Diagnosis Of Mitral Valve Disease Research Articles

Automatic 3D mitral valve leaflet segmentation and validation of quantitative measurement

3D transesophageal echocardiography (TEE) is widely used in the diagnosis of mitral valve disease and is also well suited for guiding cardiac interventions. The aim of this work is to achieve patient-specific 3D TEE mitral valve leaflet segmentation without any user interaction and to assess the feasibility of 3D quantitative measurements on automatic segmentation model. We suggested a novel pre-training strategy to better implement automatic segmentation. The strategy refers to classify the diastolic and systolic states of the mitral valve through a 3D convolutional neural network architecture, and then use the pretrained weights obtained from the classification task to initialize the parameters of the 3D segmentation deep learning framework. To determine the accuracy of geometric parameters of segmentation model, the measurements of the segmentation model were compared with those obtained by the clinical software. Statistical analysis was performed by using Intraclass Correlation Coefficient and Bland–Altman method. Fourteen 3D volumes were used to evaluate the segmentation performance. The results show a Dice Similarity Coefficient (DSC) of 0.877±0.027 and an Average Surface Distance (ASD) of 0.925±0.392 mm. Twenty-eight 3D volumes were used for the quantitative measurement. The statistical results show that the mitral annular parameters have a good agreement between segmentation model and clinical software except for the annular height. We developed a fully automatic methodology to segment the mitral valve leaflet from 3D TEE and demonstrated the feasibility of improving segmentation performance with the proposed pre-training strategy. The automatic segmentation model was proved to be reliable for performing quantitative measurements of mitral valve annulus dimensions. The results indicate that the precision of the automatic segmentation methodology could pave the way for application in quantification, modeling and surgical planning tools.

Neural collaborative filtering for unsupervised mitral valve segmentation in echocardiography

The segmentation of the mitral valve annulus and leaflets specifies a crucial first step to establish a machine learning pipeline that can support physicians in performing multiple tasks, e.g. diagnosis of mitral valve diseases, surgical planning, and intraoperative procedures. Current methods for mitral valve segmentation on 2D echocardiography videos require extensive interaction with annotators and perform poorly on low-quality and noisy videos. We propose an automated and unsupervised method for the mitral valve segmentation based on a low dimensional embedding of the echocardiography videos using neural network collaborative filtering. The method is evaluated in a collection of echocardiography videos of patients with a variety of mitral valve diseases, and additionally on an independent test cohort. It outperforms state-of-the-art unsupervised and supervised methods on low-quality videos or in the case of sparse annotation.

Angiotensin-converting enzyme activity in Cavalier King Charles Spaniels with an ACE gene polymorphism and myxomatous mitral valve disease.

Myxomatous mitral valve disease (MMVD) is the most common heart disease in the dog. It is particularly common in the Cavalier King Charles Spaniel (CKCS) breed and affected dogs are frequently managed with angiotensin-converting enzyme inhibitors (ACE-I). We have previously identified a canine ACE gene polymorphism associated with a decrease in angiotensin-converting enzyme (ACE) activity. The aim of this study was to evaluate for the prevalence of the ACE polymorphism in CKCS with mitral valve disease and to determine whether the presence of the polymorphism is associated with alterations in ACE activity at different stages of cardiac disease. Seventy-three dogs with a diagnosis of mitral valve disease were evaluated and a blood sample was drawn for ACE polymorphism genotyping and ACE activity measurement. Forty-three dogs were homozygous for the ACE polymorphism; five were heterozygous and 25 were homozygous wild type. The mean age and the median severity of disease were not different for dogs with the polymorphism and dogs with the wild-type sequence. The median baseline ACE activity was significantly lower for the ACE polymorphism (27.0 U/l) than the wild-type sequence dogs (31.0 U/l) (P=0.02). Dogs with more severe disease and the ACE polymorphism had significantly lower levels of ACE activity than dogs with the wild-type sequence (P=0.03). The CKCS appears to have a high prevalence of the ACE variant. Dogs with the ACE variant had lower levels of ACE activity even in more advanced mitral valve disease than dogs without the variant. The clinical significance of this finding and its impact on the need for ACE-I in dogs with the polymorphism and heart disease deserves further study.

Modelling mitral valvular dynamics-current trend and future directions.

Dysfunction of mitral valve causes morbidity and premature mortality and remains a leading medical problem worldwide. Computational modelling aims to understand the biomechanics of human mitral valve and could lead to the development of new treatment, prevention and diagnosis of mitral valve diseases. Compared with the aortic valve, the mitral valve has been much less studied owing to its highly complex structure and strong interaction with the blood flow and the ventricles. However, the interest in mitral valve modelling is growing, and the sophistication level is increasing with the advanced development of computational technology and imaging tools. This review summarises the state‐of‐the‐art modelling of the mitral valve, including static and dynamics models, models with fluid‐structure interaction, and models with the left ventricle interaction. Challenges and future directions are also discussed.

Advances in echocardiography: insights into the mitral valve and implications for surgical and percutaneous repair

New echocardiographic imaging modalities, mainly based on 3D data acquisition, have markedly improved our understanding of the normal and pathologic mitral valve mechanics. Qualitative and quantitative analysis of 3D data on the mitral valve could have a clinical impact on diagnosis, patient referral, and percutaneous and surgical strategies, as well as in the evaluation of the immediate and long-term surgical outcome. This review covers the contribution of new echocardiographic imaging modalities in the diagnosis of mitral valve disease, their role in selecting and monitoring percutaneous and surgical procedures, and in the assessment of procedural outcomes. Moreover, advantages versus the standard 2D modality, as well as future applications of advanced analysis techniques, will be presented.

Three-Dimensional Echocardiography of the Mitral Valve: Lessons Learned

Three-dimensional echocardiography has markedly improved our understanding of normal and pathologic mitral valve (MV) mechanics. Qualitative and quantitative analysis of three-dimensional (3D) data on the mitral valve could have a clinical impact on diagnosis, patient referral, surgical strategies, annuloplasty ring design and evaluation of the immediate and long-term surgical outcome. This review covers the contribution of 3D echocardiography in the diagnosis of MV disease, its role in selecting and monitoring surgical procedures, and in the assessment of surgical outcomes. Moreover, advantages of this technique versus the standard 2D modality, as well as future applications of advanced analysis techniques, will be reviewed.

Assessment of Ischemic Mitral Regurgitation by Three-dimensional Echocardiography

Transthoracic and transeshophageal real-time three-dimensional (3D) echocardiographic technique provides a unique ‘en-face‘ view of the mitral leaflets and annulus by an easy acquisition of pyramidal images of whole beating heart. Conventional two-dimensional (2D) echocardiography has been greatly contributing in the clinical diagnosis of mitral valve diseases and it is certainly the standard in clinical echocardiography for the evaluation of mitral valve. Nevertheless, 2D has a disadvantage in the assessment of 3D morphology of the mitral valve complex, which is consisted of the saddle shaped annulus, four leaflets, chordae and papillary muscles. Although welltrained echocardiographers can reconstruct the 3D shape and position of the structures by multi-scanned 2D images (mental reconstruction), the newly-developed 3D echocardiographic system allows us to visually understand the configuration of the complex mitral valve morphology. Furthermore, the reconstructed 3D images can be quantitatively measured and analyzed in 3D spaces, which have never been done in 2D images. Three-dimensional evaluation of the mitral valve provides us important additional information in the clinical diagnosis of mitral valve diseases. In this session, I would like to introduce some clinical data regarding the assessment of ischemic mitral regurgitation by 3D echocardiography.

The Utility of Subvalvular Procedure for Ischemic Mitral Regurgitation

Transthoracic and transeshophageal real-time three-dimensional (3D) echocardiographic technique provides a unique ‘en-face‘ view of the mitral leaflets and annulus by an easy acquisition of pyramidal images of whole beating heart. Conventional two-dimensional (2D) echocardiography has been greatly contributing in the clinical diagnosis of mitral valve diseases and it is certainly the standard in clinical echocardiography for the evaluation of mitral valve. Nevertheless, 2D has a disadvantage in the assessment of 3D morphology of the mitral valve complex, which is consisted of the saddle shaped annulus, four leaflets, chordae and papillary muscles. Although welltrained echocardiographers can reconstruct the 3D shape and position of the structures by multi-scanned 2D images (mental reconstruction), the newly-developed 3D echocardiographic system allows us to visually understand the configuration of the complex mitral valve morphology. Furthermore, the reconstructed 3D images can be quantitatively measured and analyzed in 3D spaces, which have never been done in 2D images. Three-dimensional evaluation of the mitral valve provides us important additional information in the clinical diagnosis of mitral valve diseases. In this session, I would like to introduce some clinical data regarding the assessment of ischemic mitral regurgitation by 3D echocardiography.

Early Surgery Is Recommended for Mitral Regurgitation

Mitral regurgitation (MR), the systolic flow reversal from the left ventricle to the left atrium, is currently the most frequent valvular heart disease.1 Because MR affects predominantly patients ≥65 years of age,1 with age at surgery most often in the sixth decade,2 the observed prevalence will increase with the aging of the population. Thus, the number of US citizens affected by moderate or severe MR will almost double between 2000 and 2030, reaching almost 5 million by then.1 MR mechanism is classified as organic (intrinsic valve lesions) or functional (structurally normal mitral valve with MR caused by ventricular dysfunction).3 Indications of mitral surgery, the only current approved treatment of MR, are disputed because large clinical trials in MR have not been reported and outcome studies provide the best evidence available but require careful interpretation. The benefit of surgery is uncertain in functional MR and is not addressed here.4 However, we illustrate here that overwhelmingly coherent cumulative evidence obtained worldwide shows that early surgery should be the preferred management approach for organic MR. This approach differs from standard guidelines, and it is essential that its principles, rationales, and conduct be fully considered. Response by Gillam and Schwartz see p 804 Guidelines for the management of valve diseases mention class I versus class II indications as having agreed-on versus conflicting evidence/opinions.5 This classification is problematic for MR treatment because class I indications, based mostly on symptoms and overt left ventricular (LV) dysfunction, lead to the performance of rescue surgery (surgery for patients at considerable risk if unoperated) but do not result in optimal long-term outcomes for patients with organic MR.6,7 The concept of uniform surgical recommendations that supposedly apply equally to all centers is also problematic; recent studies have shown that the quality of …

Real-time three-dimensional echocardiographic evaluation of the mitral valve

The three-dimensional (3D) echocardiographic system allows us to visually understand the configuration of the complex mitral valve morphology, which consists of the saddle-shaped annulus, leaflets, chordae, and papillary muscles. The recent development of transesophageal real-time 3D echocardiography has led to important advances in the diagnosis of mitral valve disease. Furthermore, the reconstructed 3D images can be quantitatively measured and analyzed in 3D spaces. These observations provide us important additional information in the clinical diagnosis of mitral valve diseases.

Haemodynamic determinants of the mitral valve closure sound: A finite element study

Automatic acoustic classification and diagnosis of mitral valve disease remain outstanding biomedical problems. Although considerable attention has been given to the evolution of signal processing techniques, the mechanics of the first heart sound generation has been largely overlooked. In this study, the haemodynamic determinants of the first heart sound were examined in a computational model. Specifically, the relationship of the transvalvular pressure and its maximum derivative to the time-frequency content of the acoustic pressure was examined. To model the transient vibrations of the mitral valve apparatus bathed in a blood medium, a dynamic, non-linear, fluid-coupled finite element model of the mitral valve leaflets and chordae tendinae was constructed. It was found that the root mean squared (RMS) acoustic pressure varied linearly (r2= 0.99) from 0.010 to 0.259 mmHg, following an increase in maximum dP/dt from 415 to 12470 mm Hg s(-1). Over that same range, peak frequency varied non-linearly from 59.6 to 88.1 Hz. An increase in left-ventricular pressure at coaptation from 22.5 to 58.5mm Hg resulted in a linear (r2= 0.91) rise in RMS acoustic pressure from 0.017 to 1.41mm Hg. This rise in transmitral pressure was accompanied by a non-linear rise in peak frequency from 63.5 to 74.1 Hz. The relationship between the transvalvular pressure and its derivative and the time-frequency content of the first heart sound has been examined comprehensively in a computational model for the first time. Results suggest that classification schemes should embed both of these variables for more accurate classification.

Intraoperative inhalation of the long-acting prostacyclin analog iloprost for pulmonary hypertension

Pulmonary hypertension (PHT) contributes significantly to morbidity and mortality in cardiac surgery—especially in patients with long-standing mitral valve disease. Vasodilators administered intravenously can reduce pulmonary vascular resistance but also have an effect on the systemic circulation. Arterial hypotension must be expected, which results in reduction of right coronary blood flow and may lead to further deterioration of right ventricular performance. Inhaled nitric oxide (NO) is a more selective pulmonary vasodilator with virtually no systemic side effects. Recently, the inhalational use of the long-acting prostacyclin analog iloprost has been reported to offer superior selective pulmonary vasodilating properties relative to NO inhalation in primary PHT. We report our initial experience with the intraoperative use of iloprost inhalation in a case series of cardiac surgical patients.

Transesophageal Echocardiography

Two-dimensional transesophageal echocardiography generally has superior sensitivity and image quality compared with precordial echocardiography. Its unique anatomic perspective posterior to the heart often provides important clinical information not obtainable by other imaging approaches and technologies. It is particularly useful in the diagnosis of mitral valve disease, left atrial masses, endocarditis and its sequelae, and aortic dissections. It is also useful for examination of the left main coronary artery, left ventricular outflow tract, atrial and ventricular septa, and congenital defects. In addition to its application as a diagnostic tool in conscious patients, it can be employed intraoperatively to evaluate and guide surgical intervention. Detection of ventricular wall motion abnormalities by transesophageal echocardiography has been shown to be the most sensitive indicator of myocardial ischemia available in the clinical setting. It has potential for wide application for safely monitoring left ventricular function in patients in intensive care or under anesthesia.

A Study on Cerebral Embolism in Mitral Stenosis

To evaluate the significance of episodes of cerebral embolism in patients with mitral valve disease in Korea, 128 patients with echocardiographic diagnosis of mitral valve disease were examined. Among these, 82 patients had predominant mitral stenosis. The clinical features of 82 patients with mitral stenosis have been reviewed to elucidate the factors favoring cerebral embolism which occurred in 19 patients, i.e., incidence of 23.2%.Atrial fibrillation was present in 16 of 19 patients with cerebral embolism (84.2%). Cerebral embolic episodes occurred in 16 of 47 patients with atrial fibrillation (34.0%).The mean age (55.3 ± 12.1 years) of patients without cerebral embolism was significantly older than that (43.2 ± 14.6 years) of patients without cerebral embolism (P<0.005).There was no significant relationship between the incidence of embolism and sex, left atrial thrombi, left atrium/aortic root diameter, mitral valvular orifice area, mitral valvular vegetation or calcification, left ventricular enddiastolic dimension or left ventricular posterior wall thickness.Cerebral embolism is common in patients with mitral stenosis in our country. The presence of atrial fibrillation and low cardiac output increase the attack of cerebral emboli whereas the severity of mitral stenosis, as judged by valve area, may not correlate with the occurrence of emboli. The best treatment for cerebral embolism is prevention. Therefore, we believe that more vigorous treatment of patients with mitral valve disease who are old or associated with atrial fibrillation as well as previous embolic history is indicated.

Cardiac tumour. An echocardiographic diagnosis.

The clinical and echocardiographic features in nine patients with cardiac tumours are reviewed. In two patients, tumours were diagnosed by means of M-mode echocardiography only and in seven by means of both two-dimensional and M-mode echocardiography. The diagnosis was not made clinically in any of the nine patients. Cardiac catheterisation performed in four patients resulted in a diagnosis of mitral valve disease in two and a correct diagnosis in the other two. A definite diagnosis of cardiac tumor was not possible with M-mode echocardiography alone in three patients. A correct diagnosis was made in all seven patients in whom M-mode and two-dimensional echocardiography were performed.

Adult heart disease in western Nigeria: A clinicopathological synopsis

A synopsis of cardiovascular problems in Nigeria is presented by comparing an eight-year review of necropsies (884 cases) with a twelve-month survey of new presentations to the Department of Medicine (321 patients). Age and sex distributions are given, and the relative hypertrophy of hearts in different diseases compared. The ratio of necropsies to new presentations is used as a crude measure of mortality rates. Attention is drawn to areas of obscurity, including the differential diagnosis of mitral valve disease and the cause of unexplained right ventricular failure. The etiology of endomyocardial fibrosis, subvalvar left ventricular aneurysm, and unexplained myocardial failure is briefly discussed.

Dilatation of the left auricular appendage by the Valsalva maneuver: an aid in the diagnosis of mitral valve disease.

The roentgen diagnosis of mitral valve disease is based on the demonstration of enlargement of the left atrium. Posterior displacement of the barium-filled esophagus and the double density along the right cardiac border are the most commonly accepted manifestations. A localized bulge or convexity along the left heart border just beneath the pulmonary artery, produced by dilatation of the left auricular appendage, has long been recognized as occurring in mitral disease, but its significance has not been fully appreciated. It is one of the most reliable manifestations of that condition. Occasionally when this bulge is not evident on the conventional posteroanterior roentgenogram of the chest, it may be made visible by the performance of the Valsalva maneuver. It may be present with other evidence of enlargement of the left atrium or as a solitary finding. Except in rare instances, demonstration of enlargement of the left auricular appendage is diagnostic of disease of the mitral valve. In the postero-anterior projection, the normal left cardiac border displays three distinct curves: the upper curve, formed by the aortic arch; the middle curve, by the pulmonary artery and/or its main left branch; the lower curve, formed by the left ventricle. In mitral valve disease, an additional curve, called the lower middle arc, frequently appears immediately inferior to the pulmonary artery. It varies considerably in size. In most instances it is a distinct, clearly visible, localized bulge, while in others it consists only of straightening or an almost imperceptible convexity in the upper portion of the curve of the left ventricle. For many years there was considerable controversy as to whether this bulge was formed by the pulmonary conus or the left auricular appendage. Heim de Balsac and Routier (2) described very lucidly the normal anatomy of the left atrium following postmortem opacification. They felt that the left atrium does not normally extend to either cardiac border in the posteroanterior projection and that, as it dilates, it enlarges to the right and posteriorly, and only occasionally to the left. Their descriptions do not include the left auricular appendage. Roesler (14) believed that “the part of the heart that becomes prominent between the pulmonary artery and the left ventricle is either the conus of the right ventricle or the enlarged left auricular appendage, or the prominence may be composed of both of these. The more marked the conus enlargement and the rotation of the heart to the left, the less will the left auricular appendage participate in the formation of the border.” Many have disagreed with this concept (1, 6, 9, 10, 12, 17, 18). As early as 1929, Steel (18) accurately described the location of the left auricular appendage and pointed out that it enlarges in mitral stenosis, forming part of the left heart border.

Retrograde Catheterization of the Left Ventricle and Angiography in the Diagnosis of Mitral-Valve Disease

THE diagnosis of mitral regurgitation by conventional means is probably less satisfactory and more apt to be in error than the identification of any other valvular disturbance. For the best use of available therapeutic methods, the most precise diagnostic means are required. It is important, for example, to know whether or not mitral stenosis is accompanied by significant regurgitation before one decides first on the desirability and then on the method of surgical correction. Closed valvulotomy is commonly the procedure of choice in pure stenosis whereas "open" technics are required when significant regurgitation is also present. When mitral insufficiency is . . .

The value of the recumbent oesophagram in assessing left auricular enlargement.

1. A measurement of the posterior displacement of the oesophagus was made in the erect and recumbent right anterior oblique views in 50 normal subjects and in 50 cases with mitral valve disease. 2. Standards for this posterior displacement were established for both the erect and recumbent views. 3. The accuracy in the diagnosis of mitral valve disease was no greater in the recumbent view than in the erect view. The actual results favour the erect view in this respect (62 per cent erect, 54 per cent recumbent). 4. The degree of displacement in the erect or recumbent views was not as accurate in the diagnosis of left auricular enlargement as the presence of two or more of the following signs: a left auricular appendage, a double density and evidence of left auricular enlargement in the left and right anterior oblique views. 5. The fallacy of employing backward displacement of the oesophagus with the patient recumbent as an early sign of mitral valve disease was shown by the large percentage (56 per cent) co...

Management of patients with mitral stenosis before, during, and after mitral valvuloplasty.

IT IS NOT the province of this paper to discuss in detail the diagnosis of mitral valve disease or to delineate our criteria for selection of patients for operation. We have considered the latter problem at a previous meeting of this Association. 1 However, a few statements in this regard may be useful. At the State University of Iowa Hospitals internists, radiologists, clinical physiologists, and surgeons work as a team (Fig. 1) in the selection of patients for mitral valvuloplasty and in their management. To date 95 cardiotomies have been performed on patients ranging from 11 to 60 years of age, with an operative mortality rate of only 4.3%. We do not recommend operation on patients in whom mitral stenosis exists but in whom there are no clinical symptoms referable to this lesion. All 95 patients have had symptomatic mitral valve disease; many had been deteriorating clinically, and a few