognostic factors including T-wave inversion, polymorphic premature ventricular contractions, bileaflet prolapse, MR severity, but most importantly, those parameters of hypercontractility, mitral annulus disjunction (MAD), and myocardial fibrosis using a multimodality approach. Transthoracic echocardiography is the first-line imaging modality for the diagnosis of MVP, but also for detecting MAD and hypercontractility, followed by cardiac magnetic resonance for tissue characterization and detection of myocardial and papillary muscle fibrosis, using either late gadolinium enhancement (at the basal segment of the inferolateral wall and papillary muscles) (macro-fibrosis), or diffuse fibrosis by T1 mapping (native and post contrast T1). Moreover, there are also preliminary data on positron emission tomography utilizing ¹⁸F-fluorodeoxyglucose as a tool for providing evidence of early myocardial inflammation. The objective of this review article is to provide the clinician with an overview and a practical clinical approach to MVP for risk stratification and treatment guidance.

Machine Learning Prediction Models for Mitral Valve Repairability and Mitral Regurgitation Recurrence in Patients Undergoing Surgical Mitral Valve Repair

Background: Mitral valve regurgitation (MR) is the most common valvular heart disease and current variables associated with MR recurrence are still controversial. We aim to develop a machine learning-based prognostic model to predict causes of mitral valve (MV) repair failure and MR recurrence. Methods: 1000 patients who underwent MV repair at our institution between 2008 and 2018 were enrolled. Patients were followed longitudinally for up to three years. Clinical and echocardiographic data were included in the analysis. Endpoints were MV repair surgical failure with consequent MV replacement or moderate/severe MR (>2+) recurrence at one-month and moderate/severe MR recurrence after three years. Results: 817 patients (DS1) had an echocardiographic examination at one-month while 295 (DS2) also had one at three years. Data were randomly divided into training (DS1: n = 654; DS2: n = 206) and validation (DS1: n = 164; DS2 n = 89) cohorts. For intra-operative or early MV repair failure assessment, the best area under the curve (AUC) was 0.75 and the complexity of mitral valve prolapse was the main predictor. In predicting moderate/severe recurrent MR at three years, the best AUC was 0.92 and residual MR at six months was the most important predictor. Conclusions: Machine learning algorithms may improve prognosis after MV repair procedure, thus improving indications for correct candidate selection for MV surgical repair.

Head to Head Comparison between Different 3-Dimensional Echocardiographic Rendering Tools in the Imaging of Percutaneous Edge-to-Edge Mitral Valve Repair

MitraClip (MC) is the most common percutaneous treatment for severe mitral regurgitation (MR). An accurate two-dimensional and three-dimensional echocardiographic (3DTEE) imaging is mandatory for the optimal procedural result. Recently transillumination 3DTEE rendering (3DTr) has been introduced integrating a virtual light source into the dataset and with the addition of glass effect (3DGl) allows to adjust tissue transparency improving depth perception and anatomical structure delineation in comparison with the standard 3DTEE (3DSt). The aim of this retrospective study in 30 patients undergoing MC, was to compare 3DSt, 3DTr, and 3DGl in mitral valve (MV) evaluation and procedural result assessment. 3DTEE acquisitions obtained before and after MC were processed with 3DSt, 3DTr, and 3DGl rendering. Each reconstruction was scored for quality and for ability to recognize MV anatomy, MR origin, clip position, dimension and grasping. Imaging quality was judged good or optimal in 52%, 76%, and 96% in 3DSt, 3DTr, and 3DGl reconstructions respectively. In 26/30 patients a diagnostic incremental value was found with 3DTr vs. 3DSt and in 15/26 with 3DGl vs. 3DTr and 3DSt. Only 3DGl with perpendicular cropping of the clip allowed to visualize and measure the grasped portion of each mitral leaflets. 3DTEE imaging during MC may be improved by 3DTr and 3DGl providing a better evaluation of MV, of leaflet grasping and of residual MR jets after MC.

Echocardiographic assessment of mitral regurgitation: discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness

The echocardiographic assessment of mitral valve regurgitation (MR) by characterizing specific morphological features and grading its severity is still challenging. Analysis of MR etiology is necessary to clarify the underlying pathological mechanism of the valvular defect. Severity of mitral regurgitation is often quantified based on semi-quantitative parameters. However, incongruent findings and/or interpretations of regurgitation severity are frequently observed. This proposal seeks to offer practical support to overcome these obstacles by offering a standardized workflow, an easy means to identify non-severe mitral regurgitation, and by focusing on the quantitative approach with calculation of the individual regurgitant fraction. This work also indicates main methodological problems of semi-quantitative parameters when evaluating MR severity and offers appropriateness criteria for their use. It addresses the diagnostic importance of left-ventricular wall thickness, left-ventricular and left atrial volumes in relation to disease progression, and disease-related complaints to improve interpretation of echocardiographic findings. Finally, it highlights the conditions influencing the MR dynamics during echocardiographic examination. These considerations allow a reproducible, verifiable, and transparent in-depth echocardiographic evaluation of MR patients ensuring consistent haemodynamic plausibility of echocardiographic results.

Arrhythmic Mitral Valve Prolapse: Introducing an Era of Multimodality Imaging-Based Diagnosis and Risk Stratification

Mitral valve prolapse is a common cardiac condition, with an estimated prevalence between 1% and 3%. Most patients have a benign course, but ever since its initial description mitral valve prolapse has been associated to sudden cardiac death. Although the causal relationship between mitral valve prolapse and sudden cardiac death has never been clearly demonstrated, different factors have been implicated in arrhythmogenesis in patients with mitral valve prolapse. In this work, we offer a comprehensive overview of the etiology and the genetic background, epidemiology, pathophysiology, and we focus on the state-of-the-art imaging-based diagnosis of mitral valve prolapse. Going beyond the classical, well-described clinical factors, such as young age, female gender and auscultatory findings, we investigate multimodality imaging features, such as alterations of anatomy and function of the mitral valve and its leaflets, the structural and contractile anomalies of the myocardium, all of which have been associated to sudden cardiac death.

Novelties in 3D Transthoracic Echocardiography

Cardiovascular imaging is developing at a rapid pace and the newer modalities, in particular three-dimensional echocardiography, allow better analysis of heart structures. Identifying valve lesions and grading their severity represents crucial information and nowadays is strengthened by the introduction of new software, such as transillumination, which provide detailed morphology descriptions. Chambers quantification has never been so rapid and accurate: machine learning algorithms generate automated volume measurements, including left ventricular systolic and diastolic function, which is extremely important for clinical decisions. This review provides an overview of the latest innovations in the echocardiography field, and is helpful by providing a better insight into heart diseases.

Analysis of mitral valve morphology in dogs undergoing mitral valve repair with three-dimensional transesophageal echocardiography

INTRODUCTION

Information about real-time three-dimensional (3D) transesophageal echocardiography (TEE) for the evaluation of canine mitral valve morphology is lacking in veterinary medicine.

OBJECTIVES

To evaluate the feasibility of 3D TEE for the evaluation of canine mitral valves and whether there was a difference in mitral valve morphology between American College of Veterinary Internal Medicine (ACVIM) stages.

ANIMALS

Thirty-one dogs were evaluated, including nine dogs classified as ACVIM stage B2, 15 as stage C, and seven as stage D.

MATERIALS AND METHODS

Three-dimensional TEE was performed after anesthetic induction for mitral valve surgery, and the 3D geometry of the mitral valve apparatus was measured.

RESULTS

The intraclass correlation coefficient was good in both inter- and intraobserver analyses of the 3D measurements of mitral valve annulus geometry and excellent in both inter- and intraobserver analyses in the 3D measurements of mitral valve annular and leaflet sizes. Annulus height to commissural width ratio of stage D dogs showed significantly lower values than B2 dogs (B2: 14.2% [9.1-20.5%]; C: 10.6% [6.5-24.1%]; D: 9.5% [4.7-13.8%]). The aortic-mitral angle of stages C and D were significantly flatter than stage B2 (B2: 122.32 ± 9.39; C: 133.66 ± 8.43; D: 140.70 ± 10.70).

CONCLUSIONS

Real-time 3D echocardiography using TEE is a feasible method to evaluate the morphology of the mitral valve in dogs. The saddle shape of the mitral annulus and aortic-mitral angle were flatter in stage D. Further studies are required to understand the pathology of mitral valve disease in dogs.

Imaging the mitral valve: a primer for the interventional surgeon

Transcatheter mitral valve interventions (TMVI) have evolved over the past decade as alternatives to open surgical repair for the therapeutic management of patients with severe mitral regurgitation (MR). Concurrent with the development of these technologies, quality multi-modality cardiac imaging has become essential in patient selection and procedural guidance. The former involves assessments of the pathophysiologic mechanisms of regurgitation, valvular anatomy and morphology, as well as objective quantification of the severity of MR. Both transthoracic and transesophageal echocardiography (TEE) are crucial and serve as the gateway to diagnosis and management of mitral valvular disease. Along with multi-detector computed tomography (CT) and cardiac magnetic resonance imaging (CMR), echocardiography plays an important role for preprocedural planning and evaluation of the spatial relationships of the mitral valvular complex with the coronary sinus, circumflex coronary artery and left ventricular (LV) outflow tract. Procedures that target mitral leaflets (e.g., MitraClip, PASCAL) or annulus (e.g., Cardioband, Carillon), or provide chordal (e.g., NeoChord, Harpoon) or valvular replacement, tend to be guided by TEE and assisted by fluoroscopy. As newer devices become available and outcomes of TMVI improve, cardiac imaging will undoubtedly continue to play an essential role in the success of percutaneous mitral valve repair (MVr) and replacement. The interventional surgeon of the future must therefore have a thorough understanding of the various imaging modalities while synthesizing and integrating novel concepts (e.g., neo-LV outflow tract) as applicable to assessing valvular function and pathology.

Integration of three-dimensional echocardiography into the modern-day echo laboratory

Three-dimensional echocardiography (3DE) has emerged in recent decades from a conceptual, research tool to an important, useful imaging technique that can informatively impact daily clinical practice. However, its adoption into the modern-day echo laboratory requires the acknowledgment of its value, coupled with proper leadership, education, and resources to implement and integrate its use with conventional echo techniques. 3DE integration involves important updates regarding equipment and patient selection, assimilation of 3D protocols into current clinical routine, laboratory workflow adaptation, storage, and reporting. This review will provide a practical blueprint and key points of how to integrate 3DE into today's echo laboratory, necessary resources to implement 3D workflow, logistical challenges that remain, and future directions to further improve assimilation of this relevant echo technique into the laboratory.

Predictive Value of Pre-Operative 2D and 3D Transthoracic Echocardiography in Patients Undergoing Mitral Valve Repair: Long Term Follow Up of Mitral Valve Regurgitation Recurrence and Heart Chamber Remodeling

The “ideal” management of asymptomatic severe mitral regurgitation (MR) in valve prolapse (MVP) is still debated. The aims of this study were to identify pre-operatory parameters predictive of residual MR and of early and long-term favorable remodeling after MVP repair. We included 295 patients who underwent MV repair for MVP with pre-operatory two- and three-dimensional transthoracic echocardiography (2DTTE and 3DTTE) and 6-months (6M) and 3-years (3Y) follow-up 2DTTE. MVP was classified by 3DTTE as simple or complex and surgical procedures as simple or complex. Pre-operative echo parameters were compared to post-operative values at 6M and 3Y. Patients were divided into Group 1 (6M-MR < 2) and Group 2 (6M-MR ≥ 2), and predictors of MR ≥ 2 were investigated. MVP was simple in 178/295 pts, and 94% underwent simple procedures, while in only 42/117 (36%) of complex MVP a simple procedure was performed. A significant relation among prolapse anatomy, surgical procedures and residual MR was found. Post-operative MR ≥ 2 was present in 9.8%: complex MVP undergoing complex procedures had twice the percentage of MR ≥ 2 vs. simple MVP and simple procedures. MVP complexity resulted independent predictor of 6M-MR ≥ 2. Favorable cardiac remodeling, initially found in all cases, was maintained only in MR < 2 at 3Y. Pre-operative 3DTTE MVP morphology identifies pts undergoing simple or complex procedures predicting MR recurrence and favorable cardiac remodeling.

T1 mapping and cardiac magnetic resonance feature tracking in mitral valve prolapse

OBJECTIVES

T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation abnormalities. We sought to demonstrate that T1-map and CMR-FT may identify the presence of subclinical myocardial structural changes in patients with mitral valve prolapse (MVP).

METHODS

Consecutive MVP patients with moderate-to-severe mitral regurgitation and comparative matched healthy subjects were prospectively enrolled and underwent CMR-FT analysis to calculate 2D global and segmental circumferential (CS) and radial strain (RS) and T1-map to determine global and segmental native T1 (nT1) values.

RESULTS

Seventy-three MVP patients (mean age, 57 ± 13 years old; male, 76%; regurgitant volume, 57 ± 21 mL) and 42 matched control subjects (mean age, 56 ± 18 years; male, 74%) were included. MVP patients showed a lower global CS (- 16.3 ± 3.4% vs. - 17.8 ± 1.9%, p = 0.020) and longer global nT1 (1124.9 ± 97.7 ms vs. 1007.4 ± 26.1 ms, p < 0.001) as compared to controls. Moreover, MVP patients showed lower RS and CS in basal (21.6 ± 12.3% vs. 27.6 ± 8.9%, p = 0.008, and - 13.0 ± 6.7% vs. - 14.9 ± 4.1%, p = 0.013) and mid-inferolateral (20.6 ± 10.7% vs. 28.4 ± 8.7%, p < 0.001, and - 12.8 ± 6.3% vs. - 16.5 ± 4.0%, p < 0.001) walls as compared to other myocardial segments. Similarly, MVP patients showed longer nT1 values in basal (1080 ± 68 ms vs. 1043 ± 43 ms, p < 0.001) and mid-inferolateral (1080 ± 77 ms vs. 1034 ± 37 ms, p < 0.001) walls as compared to other myocardial segments. Of note, nT1 values were significantly correlated with CS (r, 0.36; p < 0.001) and RS (r, 0.37; p < 0.001) but not with regurgitant volume.

CONCLUSIONS

T1-map and CMR-FT identify subclinical left ventricle tissue changes in patients with MVP. Further studies are required to correlate these subclinical tissue changes with the outcome.

KEY POINTS

• T1 mapping (T1-map) and cardiac magnetic resonance feature tracking (CMR-FT) techniques have been introduced for the early detection of interstitial myocardial fibrosis and deformation abnormalities. • In MVP patients, we demonstrated a longer global nT1 with associated reduced global circumferential (CS) and radial strain (RS) as compared to control subjects. • Among MVP patients, the mid-basal left ventricle inferolateral wall showed longer nT1 with reduced CS and RS as compared to other myocardial segments. Further studies are required to correlate these subclinical tissue changes with the outcome.

Multimodality imaging assessment of mitral annular disjunction in mitral valve prolapse

OBJECTIVE

Mitral annular disjunction (MAD) is an abnormality linked to mitral valve prolapse (MVP), possibly associated with malignant ventricular arrhythmias. We assessed the agreement among different imaging techniques for MAD identification and measurement.

METHODS

131 patients with MVP and significant mitral regurgitation undergoing transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) were retrospectively enrolled. Transoesophageal echocardiography (TOE) was available in 106 patients. MAD was evaluated in standard long-axis views (four-chamber, two-chamber, three-chamber) by each technique.

RESULTS

Considering any-length MAD, MAD prevalence was 17.3%, 25.5%, 42.0% by TTE, TOE and CMR, respectively (p<0.05). The agreement on MAD identification was moderate between TTE and CMR (κ=0.54, 95% CI 0.49 to 0.59) and good between TOE and CMR (κ=0.79, 95% CI 0.74 to 0.84). Assuming CMR as reference and according to different cut-off values for MAD (≥2 mm, ≥4 mm, ≥6 mm), specificity (95% CI) of TTE and TOE was 99.6 (99.0 to 100.0)% and 98.7 (97.4 to 100.0)%; 99.3 (98.4 to 100.0)% and 97.6 (95.8 to 99.4)%; 97.8 (96.2 to 99.3)% and 93.2 (90.3 to 96.1)%, respectively; sensitivity (95% CI) was 43.1 (37.8 to 48.4)% and 74.5 (69.4 to 79.5)%; 54.0 (48.7 to 59.3)% and 88.9 (85.2 to 92.5)%; 88.0 (84.5 to 91.5)% and 100.0 (100.0 to 100.0)%, respectively. MAD length was 8.0 (7.0-10.0), 7.0 (5.0-8.0], 5.0 (4.0-7.0) mm, respectively by TTE, TOE and CMR. Agreement on MAD measurement was moderate between TTE and CMR (ρ=0.73) and strong between TOE and CMR (ρ=0.86).

CONCLUSIONS

An integrated imaging approach could be necessary for a comprehensive assessment of patients with MVP and symptoms suggestive for arrhythmias. If echocardiography is fundamental for the anatomic and haemodynamic characterisation of the MV disease, CMR may better identify small length MAD as well as myocardial fibrosis.

Two-Dimensional and Three-Dimensional Transthoracic Echocardiography as Predictive and Prognostic Indicators of All-Cause Mortality in Heart Failure with Reduced Ejection Fraction in Patients with Ischemic Heart Disease

Background

This study aimed to compare the predictive role of two-dimensional transthoracic echocardiography (2D-TTE) and three-dimensional transthoracic echocardiography (3D-TTE) on in-hospital all-cause mortality in patients with heart failure and reduced ejection fraction (HFrEF) due to ischemic heart disease (IHD).

Material/Methods

Patients (N-224) with HFrEF due to IHD who had a left ventricular ejection fraction (LVEF) <40% on admission when measured by 2D-TTE and 3D-TTE were studied and divided into survival and mortality groups. Baseline demographic and clinical characteristics were compared.

Results

Compared with the survival group (n=142), patients who died during hospitalization (n=82) were more commonly older (67.3 vs. 62.6 years), female (48.8% vs. 38.7%), with diabetes mellitus (51.2% vs. 32.4%), chronic kidney disease (48.8% vs. 32.4%), intravenous inotropes (85.4% vs. 76.1%), and intravenous vasodilators (70.7% vs. 61.3%). Regression model analysis for all-cause mortality identified significant associations with age, diabetes mellitus, myocardial infarction (MI), intravenous inotropes, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and LVEF following 2D-TTE. Age, diabetes mellitus, prior MI, the use of intravenous inotropes, NT-proBNP, LVEF, and left ventricular end-diastolic volume (LVEDV) index following 3D-TTE were significantly associated with all-cause mortality. Modeling of 2D-TTE parameters showed that the concordance statistic (C-index) increased significantly after including the LVEF, from 0.72 to 0.77 and from 0.72 to 0.80, respectively. Modeling of 3D-TTE parameters showed that the C-index increased significantly after including the LVEDV index (from 0.80 to 0.76).

Conclusions

In patients with HFrEF due to IHD, 3D-TTE was a better predictor than 2D-TTE of in-hospital all-cause mortality.

Understanding Non-P2 Mitral Regurgitation Using Real-Time Three-Dimensional Transesophageal Echocardiography: Characterization and Factors Leading to Underestimation

BACKGROUND

P2 prolapse is a common cause of degenerative mitral regurgitation (MR); echocardiographic characteristics of non-P2 prolapse are less known. Because of the eccentric nature of degenerative MR jets, the evaluation of MR severity is challenging. The aim of this study was to test the hypotheses that (1) the percentage of severe MR determined by transthoracic echocardiography (TTE) would be lower compared with that determined by transesophageal echocardiography (TEE) in patients with non-P2 prolapse and also in a subgroup with "horizontal MR" (a horizontal jet seen on TTE that hugs the leaflets without reaching the atrial wall, particularly found in non-P2 prolapse) and (2) the directions of MR jets between TTE and real-time (RT) three-dimensional (3D) TEE would be discordant.

METHODS

One hundred eighteen patients with moderate to severe and severe degenerative MR defined by TEE were studied. The percentage of severe MR between TTE and TEE was compared in P2 and non-P2 prolapse groups and in horizontal and nonhorizontal MR groups. Additionally, differences in the directions of the MR jets between TTE and RT 3D TEE were assessed.

RESULTS

Eighty-six percent of patients had severe MR according to TEE. TTE underestimated severe MR in the non-P2 group (severe MR on TTE, 57%; severe MR on TEE, 85%; P < .001) but not in the P2 group (severe MR on TTE, 79%; severe MR on TEE, 91%; P = .157). Most "horizontal" MR jets were found in the non-P2 group (85%), and this subgroup showed even more underestimation of severe MR on TTE (TTE, 22%; TEE, 89%; P < .001). There was discordance in MR jet direction between two-dimensional TTE and RT 3D TEE in 41% of patients.

CONCLUSIONS

Non-P2 and "horizontal" MR are significantly underestimated on TTE compared with TEE. There is substantial discordance in the direction of the MR jet between RT 3D TEE and TTE. Therefore, TEE should be considered when these subgroups of MR are observed on TTE.

Obstructive bioprosthetic mitral valve thrombosis

Bioprosthetic valve thrombosis (BPVT) is not uncommon but can be under diagnosed due to the lack of awareness and technical limitations of echocardiography. When suspecting BPVT, it is imperative to consider multimodality imaging to establish the diagnosis as early treatment can alter the clinical course. Here we present a case series of two patients with a history of rheumatic heart disease status post bioprosthetic mitral valve replacement who presented with acute heart failure symptoms. In both cases, supplemental imaging with real-time 3D echocardiography was critical in establishing a diagnosis of BPVT, resulting in timely treatment. These cases support updating current guidelines for the management of patients with bioprosthetic valve replacement to include more frequent surveillance imaging even if patients are asymptomatic.

Mitral Annulus Segmentation Using Deep Learning in 3-D Transesophageal Echocardiography

3D Transesophageal Echocardiography is an excellent tool for evaluating the mitral valve and is also well suited for guiding cardiac interventions. We introduce a fully automatic method for mitral annulus segmentation in 3D Transesophageal Echocardiography, which requires no manual input. One hundred eleven multi-frame 3D transesophageal echocardiography recordings were split into training, validation, and test sets. Each 3D recording was decomposed into a set of 2D planes, exploiting the symmetry around the centerline of the left ventricle. A deep 2D convolutional neural network was trained to predict the mitral annulus coordinates, and the predictions from neighboring planes were regularized by enforcing continuity around the annulus. Applying the final model and post-processing to the test set data gave a mean error of 2.0 mm - with a standard deviation of 1.9 mm. Fully automatic segmentation of the mitral annulus can alleviate the need for manual interaction in the quantification of an array of mitral annular parameters and has the potential to eliminate inter-observer variability.

Application of trans-thoracic echocardiography and coronary CT angiography to diagnose mitral valve prolapse

Objective

At present, multi-detector cardiac CT has been widely applied in the detection of heart valve morphology and function. This study aims to compare the coronary CT angiography and trans-thoracic echocardiography for patients with mitral valve prolapse.

Methods

CT angiography and trans-thoracic echocardiography were adopted to detect the movement range and thickness of valvula bicuspidalis. The ultrasonic parameters of CT angiography were considered as standard reference value.

Results

Receiver operating characteristic (ROC) curve showed that the area of mitral valve motion amplitude under ROC curve was 95% detected by CT angiography with statistical significance (P < 0.001). Based on the intercept point on the ROC curve, the sensitivity and accuracy of mitral valve amplitude detected by CT angiography was 69.2 and 95.6%, the false positive and false negative rate was 5.2 and 32.4%, the predicted value of positive and negative was 92.9 and 76.9% and the consistency rate of motion range and leaf thickness detected by CT angiography was 83.3 and 47.5%. Trans-thoracic echocardiography showed that the thickness and motion range of mitral leaflet was (1.95 ± 0.22) mm and (1.5 ± 2.28) mm. The thickness and motion range of mitral leaflet that detected by CT was (2.00 ± 0.54) mm and (3.76 ± 2.1) mm.

Conclusion

The accuracy and reliability of CT angiography for patients with mitral valve prolapse are higher than those of trans-thoracic echocardiography.

Endothelial Dysfunction in Patients with Severe Mitral Regurgitation

Mitral valve prolapse (MVP) is the most common cause of severe mitral regurgitation. It has been reported that MVP patients—candidates for mitral valve repair (MVRep)—showed an alteration in the antioxidant defense systems as well as in the L-arginine metabolic pathway. In this study, we investigate if oxidative stress and endothelial dysfunction are an MVP consequence or driving factors. Forty-five patients undergoing MVRep were evaluated before and 6 months post surgery and compared to 29 controls. Oxidized (GSSG) and reduced (GSH) forms of glutathione, and L-arginine metabolic pathway were analyzed using liquid chromatography-tandem mass spectrometry methods while osteoprotegerin (OPG) through the ELISA kit and circulating endothelial microparticles (EMP) by flow cytometry. Six-month post surgery, in MVP patients, the GSSG/GSH ratio decreased while symmetric and asymmetric dimethylarginines levels remained comparable to the baseline. Conversely, OPG levels significantly increased when compared to their baseline. Finally, pre-MVRep EMP levels were significantly higher in patients than in controls and did not change post surgery. Overall, these results highlight that MVRep completely restores the increased oxidative stress levels, as evidenced in MVP patients. Conversely, no amelioration of endothelial dysfunction was evidenced after surgery. Thus, therapies aimed to restore a proper endothelial function before and after surgical repair could benefit MVP patients.

Advanced Imaging Techniques for Mitral Regurgitation

Mitral regurgitation (MR) is one of the most commonly encountered valvular lesions in clinical practice. MR can be either primary (degenerative) or secondary (functional) depending on the etiology of MR and the pathology of the mitral valve (MV). Echocardiography is the primary diagnostic tool for MR and is key in determining this etiology as well as MR severity. While clinicians usually turn to 2 Dimensional echocardiography as first-line imaging, 3 Dimensional echocardiography (3DE) has continually shown to be superior in terms of describing MV anatomy and pathology. This review article elaborates on 3DE techniques, modalities, and advances in software. Furthermore, the article demonstrates how 3DE has reformed MR evaluation and has played a vital role in determining patient management.

Surgical Echocardiography of the MV: Focus on 3D

The mitral valve remains a complex structure where multiple forms of pathology can be seen. Mitral regurgitation continues to be one of the most common valvular diseases in the industrialized world. While intraoperative 2-dimensional transesophageal echocardiography has been commonplace for some time, 3-dimensional technology has emerged and has shown great benefit for diagnosis and guidance during mitral valve surgery. In the hands of a trained sonographer, high-quality real-time images can easily be obtained and correlate well with gross anatomical findings. The use of multiple angled views and color Doppler within 3-dimensional transesophageal echocardiography has become a valuable asset in the understanding and interpretation of the mitral valve for surgical interventions.

Transthoracic echocardiography in patients undergoing mitral valve repair: comparison of new transthoracic 3D techniques to 2D transoesophageal echocardiography in the localization of mitral valve prolapse

Successful mitral valve (MV) repair for degenerative mitral regurgitation (DMR) is mainly related to surgical expertise and MV anatomy. Although 2D echocardiography, specifically transoesophageal (TOE), provides precise information regarding MV anatomy, recent advancements in matrix technology meant a decisive step forward to the point where segmental MV analysis can be accurately performed from a noninvasive 3D transthoracic (TTE) approach. The aims of this study were: (a) to evaluate the feasibility and time required for real-time 3D TTE in a large consecutive cohort of patients with severe DMR in the assessment of MV anatomy; (b) to compare the accuracy of 3D TTE and 2D TOE versus surgical inspection in the recognition and localization of all components of the MV leaflets; (c) to establish the added diagnostic value of 3D colourDoppler examination to pure 3D morphologic evaluation. 149 consecutive patients with severe DMR underwent complete 3D TTE before surgery and 2D TOE in the operating room. Echocardiographic data obtained by the different techniques were compared with surgical inspection. 3D TTE was feasible in a relatively short time (8 ± 4 min), with good (49%) and optimal (33%) imaging quality in the majority of cases. 3D TTE had significant better overall accuracy compared to 2D TOE (93 and 91%, p < 0.05, respectively). 2D TOE was significantly more specific than 3D TTE in the identification of A3 prolapse (99 vs. 96%). The colourDoppler mode did not improve significantly the accuracy of 3D TTE, albeit it determined a better sensitivity in the detection of A2 prolapse if compared to 2D TOE (95 vs. 85%). 3D TTE with or without colourDoppler is a feasible and useful method in the analysis of MV prolapse; it allows a preoperative and noninvasive description of the pathology as accurate as the 2D TOE.

Morphologic Evaluation of the Mitral Annulus During Displacement of the Heart in Off-Pump Coronary Artery Bypass Surgery

OBJECTIVE

To evaluate the morphologic changes of the mitral annulus using 3-dimensional transesophageal echocardiography during heart displacement to expose the anastomosis site in off-pump coronary artery bypass surgery (OPCAB).

DESIGN

Prospective case series.

SETTING

Single center, university hospital.

PARTICIPANTS

The study comprised 34 consecutive patients who underwent OPCAB of the left circumflex artery (LCX) and the right coronary artery (RCA).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Mitral annulus parameters were measured using the Mitral Valve Quantification program after sternotomy (physiologic position) and during displacement of the heart to expose the LCX (LCX position) and the RCA (RCA position). The height of the mitral annulus was significantly lower in the LCX (5.76 ± 0.90 mm) and RCA (5.92 ± 0.97 mm) positions than in the physiologic position (6.96 ± 0.99 mm; both p < 0.0001). The percent change in the height of the mitral annulus was significantly greater in the mitral regurgitation group than in the mitral regurgitation nondeterioration group when in the LCX (-16.3% ± 6.0% v -11.9% ± 3.3%, p = 0.0203) and RCA (-16.9% ± 6.3% v -12.1% ± 3.8%, p = 0.0207) positions. The anteroposterior and intercommissural diameters, annulus perimeter, and surface area of the mitral annulus did not differ significantly among all heart positions.

CONCLUSIONS

The mitral annulus flattened and lost its saddle shape without expanding while in the LCX and RCA positions. The greater percent change in the height of the mitral annulus may aggravate mitral regurgitation.

Dynamic and quantitative evaluation of degenerative mitral valve disease: a dedicated framework based on cardiac magnetic resonance imaging

BACKGROUND

Accurate quantification of mitral valve (MV) morphology and dynamic behavior over the cardiac cycle is crucial to understand the mechanisms of degenerative MV dysfunction and to guide the surgical intervention. Cardiac magnetic resonance (CMR) imaging has progressively been adopted to evaluate MV pathophysiology, although a dedicated framework is required to perform a quantitative assessment of the functional MV anatomy.

METHODS

We investigated MV dynamic behavior in subjects with normal MV anatomy (n=10) and patients referred to surgery due to degenerative MV prolapse, classified as fibro-elastic deficiency (FED, n=9) and Barlow's disease (BD, n=10). A CMR-dedicated framework was adopted to evaluate prolapse height and volume and quantitatively assess valvular morphology and papillary muscles (PAPs) function over the cardiac cycle. Multiple comparison was used to investigate the hallmarks associated to MV degenerative prolapse and evaluate the feasibility of anatomical and functional distinction between FED and BD phenotypes.

RESULTS

On average, annular dimensions were significantly (P<0.05) larger in BD than in FED and normal subjects while no significant differences were noticed between FED and normal. MV eccentricity progressively decreased passing from normal to FED and BD, with the latter exhibiting a rounder annulus shape. Over the cardiac cycle, we noticed significant differences for BD during systole with an abnormal annular enlargement between mid and late systole (LS) (P<0.001 vs. normal); the PAPs dynamics remained comparable in the three groups. Prolapse height and volume highlighted significant differences among normal, FED and BD valves.

CONCLUSIONS

Our CMR-dedicated framework allows for the quantitative and dynamic evaluation of MV apparatus, with quantifiable annular alterations representing the primary hallmark of severe MV degeneration. This may aid surgeons in the evaluation of the severity of MV dysfunction and the selection of the appropriate MV treatment.

Modeling the Myxomatous Mitral Valve With Three-Dimensional Echocardiography

BACKGROUND

Degenerative mitral valve disease is associated with variable and complex defects in valve morphology. Three-dimensional echocardiography (3DE) has shown promise in aiding preoperative planning for patients with this disease but to date has not been as transformative as initially predicted. The clinical usefulness of 3DE has been limited by the laborious methods currently required to extract quantitative data from the images.

METHODS

To maximize the utility of 3DE for preoperative valve evaluation, this work describes an automated 3DE image analysis method for generating models of the mitral valve that are well suited for both qualitative and quantitative assessment. The method is unique in that it captures detailed alterations in mitral leaflet and annular morphology and produces image-derived models with locally varying leaflet thickness. The method is evaluated on midsystolic transesophageal 3DE images acquired from 22 subjects with myxomatous degeneration and from 22 subjects with normal mitral valve morphology.

RESULTS

Relative to manual image analysis, the automated method accurately represents both normal and complex leaflet geometries with a mean boundary displacement error on the order of one image voxel. A detailed quantitative analysis of the valves is presented and reveals statistically significant differences between normal and myxomatous valves with respect to numerous aspects of annular and leaflet geometry.

CONCLUSIONS

This work demonstrates a successful methodology for the relatively rapid quantitative description of the complex mitral valve distortions associated with myxomatous degeneration. The methodology has the potential to significantly improve surgical planning for patients with complex mitral valve disease.

Detailed Transthoracic and Transesophageal Echocardiographic Analysis of Mitral Leaflets in Patients Undergoing Mitral Valve Repair

A recent histological study of resected scallop-P2 in mitral valve (MV) prolapse, showed that chordae tendinae may be missing or hidden in superimposed fibrous tissue of the leaflets, contributing to their thickening. This may have relevant clinical implication because detailed analysis of MV leaflets has a central role in the evaluation of patients undergoing repair. The aim of this study was to analyze MV leaflets focusing on thickness of prolapsing segments and the presence of chordal rupture (CR). We enrolled 246 patients (age 63 ± 13 years, 72 men) with isolated P2 prolapse and also 50 age-matched patients with normal MV anatomy as control group. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) were retrospectively analyzed to quantify the length and the proximal and distal thickness of both anterior (A2) and posterior (P2) MV scallops. Measurements were performed at end diastole in the standard TTE and TEE views. TTE and TEE measurements were feasible in all cases. Echocardiographically 176 patients had CR (group A), 45 had no rupture (group B), and 25 had an uncertain diagnosis (group C). All pathological groups showed thickening and elongation of involved leaflets versus normal, whereas no differences in leaflets characteristics were found among MV groups. Most patients undergoing MV repair had CR with thickening of the prolapsed segment. These findings are in agreement with recent histological studies showing superimposed fibrous tissue on MV leaflets partially including ruptured chordae. This may also explain that in cases without ruptured chordae, thickness of the leaflets is markedly increased (hidden chordae?). In conclusion, detailed analysis of MV apparatus may further improve knowledge of these patients and may influence surgical timing.

Reproducibility of a novel echocardiographic 3D automated software for the assessment of mitral valve anatomy

Background

3D transesophageal echocardiography (TEE) is superior to 2D TEE in quantitative anatomic evaluation of the mitral valve (MV) but it shows limitations regarding automatic quantification. Here, we tested the inter-/intra-observer reproducibility of a novel full-automated software in the evaluation of MV anatomy compared to manual 3D assessment.

Methods

Thirty-six out of 61 screened patients referred to our Cardiac Imaging Unit for TEE were retrospectively included. 3D TEE analysis was performed both manually and with the automated software by two independent operators. Mitral annular area, intercommissural distance, anterior leaflet length and posterior leaflet length were assessed.

Results

A significant correlation between both methods was found for all variables: intercommissural diameter (r = 0.84, p < 0.01), mitral annular area (r = 0.94, p > 0, 01), anterior leaflet length (r = 0.83, p < 0.01) and posterior leaflet length (r = 0.67, p < 0.01). Interobserver variability assessed by the intraclass correlation coefficient was superior for the automatic software: intercommisural distance 0.997 vs. 0.76; mitral annular area 0.957 vs. 0.858; anterior leaflet length 0.963 vs. 0.734 and posterior leaflet length 0.936 vs. 0.838. Intraobserver variability was good for both methods with a better level of agreement with the automatic software.

Conclusions

The novel 3D automated software is reproducible in MV anatomy assessment. The incorporation of this new tool in clinical MV assessment may improve patient selection and outcomes for MV interventions as well as patient diagnosis and prognosis stratification. Yet, high-quality 3D images are indispensable.

Three-dimensional compared to two-dimensional transesophageal echocardiography for diagnosis of infective endocarditis

PURPOSE

Transesophageal echocardiography is crucial for the diagnosis of infective endocarditis (IE). Use of three-dimensional transesophageal echocardiography (3D-TEE) could improve the reliability of echocardiographic findings. This study sought to determine the value of 3D-TEE in the diagnosis of IE in comparison to two-dimensional (2D)-TEE and 2D transthoracic echocardiography (2D-TTE).

METHODS

In this prospective cohort study in a tertiary care university hospital 144 consecutive patients with clinically suspected IE were included. The patients were subjected to clinical, microbiological and echocardiographic evaluation (2D-TTE, 2D-TEE and 3D-TEE) and their clinical history evaluated retrospectively to establish a reference diagnosis of IE in accordance to current guideline recommendations.

RESULTS

In 48 (33 %) patients the diagnosis of IE was established. 2D-TEE and 3D-TEE showed a sensitivity, specificity, positive and negative predictive value for diagnosis of IE of 94 % and 63, 90 and 95 %, 82 and 86 % and 97 and 83 %, respectively, with similar results in patients with native and prosthetic valves. Vegetations and abscess were detected in 43 and 5 patients with final diagnosis of IE by any of the assessed echocardiographic modalities, with only one case of vegetation detected by 3D-TEE only and not by 2D-TEE.

CONCLUSIONS

In this cohort of patients with suspected IE, 3D-TEE showed substantial lower sensitivity and negative predictive value for diagnosis of IE when compared to 2D-TEE. 3D-TEE might provide additive diagnostic information with impact on clinical decisions only in individual cases.

The role of experience in echocardiographic identification of location and extent of mitral valve prolapse with 2D and 3D echocardiography

Contradiction exists on the incremental value of two-dimensional (2D) and 3D transoesophageal echocardiography (TOE) over 2D transthoracic echocardiography (TTE) for the detection of mitral valve (MV) prolapse in readers with different echocardiographic experience. Twenty patients and five healthy persons were retrospectively identified who had undergone 2D-TTE, 2D-TOE and 3D-TOE. Fifteen (75 %) patients had surgical evidence of prolapse of the posterior MV leaflet and five patients (25 %) had a dilated MV annulus without prolapse. Three reader groups with different echocardiographic expertise (novice, trainees, cardiologists) scored thus in total 675 posterior scallops. Overall there was an improvement in agreement and Kappa values from novice to trainees to cardiologists. Diagnostic accuracies of 2D-TOE were higher than those of 2D-TTE mainly in novice readers. The incremental value of 3D-TOE over 2D-TOE was mainly seen in specificities. Time to diagnosis was dramatically reduced from 2D to 3D-TEE in all reader groups (all P < 0.001). 3D-TOE also improved the agreement (+12 to +16 %) and Kappa values (+0.14 to +0.21) in all reader groups for the exact description of P2 prolapse. Differences between readers with variable experience in determining the precise localization and extent of the prolapsing posterior MV scallops exist in particular in 2D-TTE analysis. 3D-TOE analysis was extremely fast compared to the 2D analysis methods and showed the best diagnostic accuracy (mainly driven by specificity) with identification of P1 and P3 prolapse still improving from novice to trainees to cardiologists and provided optimal description of P2 prolapse extent.

Sudden cardiac arrest and coexisting mitral valve prolapse: a case report and literature review

The aetiology of sudden cardiac arrest can often be identified to underlying cardiac pathology. Mitral valve prolapse is a relatively common valvular pathology with symptoms manifesting with increasing severity of mitral regurgitation (MR). It is unusual for severe MR to be present without symptoms, and there is growing evidence that this subset of patients may be at increased risk of sudden cardiac arrest or death. The difficulty lies in identifying those patients at risk and applying measures that are appropriate to halting progression to cardiac arrest. This article examines the association of mitral valve prolapse with cardiac arrests, the underlying pathophysiological process and the strategies for identifying those at risk.