Assessment Of Mitral Valve Area Research Articles

Superiority of 3D planimetry over pressure half-time method for the assessment of mitral valve area after percutaneous edge-to-edge mitral repair

Introduction and objectivesThere is limited evidence to identify the most accurate method for measuring the mitral valve area (MVA) after percutaneous edge-to-edge mitral repair. Our objective was to evaluate the optimal method in this context and its correlation with the mean transmitral gradient. MethodsA registry of patients undergoing percutaneous mitral repair was conducted, analyzing different methods of measuring MVA and their correlation with the mean gradient. ResultsWe analyzed data from 167 patients. The mean age was 76±10.3 years, 54% were men, and 46% were women. Etiology was degenerative in 45%, functional in 39%, and mixed in 16%. Postclip MVA measurements were 1.89±0.60 cm2 using pressure half-time (PHT), 2.87±0.83 cm2 using 3D planimetry, and the mean gradient was 3±1.19mmHg. MVA using 3D planimetry showed a stronger correlation with the mean gradient (r=0.46, P<.001) than MVA obtained by PHT (r=0.19, P=.048). Interobserver agreement was also higher with 3D planimetry than with PHT (intraclass correlation coefficient of 0.90 vs 0.81 and variation coefficient of 9.6 vs 19.7%, respectively). ConclusionsOur study demonstrates that the PHT method significantly underestimates MVA after clip implantation compared with direct measurement using transesophageal 3D planimetry. The latter method also correlates better with postimplantation gradients and has less interobserver variability. These results suggest that 3D planimetry is a more appropriate method for assessing postclip mitral stenosis.

Reproducibility of transthoracic 3D echocardiography in the assessment of mitral valve area in patients with rheumatic mitral stenosis: real time versus ECG-gated 3D echocardiography.

To assess reproducibility of Real time 3D echocardiography (RT3D) and ECG-gated 3D echocardiography (EG3D) when measuring the mitral valve area (MVA) in rheumatic mitral stenosis (MS). MVA was assessed by three operators in 68 MS patients using RT3D and EG3D. Reproducibility of each technique was determined by calculating the standard error of measurements (SEM). SEM was similar between RT3D and EG3D. MVA variability was of 0.4cm² or 30% of any RT3D or EG3D measured MVA. The minimal change in MVA above which two measurements should be considered to differ significantly for the same operator was of 0.4cm² for RT3D and 0.5cm² for EG3D. For two different operators making successive measurements, the minimum significant change was of 0.5cm² for RT3D and 0.6cm² for EG3D. The minimum significant difference when switching from RT3D to EG3D or vice versa is of 0.6cm². Low temporal resolution of 6Hz has the least variability when using RT3D (0.19cm² vs. 0.26cm², p = 0.009) but significantly underestimated MVA (1.3 ± 0.4cm² vs. 1.4 ± 0.4cm², p < 10- 3) when compared to EG3D. MVA variability was significantly higher in mild MS when compared to severe MS whether it is RT3D (0.23cm² vs. 0.18cm², p = 0.02) or EG3D (0.27cm² vs. 0.16cm², p < 0.001). RT3D and EG3D are equally reproducible in the assessment of MVA in patients with MS. Further measurements standardization is required to have a clinically acceptable estimations of the true 3D MVA and minimal detectable differences.

Multimodal imaging assessment of mitral valve area after transcatheter mitral valve implantation: A three-dimensional echocardiographic and CT scan study

The assessment of mitral bioprosthetic area remains a technical challenge, and its calculation by the continuity equation using transthoracic echocardiography (TTE) may be invalidated in several situations, especially after transcatheter mitral valve implantation (TMVI). This study aims to develop a new technique to measure the mitral valve area after a TMVI using a multimodal three-dimensional echocardiographic and computed tomography (CT) approach. Among the patients hospitalized for TMVI at Bichat Hospital between June 2017 and February 2021, we selected 24 who had both a transesophageal echocardiography (TEE) and a cardiac CT after TMVI and before discharge. We performed two area measurements by planimetry: the geometric orifice area (GOA) corresponding to the area delimited by the edges of the open valve leaflets after alignment in the plane of the proximal coaptation point of the bioprosthesis leaflets; and the smallest valve area (SVA) defined by the smallest measurable area of the open prosthesis, at the free edges of the leaflets. In our cohort, the GOA was 1.73 ± 0.41 cm2 on 3D TEE and 1.75 ± 0.42 cm2 on CT. The SVA was 1.40 ± 0.31 cm2 on 3D TEE and 1.49 ± 0.37 cm2 on CT. There was a good agreement between the two techniques for GOA and SVA (ICC > 0.6, P < 0.01) and a good correlation between the two measurements on 3D TEE as well as on CT (Pearson 0.88 and 0.91 respectively, P < 0.001). Our work suggests a new approach to multimodal assessment of prosthetic mitral valve area after TMVI, using 3D TEE and CT scan. Further studies are needed to complete our results, especially to confirm the feasibility and reproducibility of the measurements. It would also be interesting to correlate these area measurements with the clinical prognosis of patients after TMVI. Agreement between 3D TEE and CT measurements (Fig. 1).

Multiperspective Three-Dimensional Transthoracic Echocardiographic Assessment of Mitral Valve Area in Patients With Rheumatic Mitral Stenosis

Rheumatic mitral stenosis (MS) remains common in low- and middle-income countries with significant morbidity and mortality.1,2 Echocardiographic planimetry of the mitral valve (MV) area (MVA) correlates with anatomic MVA of explanted valves better than MVA estimated by other methods.3 Three-dimensional (3D) echocardiography provides better alignment of the imaging plane at the mitral leaflet tips, yielding a more accurate planimetric measurement of the MVA.4

Assessment of mitral valve area by 3D planimetry after percutaneous mitral valve repair

Abstract Background Percutaneous mitral valve (MV) repair has become an effective therapeutic alternative to MV surgery in high-risk surgical patients with severe MR. Persistent pulmonary hypertension after mitral valve replacement has shown an increased risk of morbidity and mortality. Improvement of pulmonary systolic arterial pressure (PSAP) post-MitraClip has been reported, however relative mitral stenosis may hamper this benefit. Few data is available regarding the best echocardiographic parameter to determine mitral stenosis after the procedure. Purpose To evaluate the correlation between the residual mitral valve area (MVA) by 3D planimetry, the pressure half time (PHT) and the transmitral gradient after percutaneous edge-to-edge mitral repair. Methods This is a single-center, retrospective study. We enrolled 88 consecutive patients who underwent a percutaneous MV repair with the MitraClip system between 2010 and 2020 at our tertiary university hospital, with eligibility evaluation by transesophageal echocardiogram (TEE). All patients had moderate to severe (3+) or severe (4+) primary or secondary MR. Results The mean age was 76.2±10.4 years and 64.8% of the patients were male. Above 88% of patients were in New York Heart Association class III/IV. Baseline 3D planimetry MVA was 5.3±1.4cm2 and mean gradient pre-implantation was 1.8±0.8mmHg. After the procedure, MVA reduced to 2.9±0.8cm2 and mean gradient was 2.8±1.4mmHg. Both 3D planimetry and mean gradient were very significantly correlated (r −0.5; p&amp;lt;0.001) (Figure 1), whereas no correlation was note between mean gradient and PHT (r 0.17; p=0.117) Conclusion After MitraClip implantation, the assessment of mitral valve area by 3D planimetry is significantly correlated with the transmitral mean gradient, unlike PHT. Funding Acknowledgement Type of funding sources: None. Figure 1. Correlation of post-procedural 3D MVA and transmitral mean gradient

Agreement between three-dimensional planimetry and mitral navigation method in the assessment of mitral valve area in rheumatic severe mitral stenosis

Introduction Rheumatic heart disease predisposes to structural changes in the mitral valve including commissural fusion and calcification with subsequent narrowing of the mitral valve orifice resulting in rheumatic mitral stenosis (RMS). To define the best therapeutic strategy, an accurate measurement of mitral valve area (MVA) for RMS is of paramount importance. The propose of the present study was to assess the agreement between the mitral navigation method (MVN) and three-dimensional (3D) planimetry in the assessment of MVA in patients with RMS. Methods Patients who were diagnosed with a different degree of mitral stenosis with the standard transthoracic echocardiography methods such as the pressure half time and planimetry underwent 3D transesophageal echocardiography (TEE) examination. 3D TEE zoom mitral valve planimetry was measured in the diastolic frame during the mitral valve’s largest opening. By using MVN software of the Philips Q-Lab, MVA was measured at its maximum diastolic opening. Both 3D planimetry (3DPL) and MVN were measured at the mid diastole during the mitral valve’s largest opening. Results In this retrospective analysis, we examined consecutive 37 RMS patients (mean age 51.1 ± 11.6 years, 31 patients were female). MVA measured by the MVN method was found to be highly correlated with the 3D MVA measured by 3DPL (r = 0.937, p<.001). Conclusions Based on our results, we showed that the MVN method may be additionally used in detecting the severity of RMS.

Degenerative mitral valve stenosis: Diagnosis and management.

Mitral stenosis (MS) is a common valvular disease characterized by narrowing of the mitral valve orifice and a reduction in mitral valve area (MVA). While rheumatic MS (RMS) is frequently encountered in young individuals in developing countries, degenerative MS (DMS) is seen in the elderly in developed countries and its prevalence is increasing. DMS is usually a late presentation of mitral annular calcification (MAC). Accurate assessment of MVA in patients with MAC is challenging due to the alterations in the atrial and valvular structures as well as the presence of other comorbidities in this aging population. We will review the epidemiology, etiology, pathophysiology, diagnostic assessment, and management of DMS and compare the findings with RMS. The latest therapeutic approaches, including medical, surgical, and transcatheter valvular interventions, will be discussed.

The Most Accurate Method for Measurement of Mitral Valve Area in Mitral Stenosis by Direct Planimetery Three Dimensional Transesophageal Echocardiography (3D TEE)

DEAR EDITOR,Three-dimensional (3D) transesophageal echocardiography (TEE) is a powerful tool for assessment of mitral valve area with multiplanar reconstruction (MPR) or direct planimetery in patients with rheumatic mitral valve stenosis. Two dimensional transthorasic echocardiography (2D TTE) is a well-known conventional method in these patients which is used routinely. This method is less accurate than 3D TEE because mitral valve is saddle shaped and 2D images cannot image this valve correctly [1-7]. Exact method for 3D mitral valve area measurement is not determined yet and MPR was used as an accurate method. Direct planimetery by 3D TEE emerged as a novel method to evaluate mitral valve area with least variability [8].

P1768PISA 3D method avoids the requirement of an angle correction factor for mitral valve area assessment in mitral stenosis

P1768PISA 3D method avoids the requirement of an angle correction factor for mitral valve area assessment in mitral stenosis

A Study of Assessment of Mitral valve area before and after percutaneous balloon mitral valvuloplasty using Mitral leaflet separation index in a tertiary care center

A Study of Assessment of Mitral valve area before and after percutaneous balloon mitral valvuloplasty using Mitral leaflet separation index in a tertiary care center

Mitral leaflet separation index. An easy two dimensional echocardiography technique for assessment of mitral valve area before and after percutaneous balloon mitral valvuloplasty.

AimTo evaluate the reliability of the mitral leaflet separation (MLS) index against the traditional echocardiographic methods in measuring mitral valve area (MVA) pre and post percutaneous balloon mitral valvuloplasty (PBMV).MethodsNinety patients suffering symptomatic moderate to severe MS underwent PBMV at Ain Shams University Hospital in cardiology department. Seventy of the patients were females representing 77.8% and 20 were males representing 22.2%. Their age ranged from 22 to 56 years. All patients were subjected to full transthoracic echocardiography (TTE) examination pre and post PBMV. MLS index was introduced as a comparative parameter with traditional echocardiographic methods for assessment of MVA, measuring average of distance between tips of MV leaflets in parasternal long axis and four chamber two dimensional echocardiographic views.ResultsMVA increased from 0.95 ± 0.28 to 2.21 ± 0.41 cm2 (P=0.001) using 2D planimetry; and increased from 0.93 ± 0.23 to 2.21 ± 0.46 cm2 (P= 0.0011) by pressure half time method (PHT). MLS index was correlated with MVA by 2D planimetry pre and post PBMV (r=0.453) and (r=0.668) respectively (p=0.0001) and strongly correlated with MVA using PHT post PBMV (r=0.768) (p=0.0001). Post PBMV 14 patients suffered significant mitral regurgitation 3 of them were transferred to surgery. MLS index above 11.75 mm and below 9.15 mm had excellent positive predictive value for detecting mild and severe MS respectively.ConclusionThe MLS index it is a simple and effective method for assessment of the MVA, it has an excellent correlation with MVA with an excellent sensitivity and specificity for the prediction of effective MVA. The MLS index cannot evaluate outcome of PBMV because it is an anatomical parameter and not flow dependent thus does not correlate with grades of mitral regurgitation.

Effect of Percutaneous Edge-to-Edge Repair on Mitral Valve Area and Its Association With Pulmonary Hypertension and Outcomes

Percutaneous edge-to-edge repair using the MitraClip system causes reduction in mitral valve area (MVA). However, its clinical impact is not fully elucidated. This study assessed the impact of postprocedural MVA reduction on pulmonary hypertension and outcomes. A total of 92 patients with grades 3 to 4+ mitral regurgitation (MR) who underwent MitraClip therapy were retrospectively reviewed. Using intraprocedural, 3-dimensional transesophageal echocardiography, postprocedural MVA was obtained by 2 optimized planes through the medial and lateral orifices of the repaired valve. MVA was reduced by 60.1% immediately after MitraClip procedure (p <0.001). Postprocedural MVA correlated moderately with mean transmitral pressure gradient (TMPG) in the majority of patients (r=-0.56, p <0.001), but discordance of MVA and TMPG was observed in 40% of patients. In multivariable linear regression analysis, postprocedural MVA ≤1.94cm2 was independently associated with a blunted decrease in systolic pulmonary artery pressure at 1-month follow-up (β-estimate-4.63, 95% confidence interval-9.71 to-0.15, p=0.042). Postprocedural MVA ≤1.94cm2 was an independent predictor of all-cause mortality and heart failure hospitalization after MitraClip (hazard ratio 4.28, 95% confidence interval 1.56 to 11.7, p= 0.005) even after adjustment for age, gender, atrial fibrillation, cause of MR, left ventricular systolic function, pre-existing pulmonary hypertension, and residual MR. After further adjustment for TMPG ≥5mm Hg, postprocedural MVA ≤1.94cm2 remained predictive for adverse outcomes (p= 0.048). In conclusion, the intraprocedural assessment of MVA by 3-dimensional transesophageal echocardiography can predict hemodynamic response and postprocedural prognosis after MitraClip therapy.

Impact of Balloon Mitral Valvuloplasty on Net Atrioventricular Compliance and Echocardiographic Assessment of Mitral Valve Area by Pressure Half Time versus Proximal Isovelocity Surface Area

Abstract Background: We studied the relations between net-atrioventricular compliance (Cn) and balloon mitral valvuloplasty (BMV) and tested effects of Cn on mitral valve area by proximal isovelocity surface area (MVAPISA) and pressure half time (MVAPHT) before and after BMV. Methods and Results: Thirty-six BMV candidates were studied. Echocardiography was done before, immediately after BMV for all patients and 1-month after BMV for 13 patients. MVA was calculated invasively, (MVAGorlin, reference method), by planimetry (MVAPLN), in addition to PHT and PISA. Differences from MVA-PLN were calculated as d-PHT and d-PISA and Cn was calculated (1270 X (MVA-PLN/E-slope). Mean age was 36.1 ± 12.5 years, 25(69%) were females, 8(22%) were in atrial fibrillation. MVAPHT correlated with MVAGorlin after, but not before, BMV (r= 0.53, 0.240, p= 0.014, 0.202). MVAPISA correlated with MVAGorlin after and before BMV(r= 0.85, 0.89, all p<0.001). Both MVAPHT, and MVAPISA correlated with MVAPLN 1-month after BMV (r=0.58, 0.92, p<0.001, =0.048). d-PHT showed similar pattern of negative correlations with Cn before, immediately after, and 1 month after BMV (r= 0.69, 0.76, 0.69, p= <0.001,<0.001, =.013), while d-PISA did not. Cn independently predicted persistent pulmonary hypertension after BMV. Conclusion: MVAPHT, unlike MVAPISA is extremely affected by Cn irrespective of the time of measurement in relation to BMV. Cn is a major determinant of persistent pulmonary hypertension after BMV.

Intraoperative Echocardiographic Assessment of Mitral Valve Area After Degenerative Mitral Valve Repair: A Call for Guidelines or Recommendations.

Intraoperative Echocardiographic Assessment of Mitral Valve Area After Degenerative Mitral Valve Repair: A Call for Guidelines or Recommendations.

Proximal Flow Convergence Method by Three-Dimensional Color Doppler Echocardiography for Mitral Valve Area Assessment in Rheumatic Mitral Stenosis

The two-dimensional (2D) proximal isovelocity surface area (PISA) method has important technical limitations for mitral valve orifice area (MVA) assessment in mitral stenosis (MS), mainly the geometric assumptions of PISA shape and the requirement of an angle correction factor. Single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions or the requirement of an angle correction factor. The aim of this study was to validate this method in patients with rheumatic MS. Sixty-three consecutive patients with rheumatic MS were included. MVA was assessed using the transthoracic 2D and 3D PISA methods. Planimetry of MVA (2D and 3D) and the pressure half-time method were used as reference methods. The 3D PISA method had better correlations with the reference methods (with 2D planimetry, r = 0.85, P < .001; with 3D planimetry, r = 0.89, P < .001; and with pressure half-time, r = 0.85, P < .001) than the conventional 2D PISA method (with 2D planimetry, r = 0.63, P < .001; with 3D planimetry, r = 0.66, P < .001; and with pressure half-time, r = 0.68, P < .001). In addition, a consistent significant underestimation of MVA using the conventional 2D PISA method was observed. A high percentage (30%) of patients with nonsevere MS by 3D planimetry were misclassified by the 2D PISA method as having severe MS (effective regurgitant orifice area < 1 cm(2)). In contrast, the 3D PISA method had 94% agreement with 3D planimetry. Good intra- and interobserver agreement for 3D PISA measurements were observed, with intraclass correlation coefficients of 0.95 and 0.90, respectively. MVA assessment using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.

Assessment of mitral valve area in patients with mitral stenosis with 3-dimensional proximal isovelocity surface area

Objective To determine the most suitable Nyquist velocity for applying the threedimensional proximal isovelocity surface area (PISA) (3d-PISA) to calculate mitral valve area (MVA) in patients with mitral stenosis (MS).Methods 20 patients with MS were studied by single-beat three-dimensional color Doppler echocardiography.The MVA was measured by the methods of planimetry (MVApl),two-dimensional PISA (MVA2d-PISA) and 3d-PISA (MVA3d-PISA).MVApl was used as reference methods.At the Nyquist velocities of 32,26 and 19 cm/s,the differences between MVA2d-PISA,MVA3d-PISA and MVApl were analyzed,and then the correlation between MVA2d-PISA,MVA3d-PISA and MVApl were analyzed respectively.Results The 3d-PISA method provided the most accurate estimation of MVA at the Nyquist velocity of 19 cm/s when compared with planimetry.MVA3d-PISA was more accurate than MVA2d-PISA.The acceptable correlations were observed between MVA3d-PISA,MVA2d-PISA and MVApl respectively (r =0.98,r =0.89).Conclusions The 3d-PISA method provided the most accurate estimation of MVA at the Nyquist velocity of 19 cm/s,which provided a new method to calculate mitral valve area with mitral stenosis. Key words: Echocardiography; Mitral valve stenosis; Three-dimensional proximal isovelocity surface area; Nyquist velocity

PW360 Correlation of Echocardiographic Assessment of Mitral Valve Area with the Gorlin Formula in Patients with Mitral Stenosis undergoing Percutaneous Balloon Mitral Valvuloplasty

PW360 Correlation of Echocardiographic Assessment of Mitral Valve Area with the Gorlin Formula in Patients with Mitral Stenosis undergoing Percutaneous Balloon Mitral Valvuloplasty

Assessment of Mitral Valve Area During Percutaneous Mitral Valve Repair Using the MitraClip System

Quantification of the mitral valve area (MVA) is important to guide percutaneous mitral valve repair using the MitraClip system. However, little is known about how to best assess MVA in this specific situation. Immediately before and after MitraClip implantation, comprehensive 3-dimensional (3D) transesophageal echocardiography data were acquired for MVA assessment by the pressure half-time method and by two 3D quantification methods (mitral valve quantification software and 3D quantification software). In addition, transmitral gradients by continuous-wave Doppler (dPmeanCW) were measured to indirectly assess MVA. Data are given as median (interquartile range). Thirty-three patients (39% women) with a median age of 77.1 years (12.4 years) were studied. Before intervention, the median MVAs by the pressure half-time method, mitral valve quantification software, and 3D quantification software were 4.4 cm(2) (2.0 cm(2)), 4.7 cm(2) (2.4 cm(2)), and 6.2 cm(2) (2.4 cm(2)), respectively (P<0.001). After intervention, MVA was reduced to 1.9 cm(2) (0.7 cm(2)), 2.1 cm(2) (1.1 cm(2)), and 2.8 cm(2) (1.1 cm(2)), respectively (P=0.001). The median values for dPmeanCW before and after intervention were 1.0 mm Hg (1.0 mm Hg) and 3.0 mm Hg (3.0 mm Hg; P<0.001), respectively. At discharge, the median dPmeanCW was 4.0 mm Hg (3.0 mm Hg). In multivariate regression analyses including body surface area, the 3 different MVA methods, and dPmeanCW, a post-dPmeanCW ≥5 mm Hg was the best independent predictor of an elevated transmitral gradient at discharge. Transmitral gradients by continuous-wave Doppler are quick, feasible in all patients, and superior to direct peri-interventional assessment of MVA. A postinterventional transmitral gradient by continuous-wave Doppler of ≥5 mm Hg best predicted elevated transmitral gradients at discharge.

Assessment of mitral valve area by 3D echocardiography in rheumatic mitral stenosis: Validation of offline 3D planimetry measure

The aim of this study is to validate the feasibility and accuracy of performing offline planimetric measurement of mitral valve area (MVA) using real time 3-dimensional transesophageal echocardiography (3D TEE), and to compare it with methods used routinely in clinical practice: 2-dimensional (2D) planimetry and pressure half time (PHT). Measurements of MVA by (2D) planimetry and Doppler (PHT) remain the mainstay methods used in routine clinical practice. 3D TEE provides more improved accuracy and reproducibility over 2D methods in theassessment of mitral valve morphology. Planimetry of the MVA by 3D echocardiography has only been done through multi-planar reconstruction of the mitral valve orifice. However using offline 2D image calibration and measurement tools allows us to measure MVA by 3D planimetry. 45 patients with moderate to severe rheumatic mitral stenosis were referred for transthoracic and transesophageal (TEE) echocardiography 2D and 3D. Offline planimetric measurement of MVA obtained from real time 3D TEE zoom views of the mitral valve from both left atrial (MVA 3DPLA) and left ventricular side (MVA 3DPLV) were compared to MVA by 2D planimetry and PHT. MVA measurements (2D and 3D) were reported by two independent readers and interobserver variability was assessed. MV areas measured by these three methods were compared using Altman and Bland methods and Shukla’s correlation. The Altman and bland analysis showed consistency among all three measurements methods. 3 DTEE showed the least variability across different clinicians compared to 2 DTEE and PHT, Mean difference 0.08, −0.15, and −.17, respectively. 3DTEE planimetry appears to be a consistent technique for measuring MVA and provides the least variability in practical setting.

THE ABILITY OF THE RADIUS OF PROXIMAL ISOVELOCITY SURFACE AREA TO ASSESS THE ANATOMIC AND HEMODYNAMIC SEVERITY OF MITRAL STENOSIS AFTER FIXING ALIASING VELOCITY

Proximal isovelocity surface area (PISA) has emerged as an accurate method for assessment of mitral valve area (MVA) in patients with mitral stenosis (MS). Test the hypothesis that PISA radius (PISA-r) can be used to assess MS if aliasing velocity (Val) is set to a constant. 70 consecutive