4D-transesophageal echocardiography and emerging imaging modalities for guiding mitral valve repair.

Abstract

Two-dimensional transesophageal echocardiography (2D-TEE) had a transformative impact on surgical treatment of mitral valve pathology in the 1980s. 2D-TEE provided unprecedented, high-quality views of the mitral valve that enabled pre-operative repair strategizing and immediate post-operative assessment of repair efficacy. Several decades later, the commercialization of four-dimensional transesophageal echocardiography (4D-TEE) and other emerging imaging modalities such as 4D computed tomography (4DCT) and cardiac magnetic resonance imaging (CMRI) potentiate yet another transformative phase in the practice of mitral valve repair surgery. Bypassing the “mental integration” step required for 2D image interpretation, these higher dimensional modalities provide a more intuitive, complete description of valve morphology and dynamics that can be leveraged as a tool for more effective surgical decision support. Current research shows that these modalities may enhance mitral valve repair outcomes in four ways: (I) by increasing the precision of mitral valve diagnostics in order to tailor the repair plan to an individual’s valve pathology; (II) as a means of risk stratification to determine which patients might benefit from valve repair over valve replacement; (III) by predicting the outcome of a given repair technique using image-derived valve models as input to computational biomechanical analysis; and (IV) by optimizing annuloplasty ring design. Research highlights in each of these areas are given below.