Annular Dynamics Research Articles

3 D assessment of mitral annular dynamics in mitral stenosis: A novel parameter to assess stenosis severity

3 D assessment of mitral annular dynamics in mitral stenosis: A novel parameter to assess stenosis severity

Invited Commentary

The report of David and colleagues [1David T.E. David C.M. Manlhiot C. Simplici-T Annuloplasty Band for mitral valve repair for degenerative disease.Ann Thorac Surg. 2014; 98: 1551-1556Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar] using an unmeasured, experience-based approach for mitral annuloplasty is similar to that of Brown and colleagues [2Brown M.L. Schaff H.V. Li Z. Suri R.M. Daly R.C. Orsulak T.A. Results of mitral valve annuloplasty with a standard-sized posterior band: is measuring important?.J Thorac Cardiovasc Surg. 2009; 138: 886-891Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. Bothe and colleagues [3Bothe W. Miller C. Doenst T. Sizing for mitral annuloplasty: where does science stop and voodoo begin?.Ann Thorac Surg. 2013; 95: 1475-1483Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar] recently provided an insightful summary of the need for detailed studies of the effects of the various mitral annuloplasty techniques. We also believe that the issues involved are complex and require rigorous investigation using clinical, echo, 2D, 3D, cMRI, cardiac CTA, finite stress analysis, and other engineering data to appreciate fully the effects of different repairs. Our own focus during repair is restoration of the relationships of all the elements whose interrelated structures and dynamic behavior are necessary for normal mitral valve function, starting with normal mitral diastolic locking [4Lawrie G.M. Structure, function, and dynamics of the mitral annulus: importance in mitral valve repair for myxomatous mitral valve disease.Methodist Debakey Cardiovasc J. 2010; 6: 8-14PubMed Google Scholar, 5David D. Michelson E.L. Naito M. Chen C.C. Schaffenburg M. Dreifus L.S. Diastolic locking of the mitral valve: importance of atrial systole and intraventricular volume.Circulation. 1983; 67: 640-645Crossref PubMed Scopus (36) Google Scholar, 6Decloedt A. Verheyen T. Sys S. De Clercq D. Bijnens B. Loon G.V. Influence of atrioventricular interaction on mitral valve closure and left ventricular isovolumic contraction measured by tissue Doppler imaging.Circ Cardiovasc Imaging. 2013; 6: 109-116Crossref PubMed Scopus (12) Google Scholar]. We have reported 100% reparability [7Lawrie G.M. Earle E.A. Earle N.R. Intermediate-term results of a nonresectional dynamic repair technique in 662 patients with mitral valve prolapse and mitral regurgitation.J Thorac Cardiovasc Surg. 2011; 141: 368-376Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar], superior durability of the annulus attachment [7Lawrie G.M. Earle E.A. Earle N.R. Intermediate-term results of a nonresectional dynamic repair technique in 662 patients with mitral valve prolapse and mitral regurgitation.J Thorac Cardiovasc Surg. 2011; 141: 368-376Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 8Spratt J.R. Spratt J.A. Beachley V. Kang Q. Strength comparison of mitral annuloplasty ring and suturing combinations: an in-vitro study.J Heart Valve Disease. 2012; 21: 286-292PubMed Google Scholar], and restoration of near normal annular dynamics [9Little S.H. Ben Zekry S. Lawrie G.M. Zoghbi W.A. Dynamic annular geometry and function in patients with mitral regurgitation: insights from three dimensional annular tracking.J Am Soc Echocardiogr. 2010; 23: 872-879Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar, 10Ben Zekry S. Lang R. Sugeng L. et al.Mitral annulus dynamics early after valve repair: Preliminary observations of the effect of resectional versus non-resectional approaches.J Am Soc Echocardiogr. 2011; 24: 1233-1242Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar]. Left ventricular outflow tract dimensions and aortic-mitral angle by cMRI are unchanged postoperatively. Strain analysis showed normal strain distribution in all cases [11Ben Zekry S. Lawrie G. Little S. et al.Comparative evaluation of mitral valve strain by deformation tracking in 3-D echocardiography.Cardiovasc Eng Tech. 2012; 3: 402-412Crossref Scopus (13) Google Scholar]. No patient has undergone reoperation for SAM [7Lawrie G.M. Earle E.A. Earle N.R. Intermediate-term results of a nonresectional dynamic repair technique in 662 patients with mitral valve prolapse and mitral regurgitation.J Thorac Cardiovasc Surg. 2011; 141: 368-376Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar]. Preservation of normal annular dynamics eliminates the need for leaflet resection and enables the repair rate to rise to 100%, with 90% durability at 10 years by echo. We believe that optimal annular function is the essential foundation for reproducibly excellent results. Simplici-T Annuloplasty Band for Mitral Valve Repair for Degenerative DiseaseThe Annals of Thoracic SurgeryVol. 98Issue 5PreviewSizing of annuloplasty rings and bands is variably based on intertrigonal or intercommissural distances or estimation of the anterior leaflet area. This study examines the results of mitral valve repair with Simplici-T annuloplasty band without predetermining its length in patients with mitral regurgitation (MR) as a result of degenerative disease. Full-Text PDF

Mitral valve repair: an echocardiographic review: Part 2.

Echocardiographic imaging of the mitral valve before and immediately after repair is crucial to the immediate and long-term outcome. Prior to mitral valve repair, echocardiographic imaging helps determine the feasibility and method of repair. After the repair, echocardiographic imaging displays the new baseline anatomy, assesses function, and determines whether or not further management is necessary. Three-dimensional imaging has improved the assessment of the mitral valve and facilitates communication with the surgeon by providing the surgeon with an image that he/she might see upon opening up the atrium. Further advancements in imaging will continue to improve the understanding of the function and dysfunction of the mitral valve both before and after repair. This information will improve treatment options, timing of invasive therapies, and advancements of repair techniques to yield better short- and long-term patient outcomes. The purpose of this review was to connect the echocardiographic evaluation with the surgical procedure. Bridging the pre- and post-CPB imaging with the surgical procedure allows a greater understanding of mitral valve repair.

Normal mitral annulus dynamics and its relationships with left ventricular and left atrial function.

Mitral annulus (MA) geometry and dynamics are crucial for preserving normal mitral valve (MV) function. Static reference values for MA parameters have been reported, but the normal MA dynamics during the entire cardiac cycle remains controversial. MV full-volume datasets were obtained by three-dimensional transthoracic echocardiography from 50 healthy volunteers (18-74 years; 31 men) to assess MA changes in size and shape during entire cardiac cycle. Using simultaneous multiplanar review, projected MA area (MAA) and circumference (MAC), antero-posterior (AP) and anterolateral-posteromedial (ALPM) diameters, and sphericity index (SphI) were obtained at: mitral valve closure (MVC), mid- and end-systole (ES), early- (EDF) and late-diastolic filling, and end-diastole. MAA and AP diameter were the most "active" parameters, changing in all reference frames (p < 0.001). MAA and AP diameter started to contract before MVC (during the left atrial contraction), reaching their minimum at MVC. Maximum MAA occurred at ES, while maximum AP diameter and SphI occurred at EDF. MAA fractional shortening was 35 ± 10 %. AP diameter change was 25 ± 10 %. MAC, ALPM and SphI showed similar patterns during left ventricular (LV) systole, and remained unchanged during diastole. Fractional change was 35 ± 10 % for MAC, and 13 ± 8 % for ALPM diameter. Our study provides the normal dynamics of the MA during the entire cardiac cycle. It reveals "pre-systolic" contraction of the MA, related to left atrial (LA) contraction, and minimal MAA during early LV systole. Therefore, the normal MA dynamics relates to a "physiologic LA-LV coupling", and a complete MA contraction requires both and properly timed LA and LV systole.

218 * EFFECT OF PULMONARY HYPERTENSION ON OVINE TRICUSPID ANNULAR DYNAMICS

OBJECTIVES: Pulmonary hypertension (PHT) is associated with tricuspid annular dilatation, but the effect of acute increase of pulmonary pressure on three-dimensional (3D) tricuspid annular dynamics and shape is unknown. Better understanding of tricuspid annular dynamics may lead to improved and more durable surgical reparative techniques. METHODS: In nine open-chest anaesthetized sheep nine sonomicrometry crystals were implanted on the right ventricle while on cardiopulmonary bypass. Additional nine crystals were implanted around the tricuspid annulus (TA) with one crystal at each commissure defining three separate annular regions: anterior, posterior and septal. Two additional equidistant crystals were implanted between each commissure, creating three segments for every region. Pressure transducers were placed in the left ventricular (LV), right ventricular (RV) and right atrium. PHT was induced by acute pulmonary artery constriction with a pneumatic occluder. Sonomicrometry and echocardiographic data were collected before and after induction of PHT. TA area, regional and total perimeter, and 3D annular geometry were calculated from 3D crystal coordinates. Regional annular contraction was defined as the percentage difference between maximal and minimal region length during the cardiac cycle. RESULTS: PHT increased RV pressure from 31 ± 9 mmHg to 46 ± 13 mmHg (P= 0.001) and decreased left ventricular (LV) pressure from 111 ± 24 mmHg to 78 ± 36 mmHg (P= 0.018). There was no significant tricuspid regurgitation observed with PHT. During PHT, the TA area increased by 12±13% from 641±139 mm 2 to 721±177 mm 2 (P=0.037). The total perimeter increased from 103±11 mm to 109±13 mm (P= 0.02). All annular regions dilated significantly with PHT with 8 ± 10, 5 ± 5 and 5 ± 5% increase in anterior, posterior and septal annular length, respectively (P< 0.05). PHT reduced regional annular contraction in the anterior region only (17 ± 7 vs 14 ± 8%; P= 0.02). The TA had a complex 3D saddle geometry and the shape of the annulus was altered during PHT only in the antero-posterior region. CONCLUSIONS: The changes in tricuspid annular conformation, contractility and its 3D geometry observed during acute ovine PHT may help in the design of new pathology-specific tricuspid annular rings.

Imaging Challenges in Secondary Mitral Regurgitation

Chronic secondary mitral regurgitation (SMR) is a complex entity that is often clinically underappreciated.1 It complicates either ischemic heart disease or dilated cardiomyopathy; its prevalence varies among series but may reach ≤50% in patients with heart failure.2 When present, SMR may exhibit a broad range of severity and confers an adverse prognosis, which is worse with increasing severity of mitral regurgitation (MR).3,4 The management of SMR poses a unique set of challenges, based partly on the complexity of the valve disorder and the still-evolving adoption of the optimal therapeutic approach.5 Noninvasive imaging and, in particular, echocardiography, plays a critical role for the initial and longitudinal assessment, for individual risk stratification and outcome prediction, and for guiding intervention in patients with chronic SMR.6 SMR develops because of a combination of mitral leaflet tethering secondary to left ventricular (LV) dilatation/deformation with papillary displacement/discoordination, annular dilatation/dysfunction, insufficient LV-generated closing forces attributable to reduction of LV contractility, and global LV/papillary muscle dyssynchrony.1,5 Tethering of the mitral leaflets is the principal lesion of SMR and results in restriction of systolic leaflet motion, namely type IIIb of Carpentier’s classification. SMR does not typically occur in global LV dysfunction without tethering. However, once tethering occurs, leaflet closure is further impaired by LV dysfunction because there is decreased force opposing tethering.6–9 The key event in the pathogenesis of SMR is the distortion of normal LV geometry—regional and global LV remodeling—with subsequent apical and lateral displacement of papillary muscles, which, in turn, draws the chordae tendineae away from the line of coaptation.7,8 The extent of LV systolic dysfunction and dilatation is weakly correlated to the degree of SMR unless accompanied by geometric distortion in the region of the papillary muscles.1,9 …

(648) - Effect of Left Ventricular Assist Device on Ovine Tricuspid Annular 3D Geometry

Left ventricular unloading may alter right ventricular shape and function and lead to tricuspid regurgitation, but the effect of left ventricular assist device (LVAD) support on tricuspid annular dynamics and geometry is unknown. In seven open chest anesthetized sheep 9 sonomicrometry crystals were implanted on the right ventricle (RV). Additional 9 crystals were implanted around the tricuspid annulus with one crystal at each commissure defining three separate annular regions: anterior, posterior, and septal. LV unloading was achieved by connecting a cannula in the aorta and left atrium to a continuous flow external pump. Sonomicrometry and epicardial echocardiographic data were collected during three consecutive heart beats before and after full LVAD support. Tricuspid annular area, regional and total perimeter were calculated from crystal coordinates while annular 3D geometry was expressed as the orthogonal distance of each annular crystal to the least square plane of all annular crystals. Hemodynamic parameters are presented in Table 1. There was no significant tricuspid regurgitation observed either before or during LV unloading. RV free wall to septum diameter increased significantly at end-diastole with LV unloading from 23±7mm to 25±7mm (p=.009). During LVAD support, tricuspid annular area (795±209mm2 vs 761±215mm2, p=.7) and total perimeter (111±17mm vs. 107±18mm before and during LVAD, respectively p=.9) did not change from baseline. Annular contraction was greatest in anterior and smallest in the septal region and was not altered with LV unloading. Tricuspid annulus had a complex 3D saddle shape geometry that was unaffected by LVAD support. Mechanical LV unloading increased RV free wall to septum diameter without affecting RV volume and did not alter dynamic motion or 3D geometry of the tricuspid annulus. Acute LV unloading and septal shift alone are not sufficient to significantly alter TV annulus dynamics and potentially contribute to tricuspid regurgitation.Tabled 1HemodynamicsBaseline (n=7)LVAD (n=7)pPump flow (l/min)3.8±0.3HR (min-1)108±34100±30.3LVP max. (mmHg)100±1280±28.12LV EDP (mmHg)15±108±10.001MAP (mmHg)92±14104±14.02RVP max. (mmHg)26±422±6.02RV EDP (mmHg)12±511±4.14RV EDV (ml)60±1158±12.9RV ESV (ml)52±1149±12.8CVP (mmHg)12±211±2.4 Open table in a new tab

In-Vivo Analysis of Selectively Flexible Mitral Annuloplasty Rings Using Three-Dimensional Echocardiography

Selectively flexible rings, Colvin-Galloway (CG) Future and Carpentier-Edwards (CE) Physio II, are used for annuloplasty during mitral valve repair to facilitate dynamic annular motion while preventing annular dilation. In this study, we assessed the extent and nature of the flexibility of these rings invivo, which has not been objectively demonstrated. Three-dimensional transesophageal echocardiography was used intraoperatively to acquire data regarding dynamic motion of mitral annuli and annuloplasty rings in 33 patients undergoing mitral repair (15 CG Future and 18 CE Physio II) and in 15 control patients. Data were analyzed to assess the dynamic changes in annular geometry after implantation of selectively flexible rings. After annuloplasty, there was an immediate and significant decrease in annular displacement (p < 0.001) and annular displacement velocity (p < 0.01). Dynamic change in multiple variables including anteroposterior diameter (p < 0.001) and annular area (p < 0.001) was also significantly depressed. In comparison with normal mitral valves, partially flexible rings allowed limited dynamic motion: percentage changes in anteroposterior diameter (p < 0.001), anterolateral posteromedial diameter (p < 0.001), and total circumference (p < 0.001) were significantly lower. Compared with each other, the two rings resulted in similar changes in anterior annulus length (p= 0.93), posterior annular length (p= 0.82), and annular area (p= 0.31). Mitral annular dynamics were uniformly depressed after implantation of these rings. Selective flexibility could not be demonstrated invivo using echocardiographic data.

Is Physiologic Annular Dynamics Preserved After Mitral Valve Repair With Rigid or Semirigid Ring?

Various rings are available to achieve more physiologic mitral valve repair from viewpoints of physiologic mitral annular structure or dynamics. We evaluated preoperative and postoperative mitral annular structures and dynamics. Thirty-six patients underwent mitral valve repair for degenerative mitral insufficiency. Carpentier-Edwards Physio II ring (semirigid [Edwards Lifesciences, Irvine, CA]), St. Jude Medical Rigid Saddle Ring (RSR [St. Jude Medical, St. Paul, MN]), and MEMO 3D ring (semirigid [Sorin SpA, Milan, Italy]) were implanted in 13, 12, and 11 patients, respectively. Intraoperative real-time three-dimensional transesophageal echocardiography was performed before and after repair. The postoperative anteroposterior diameter reduction rate from end diastole to end systole was significantly (p<0.0001) larger in MEMO (9.58%±2.91%) than in Physio II (0.98%±1.04%) and RSR (1.94%±1.95%). There were no significant differences in the commissure-to-commissure diameter reduction rates among the groups: 0.81%±1.98% for Physio II, 0.12%±0.53% for RSR, and 0.51%±1.98% for MEMO. The postoperative end-systolic annular height commissure width ratio was significantly (p<0.0001) larger in both Physio II (17.9%±3.0%) and RSR (18.5%±1.6%) than in MEMO (13.6%±3.0%). The postoperative annular height commissure width ratio increase rate from end diastole to end systole was significantly larger in MEMO (5.1%±2.3%) than in Physio II (0.1%±0.6%) and RSR (0.3%±0.5%). Physio II and RSR could restore the physiologic three-dimensional annular shape, but the annular motion was diminished. Conversely, MEMO could preserve both the anteroposterior movement and folding dynamics, but no three-dimensional restoration of the mitral annulus was obtained.

A good surgical option for ischemic mitral regurgitation in co-morbid patients: semicircular reduction annuloplasty.

BackgroundRing annuloplasty is the standard treatment of ischemic mitral regurgitation (MR), however, it has been associated with some drawbacks. It abolishes normal annular dynamics and freezes the posterior leaflet. In the present study, we evaluated Paneth suture annuloplasty in chronic ischemic MR and both early and mid-term outcomes of the technique on a selected population.MethodsThe study period was from June 2010 to June 2012. We operated on 21 patients who had the diagnosis of coronary artery disease and MR of grade 3 or 4. The patients had both a coronary artery bypass operation and the mitral semicircular reduction annuloplasty described by Paneth-Burr. The data on the patients were retrospectively collected. Patients were contacted by outpatient clinic controls for mid-term results.ResultsThe male/female ratio was 10/11. The mean age of the patients was 71.0 ± 6.4 years. Preoperative and postoperative left ventricular ejection fraction was statistically similar (P = 0.973). Early postoperative MR grade (mean, 0.57 ± 0.51) was statistically lower than the preoperative MR grades (mean, 3.38 ± 0.50) (P < 0.001). There was no revision for excess bleeding. Two patients had prolonged hospitalization, one for sternal infection and the other for severe chronic obstructive pulmonary disease. No hospital or late postoperative deaths occurred. The mean late postoperative MR grade was 0.66 ± 0.97 degrees. One patient had progression of MR in the later follow-up, which was treated by mitral valve replacement.ConclusionSemicircular reduction annuloplasty is an effective, inexpensive and easy surgical annuloplasty technique with low mortality and morbidity in severe symptomatic ischemic MR.

Real‐Time 3‐Dimensional Dynamics of Functional Mitral Regurgitation: A Prospective Quantitative and Mechanistic Study

BackgroundThree‐dimensional transthoracic echocardiography (3D‐TTE) with dedicated software permits quantification of mitral annulus dynamics and papillary muscle motion throughout the cardiac cycle.Methods and ResultsMitral apparatus 3D‐TTE was acquired in controls (n=42), patients with left ventricle dysfunction and functional mitral regurgitation (LVD‐FMR; n=43) or without FMR (LVD‐noMR, n=35). Annulus in both normal and LVD‐noMR subjects displayed saddle shape accentuation in early‐systole (ratio of height to intercommissural diameter, 10.6±3.7 to 13.5±4.0 in normal and 9.1±4.3 to 12.6±3.6 in LVD‐noMR; P<0.001 for diastole to early‐systole motion, P=NS between those groups). In contrast, saddle shape was unchanged from diastole in FMR patients (10.0±6.4 to 8.0±5.2; P=NS, P<0.05 compared to both other groups). Papillary tips moved symmetrically towards to the midanterior annulus in control and LVD‐noMR subjects, maintaining constant ratio of the distances between both tips to midannulus (PtAR) throughout systole. In LVD‐FMR patients midsystolic posterior papillary tip to anterior annulus distance was increased, resulting in higher PtAR (P=0.05 compared to both other groups). Mechanisms of early‐ and midsystolic FMR differed between different etiologies of LV dysfunction. In patients with anterior MI and global dysfunction annular function and dilatation were the dominant parameters, while papillary muscle motion was the predominant determinant of FMR in patients with inferior MI.ConclusionsInadequate early‐systolic annular contraction and saddle‐shape accentuation in patients with impaired LV contribute to early–mitral incompetency. Asymmetric papillary tip movement towards the midanterior annulus is a major determinant of mid‐ and late‐systolic functional mitral regurgitation.

Dynamic 3-Dimensional Echocardiographic Assessment of Mitral Annular Geometry in Patients With Functional Mitral Regurgitation

Mitral valve (MV) annular dynamics have been well described in animal models of functional mitral regurgitation (FMR). Despite this, little if any data exist regarding the dynamic MV annular geometry in humans with FMR. In the current study we hypothesized that 3-dimensional (3D) echocardiography, in conjunction with commercially available software, could be used to quantify the dynamic changes in MV annular geometry associated with FMR. Intraoperative 3D transesophageal echocardiographic data obtained from 34 patients with FMR and 15 controls undergoing cardiac operations were dynamically analyzed for differences in mitral annular geometry with TomTec 4D MV Assessment 2.0 software (TomTec Imaging Systems GmbH, Munich, Germany). In patients with FMR, the mean mitral annular area (14.6 cm(2) versus 9.6 cm(2)), circumference (14.1 cm versus 11.4 cm), anteroposterior (4.0 cm versus 3.0 cm) and anterolateral-posteromedial (4.3 cm versus 3.6 cm) diameters, tenting volume (6.2 mm(3) versus 3.5 mm(3)) and nonplanarity angle (NPA) (154 degrees ± 15 versus 136 degrees ± 11) were greater at all points during systole compared with controls (p < 0.01). Vertical mitral annular displacement (5.8 mm versus 8.3 mm) was reduced in FMR compared with controls (p < 0.01). There are significant differences in dynamic mitral annular geometry between patients with FMR and those without. We were able to analyze these changes in a clinically feasible fashion. Ready availability of this information has the potential to aid comprehensive quantification of mitral annular function and possibly assist in both clinical decision making and annuloplasty ring selection.

Three-Dimensional Echocardiographic Analysis of Mitral Annular Dynamics

Background— Proponents of flexible annuloplasty rings have hypothesized that such devices maintain annular dynamics. This hypothesis is based on the supposition that annular motion is relatively normal in patients undergoing mitral valve repair. We hypothesized that mitral annular dynamics are impaired in ischemic mitral regurgitation and myxomatous mitral regurgitation. Methods and Results— A Philips iE33 echocardiographic module and X7–2t probe were used to acquire full-volume real-time 3-dimensional transesophageal echocardiography loops in 11 normal subjects, 11 patients with ischemic mitral regurgitation and 11 patients with myxomatous mitral regurgitation. Image analysis was performed using Tomtec Image Arena, 4D-MV Assessment, 2.1 (Munich, Germany). A midsystolic frame was selected for the initiation of annular tracking using the semiautomated program. Continuous parameters were normalized in time to provide for uniform systolic and diastolic periods. Both ischemic mitral regurgitation (9.98±155 cm 2 ) and myxomatous mitral regurgitation annuli (13.29±3.05 cm 2 ) were larger in area than normal annuli (7.95±1.40 cm 2 ) at midsystole. In general, ischemic mitral regurgitation annuli were less dynamic than controls. In myxomatous mitral regurgitation, annular dynamics were also markedly abnormal with the mitral annulus dilating rapidly in early systole in response to rising ventricular pressure. Conclusions— In both ischemic mitral regurgitation and myxomatous mitral regurgitation, annular dynamics and anatomy are abnormal. Flexible annuloplasty devices used in mitral valve repair are, therefore, unlikely to result in either normal annular dynamics or normal anatomy.

Mitral Annulus Dynamics Early after Valve Repair: Preliminary Observations of the Effect of Resectional Versus Non-Resectional Approaches

Mitral repair is recommended for patients with significant organic mitral regurgitation (MR). The nonresectional dynamic mitral valve repair (NVR) method involves a complete flexible ring and artificial chordal insertion but without leaflet resection or annular plication. The aim of this study was to compare changes in mitral annular structure and function after the NVR technique with those after a resectional mitral valve repair (RVR) method, which involves leaflet resection and annuloplasty with a partial flexible ring. Patients with organic severe MR undergoing mitral valve repair with either technique underwent three-dimensional transesophageal echocardiography before and after surgery. The mitral annulus was tracked offline and measured throughout the cardiac cycle. Mitral leaflet mobility was also measured. Fifteen patients underwent repair with NVR, and 13 underwent repair with RVR (age, 56 vs 61 years, respectively). Both operations reduced mitral annular area significantly (maximum area reduction, from 18.5 ± 4.6 to 6.6 ± 1.7 cm(2) and from 20.1 ± 4.8 to 6 ± 1.5 cm(2) with the NVR and RVR techniques, respectively; P < .001). In contrast to RVR, patients who underwent NVR maintained dynamic changes in mitral annular area, circumference, and anterior-posterior diameter during the cardiac cycle. Mitral leaflet mobility was reduced with both techniques, but posterior leaflet mobility was restricted with RVR. The size of the mitral annulus is reduced after repair with either surgical approach. Compared with resectional valve repair, more dynamic changes in the structure of the mitral annulus are maintained during the cardiac cycle with the NVR technique early postoperatively, along with more preserved motion of the posterior leaflet.

Three-dimensional echocardiography and mitral valve prolapse diagnosis: new insights into leaflet and cardiac chamber morphology, and annulus dynamics

Abstract Objectives This report will focus on current and future applications of three-dimensional echocardiography in both in the pre-operative (mainly transthoracic three-dimensional echocardiography) and intraoperative (transesophageal three-dimensional echocardiography) evaluation of prolapsed mitral valves. Both qualitative (morphologic) and quantitative advantages of this technique will be highlighted. Moreover, new insights into the morphology and dynamics of the leaflets, cardiac chamber and annulus are discussed. Conclusions Real-time 3D echocardiography offers distinct advantages over 2D imaging for evaluation of the mitral valve apparatus. It provides a more authentic representation of mitral valve morphology and is useful not only in the pre-operative and post-operative evaluation of patients undergoing mitral valve prolapse surgery, but is already used in several interventional procedures and may facilitate the continuous evolution of new techniques.

117 Tricuspid valve annular dynamics in normal vs dilated right hearts; a 3D TOE Study

BackgroundThe tricuspid valve annulus (TVA) is a complex three dimensional structure that is non-planar, and is incompletely understood. The dynamics of the normal TVA has not been described in any...

Characterization of Mitral Valve Annular Dynamics in the Beating Heart

The objective of this study is to establish a mathematical characterization of the mitral valve annulus that allows a precise qualitative and quantitative assessment of annular dynamics in the beating heart. We define annular geometry through 16 miniature markers sewn onto the annuli of 55 sheep. Using biplane videofluoroscopy, we record marker coordinates in vivo. By approximating these 16 marker coordinates through piecewise cubic splines, we generate a smooth mathematical representation of the 55 mitral annuli. We time-align these 55 annulus representations with respect to characteristic hemodynamic time points to generate an averaged baseline annulus representation. To characterize annular physiology, we extract classical clinical metrics of annular form and function throughout the cardiac cycle. To characterize annular dynamics, we calculate displacements, strains, and curvature from the discrete mathematical representations. To illustrate potential future applications of this approach, we create rapid prototypes of the averaged mitral annulus at characteristic hemodynamic time points. In summary, this study introduces a novel mathematical model that allows us to identify temporal, regional, and inter-subject variations of clinical and mechanical metrics that characterize mitral annular form and function. Ultimately, this model can serve as a valuable tool to optimize both surgical and interventional approaches that aim at restoring mitral valve competence.

The Mitral Valve by Three-Dimensional Echocardiography

A comprehensive evaluation of patients with mitral valve disease must include an echocardiographic examination of the mitral valve apparatus and resultant hemodynamic changes due to mitral pathology. Three-dimensional echocardiography has impacted on the diagnosis of mitral valve prolapse but has mostly existed in a research realm. After decades of development, three-dimensional echocardiography is now easily performed and readily incorporated in the assessment of mitral valve disease in daily clinical practice. Unique anatomic views of the mitral valve, accurate quantitative assessment of the mitral valve orifice area, and delineation of segmental prolapse are several advantages of three-dimensional echocardiography. Moreover, there is a wealth of data that can be derived from a three-dimensional volume, enabling more detailed analysis of mitral valve apparatus and valve annular dynamics. This review highlights current applications of three-dimensional echocardiography in the routine evaluation of mitral valve disease.

Clinical Summaries

Clinical Summaries

Pitfalls of anatomical aortic valve area measurements using two-dimensional transoesophageal echocardiography and the potential of three-dimensional transoesophageal echocardiography

The aims of this study were to (i) investigate aortic annulus dynamics using two-dimensional (2D) speckle tracking echocardiography, (ii) determine optimal 2D short-axis view for the calculation of planimetric aortic valve area (AVA), and (iii) compare 2D planimetric AVA extracted from volumetric three-dimensional data sets using real-time 3DTEE (three-dimensional transoesophageal echocardiography) with standard 2DTEE planimetry. We studied 60 patients with aortic stenosis (AS) and 10 control subjects. AVA was calculated by standard 2DTEE planimetry method, volumetric 3DTEE method, and continuity equation (CE) from transthoracic echocardiography. In addition, aortic annular motion was studied using 2D speckle tracking. Aortic annulus moves cranially during early systole and subsequently moves caudally during the remainder of systole and isovolumic relaxation. Annulus again moved in the cranial direction during diastole in both groups. Although AVA correlated well between 2DTEE and 3DTEE methods (r = 0.95), 2DTEE showed a significantly larger AVA compared with 3DTEE method (1.26 +/- 0.39 vs. 1.10 +/- 0.39 cm(2), P < 0.001). In patients in whom aortic cusps were visible in 2DTEE short-axis images during systole only (n = 45), AVA using 2DTEE was still larger than that measured with 3DTEE. However, the bias in AVA was significantly lower compared with the remaining 15 patients (-0.13 +/- 0.11 vs. -0.26 +/- 0.12 cm(2), P < 0.005). Although both methods showed moderate correlation with AVA by CE (r = 0.78, 0.75), mean differences were significantly smaller by 3DTEE than 2DTEE (-0.01 +/- 0.25 vs. -0.17 +/- 0.27 cm(2), P < 0.001). Aortic annular motion affects the calculation of AVA using 2DTEE. Three-dimensional transoesophageal echocardiography has a potential for more accurate determination of anatomical AVA.