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European Journal of Echocardiography 2004 5(3):212-222; doi:10.1016/j.euje.2004.01.005
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Copyright © 2004, The European Society of Cardiology

Three-dimensional echocardiography is superior to multiplane transoesophageal echo in the assessment of regurgitant mitral valve morphology

Anita Macnab*, Nicholas P Jenkins, Benjamin J.M Bridgewater, Timothy L Hooper, Donna L Greenhalgh, Mark R Patrick and Simon G Ray

Regional Cardiothoracic Unit, Wythenshawe Hospital, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK

Received 27 May 2003; received in revised form 13 January 2004; accepted after revision 14 January 2004.

* Corresponding author. 7 Birchlea, Altrincham, Cheshire, UK. Tel./fax: +44-161-9294266. abheartdoc{at}hotmail.com


   Abstract
Top
 Abstract
1 Introduction
 2 Methods
 3 Results
 4 Discussion
 5 Limitations of the...
 6 Conclusions
 Appendix A. Abbreviation list
 References
 
Aims: Transoesophageal echocardiography (TOE) plays a vital role in the assessment of mitral valve morphology. However, the accuracy of TOE may be limited by inadequate recognition of all segments. We aimed to evaluate the role of three-dimensional (3D) echocardiography in this respect.

Methods and results: Seventy-five patients were studied prior to mitral valve repair surgery. A scoring protocol was devised for recognition of the eight Carpentier segments (0 = inadequate for analysis, 1 = adequate, 2 = good). Using surgical findings as the gold standard, TOE and 3D were compared for adequate recognition scores and accurate detection of functional morphology. Adequate recognition was more frequently obtained with 3D imaging (97% of segments by 3D c.f. 90% by TOE; p = 0.000). The major difference was seen at the commissures (adequate scores in 143/150 commissures by 3D c.f. 90/150 by TOE; p<0.000). 3D matched more closely to surgical findings, achieving exact functional description in 92% of segments vs 79% segments with TOE (p = 0.000). This incremental value of 3D was seen in both commissures and the anterior leaflet but not in the posterior leaflet.

Conclusions: In this study 3D was superior not only for complete recognition of the mitral valve but also for the accurate localisation and identification of pathology.

Keywords: Three-dimensional echocardiography; Mitral regurgitation; Valve repair


   1 Introduction
Top
 Abstract
 1 Introduction
2 Methods
 3 Results
 4 Discussion
 5 Limitations of the...
 6 Conclusions
 Appendix A. Abbreviation list
 References
 
Severe mitral regurgitation (MR) due to organic valve disease carries a high risk of morbidity and mortality.1–4 Mitral valve repair surgery is now recommended early in the course of the disease5–9 and the timing of this intervention is critically linked to a comprehensive anatomical and functional knowledge of the diseased valve.8–13 As repair techniques have advanced,14–17 so has the need to obtain accurate information prior to surgery. This has been particularly crucial for complex valve disease such as bi-leaflet and commissural pathology, which have often posed difficulties to the surgeon.11,17,18

Multiplane TOE plays a vital role in assessing the feasibility of repair19–23 but demands specialist skill and experience. Even in competent hands evaluation of the commissural zones, in particular, can be very difficult. Preliminary data suggest that 3D echocardiography may overcome some of the limitations of TOE and thus play a valuable role in the evaluation of patients undergoing mitral repair.24–27

In this study we undertook a prospective comparison of TOE and 3D echocardiographic assessment of mitral pathology using surgical findings as gold standard. The two major attributes that were compared between the imaging modalities were: (a) the adequacy of recognition of all components of the mitral valve leaflets and (b) the accuracy of description of leaflet morphology and function.


   2 Methods
Top
 Abstract
 1 Introduction
 2 Methods
3 Results
 4 Discussion
 5 Limitations of the...
 6 Conclusions
 Appendix A. Abbreviation list
 References
 
2.1 Study population
Adult patients were recruited to undergo 3D acquisition at the time of their routine TOE prior to mitral valve repair at our surgical unit. All patients had severe MR (≥grade 3) based on semi-quantitative assessment28,29 with TOE. Patients were excluded if they had associated mitral stenosis or if their 3D acquisition was unsuccessful. Following appropriate consent, patients underwent standard multiplane TOE either under sedation during a routine TOE list in the outpatient setting, or under general anaesthesia (GA) in the operating room immediately prior to surgery.

2.2 Aetiology of MR
Gross aetiology was classified as degenerative, infective, or functional. The Carpentier nomenclature10 was applied to the mitral leaflets (i.e. A1/A2/A3 = lateral, middle and medial scallops of the anterior leaflet, P1/P2/P3 = lateral, middle and medial scallops of the posterior leaflet, ALC = anterolateral commissure and PMC = posteromedial commissure to denote the eight mitral leaflet segments). The function of each scallop was classified by the operating surgeon as normal (normal coaptation), flail (eversion of leaflet tip into left atrium during systole due to chordal rupture), prolapsing (displacement of any part of leaflet above the annular plane due to chordal elongation), tethered (malcoaptation due to left ventricular dysfunction and subvalvular traction), perforated (breech of leaflet body), eroded (leaflet edge destruction) or aneurysmal (localised leaflet distortion). The surgeons also recorded the presence or absence of ruptured chordae.

2.3 2D imaging of the mitral valve
A commercially available echo system (Hewlett Packard Sonos 5500 machine with a 5 MHz multiplane probe Phillips, Andover, Massachusetts, USA) was used for the TOE imaging of the mitral valve. Two experienced TOE operators (>500 procedures each) obtained standard views from oesophageal and gastric windows for the 2D assessment.30 Particular emphasis was placed on attempting to visualise the commissural zones, with vertical pullback of the probe from the five-chamber 0° view for the anterolateral commissure and clockwise rotation from the two-chamber 90° view for the posteromedial commissure. The trans-gastric view was also used to visualise the valve closure line and commissures. Both operators analysed the images and applied the scoring protocols detailed below. All the mitral valves were deemed suitable for repair on the basis of the TOE assessment.

2.4 3D acquisition and reconstruction
From a mid-oesophageal view, rotational scanning at 3° intervals was used to acquire 61 2D images of the mitral valve (Hewlett Packard 3D acquisition software) gated to heart rate and respiration. The ECG gates were set with RR intervals below 200 ms in the expiratory phase of the respiratory cycle. The images were digitised and stored on magneto-optical disks for off-line analysis. Only one complete acquisition was attempted for each patient. Using a voxel-based 3D workstation (Echoscan 4.1, TomTec, Munich, Germany), reconstruction of the mitral valve was carried out by an experienced operator at a later date blinded to the TOE and surgical findings. Six cut planes were used to visualise the mitral valve in 3D (Fig. 1). The surgical en-face view of the valve was used to guide the positioning of five long axis planes cutting the closure line. Artifacts were minimised by placing the cutting line as close to the regions of interest as possible and darkening the blood pool by optimising the transparency and threshold settings. To calculate the inter-observer variability in 3D assessment, an inexperienced operator also analysed the reconstructions in 20 randomly selected patients.


Figure 1
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  		Figure 1 Six standard cut planes for 3D reconstruction of the mitral valve. The figure shows the mitral valve reconstructed in 3D using six cut planes. (A) En-face view of the valve in systole showing a flail segment at P2 near the junction with P1. The closure line is demarcated with the black dotted line. Guided by this view three longitudinal views were reconstructed through A1 on the right and P1 on the left (B), A2 on the right and P2 on the left (C) and A3 on the left with P3 on the right (D). More oblique cut planes were used to visualise the commissural zones (E, anterolateral and F, posteromedial). In these last two reconstructions, the commissural zones are at the corners demarcated by the white dotted lines. Landmarks such as the left atrial appendage (LAA) and the Aorta (Ao) are indicated. These six reconstruction planes were used as standard for all the valves studied. LA = left atrium.

 
2.5 Scoring protocol
The TOE and 3D images were analysed off-line separately and blinded to the surgical findings. A total of 600 mitral valve segments were analysed (eight per patient). A three-point scoring protocol was applied to all eight mitral valve segments according to ease of recognition and confidence of interpretation of segmental function: 0 = inadequate for analysis, 1 = adequate and 2 = good. Segments graded 0 could not be identified clearly. Segments graded 1 could be identified and pathology assessed. Segments graded 2 were clearly and easily identified with excellent image quality. Mean scores and frequency of adequate scores (score≥1) were compared for the two imaging systems.

2.6 Accuracy of functional morphology
Using functional morphology described by the operating surgeon as the gold standard, the accuracy of each type of echo assessment was determined. The surgeon described the anatomy of the valve using the same proforma used for the echocardiographic analysis. The surgeon was aware of the 2D findings but not the 3D analysis. Segments were counted as accurately imaged if they matched surgical findings precisely in terms of description of pathology and correct location. The segments that were not adequately recognised (score=0) were coded as inaccurate. For segments that were adequately recognised, the reasons for inaccuracies were recorded as incorrect description of pathology (e.g. calling a "flail" segment "prolapsed") or incorrect localisation despite correct portrayal of pathology (e.g. correctly diagnosing "flail" in the posterior leaflet but on P1 instead of on the adjacent P2).

2.7 Statistics
Statistical analysis was performed using the Statistical Package for the Social Sciences version 10.1.0 for Windows. All grouped data are presented as mean value ± SD. The chi-squared test, the student t-test and the one-way analysis of variance with subsequent two-tailed t-tests were used to compare differences between groups. Inter-observer correlations were made using the Pearson coefficient. A probability of <0.05 was considered significant.


   3 Results
Top
 Abstract
 1 Introduction
 2 Methods
 3 Results
4 Discussion
 5 Limitations of the...
 6 Conclusions
 Appendix A. Abbreviation list
 References
 
3.1 Baseline characteristics
Out of 87 consecutive patients recruited for the study, 12 patients (14%) were later excluded due to unsuccessful 3D acquisition. All failed acquisitions were attempts during TOE under sedation. The reasons for failure included movement artifacts caused by coughing or hiccups, difficulty with ECG gating, and equipment failure. Baseline characteristics for the remaining 75 patients in the study were: 59% male, mean ± SD age 62±13 years (range 22–81 years), 75% in sinus rhythm. Forty-nine patients had their 3D acquisition during routine pre-operative imaging in the anaesthetic room under general anaesthesia. The other 26 patients had their procedure in the outpatient setting during TOE under sedation. Baseline demographics were comparable between the two groups [mean ± SD age 61±11 vs 62±14, 54% male vs 59% and 69% sinus rhythm vs 78% for sedation c.f. anaesthesia, respectively; all p = NS].

3.2 Time taken to acquire and reconstruct in 3D
The mean ± SD acquisition time was 3.91±1.89 overall. Acquisitions during sinus rhythm were significantly shorter than during atrial fibrillation [mean ± SD 3.47±1.47 min for sinus rhythm vs 5.44±2.84 min for fibrillation; p = 0.015]. Acquisition times for 3D under anaesthesia were also significantly shorter than under sedation [mean ± SD 2.55±0.56 min under anaesthesia vs 4.75±1.87 min with sedation overall; p<0.001]. The mean ± SD reconstruction time calculated for a random selection of 20 cases was 19.41±7.6 min (range 5.45–28.42 min).

3.3 Aetiology of MR
Degenerative valve disease accounted for 77% (58 patients) of the aetiologies, functional 16% (12 patients) and endocarditis 6% (five patients). Of the 600 mitral segments the distribution of functional morphology was as follows: normal 483 (81%) segments, flail 58 (10%), prolapsed 38 (6%), tethered 15 (3%), perforate five (<1%), eroded leaflet edge two (<1%) and aneurysmal one (<1%) segments. The majority of patients had posterior leaflet pathology (41 patients with posterior leaflet alone, 12 bi-leaflet, 11 anterior leaflet alone, four with commissural involvement and seven with no leaflet involvement). Single segment pathology was the commonest abnormality (32 patients), followed by two-segment disease (20 patients).

3.4 Recognition scores
Total 3D scores for the mitral valves were significantly better than TOE scores (mean ± SD score 13.93±2.69 by 3D vs 10.29±1.98 by TOE; p = 0.000). This superiority by 3D was irrespective of rhythm (p = 0.000 for both sinus rhythm and atrial fibrillation) and method of acquisition (p = 0.000 for both anaesthetic and sedation). The numbers of "adequate" or "good" scores (i.e. scores≥1) were 582/600 (97%) segments by 3D compared with 538/600 (90%) segments by TOE, p<0.001. In this respect the commissural zones benefited the most from 3D imaging [adequate scores in 143/150 (95%) commissures by 3D vs 90/150 (60%) by TOE; p<0.001]. In 34 patients TOE identified both commissures but in 19 patients neither commissure was recognised with certainty. In the 21 patients where the observers were able to recognise only one of the commissures, the ALC was easier than the PMC (ALC recognised in 13 patients vs PMC in eight). Segmental analysis showed 3D scores were statistically superior for all but the middle scallops of both leaflets (Fig. 2).


Figure 2
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  		Figure 2 Segmental recognition scores for 3D compared with TOE. Values represent the number of mitral valve segments assigned to each category of recognition score. Inadequate recognition scores (score=0) were more frequently observed with TOE in all segments except the middle scallops of both leaflets. p-Values represent statistical differences between the mean scores for each segment obtained by the two modalities. *Indicates statistical significance.

 
3.5 Accuracy of functional assessment
Using surgical classification as gold standard, the function of all 600 segments was examined. When non-recognised segments were counted as inaccuracies, 3D was substantially superior to TOE [accurate in 553/600 (92%) segments compared with 476/600 (79%) segments; p = 0.000]. Even when non-recognised segments were excluded from analysis, 3D was significantly better [accurate in 553/582 (95%) compared with 478/538 (89%); p<0.001]. The superiority of 3D was seen in all anterior leaflet segments and the commissural zones but not in the posterior leaflet segments (Fig. 3).


Figure 3
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  		Figure 3 Segmental accuracy for 3D compared with TOE. Values shown are the numbers of segments accurately recognised and correctly assigned to a functional category by the two imaging modalities. 3D was significantly more accurate than TOE for the anterior leaflet and both commissures but not the posterior leaflet. p-Values represent statistical differences between the rates of accuracy obtained for each component of the mitral valve by the two modalities. *Indicates statistical significance.

 
3.6 Scrutiny of inaccuracies
Table 1 represents the categorisation of inaccuracies. TOE was significantly worse at recognising segments and describing morphology. Both modalities were comparable in describing the correct morphology but in the wrong location. A significant proportion of segments were inaccurately assigned to morphological categories despite achieving excellent recognition scores (i.e. scores of 2) by both modalities. With these scores, however, 3D matched significantly better with surgical findings than TOE assessment [3D accurate in 440/463 (90%) segments with score=2 compared with 203/235 (86%) segments by TOE, p<0.05].


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  		Table 1 Comparison of inaccuracies between 3D and TOE assessments

 
Three-dimensional echocardiography was vastly superior in its negative predictive value in terms of the correct recognition of 483 normal leaflet segments [446 (92%) segments accurately assigned as "normal" by 3D vs 394 (82%) by TOE; p = 0.000]. For the assessment of the major pathologies 3D was superior for flail and prolapsed segments but comparable for tethered leaflets [accuracy by 3D vs TOE 98% vs 90% for flail (n = 58; p = 0.025), 87% vs 45% for prolapse (n = 38; p = 0.007), and 73% vs 87% for tethered segments (n = 15; p = 0.414)]. The principal reasons for misdiagnosis by both modalities are presented in Table 2.


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  		Table 2 Cause of inaccuracies for the commonest functional morphologies

 
3.7 Identification of ruptured chordae
Ruptured chordae were confirmed on surgical inspection in 40 patients. Sensitivity of TOE was superior to 3D in the identification of chordal rupture but specificity was comparable [sensitivity 90% vs 76% (p = 0.025) and specificity 74% vs 91% (0.059) for TOE and 3D, respectively].

3.8 Assessment of complex mitral valve disease
Twenty-three patients were identified as having complex mitral valve pathology. These patients had either more than one type of pathology (e.g. perforation A2, aneurysm A3 and flail P2) or involvement of two or more non-adjacent segments (e.g. prolapse A1, A2, P2 and P3) or extensive valve abnormality (e.g. prolapse of A2, A3, PMC and P3). Three patients had anterior leaflet pathology, five posterior leaflet, 11 bi-leaflet and four patients had commissural involvement. Three-dimensional echocardiography was significantly better than TOE not only in overall recognition scores in these patients (mean ± SD score 13.61±2.64 by 3D vs 10.22±1.73 by TOE; p = 0.000) but also for the accurate description of morphology [3D accurate in 173/184 (94%) segments compared with 148/184 (80%) by TOE; p = 0.003].

3.9 Inter-observer variability in 3D assessment
Twenty reconstructed 3D studies were randomly selected and evaluated by an operator with no experience in 3D imaging. There was close agreement in recognition scores between this observer and the experienced observer (r = 0.640; p = 0.002) with no significant difference in the scores (mean ± SD score 13.00±1.71 by the inexperienced operator vs 13.60±2.35 by the experienced operator). Similarly, there was close agreement between both observers in describing functional morphology from the 3D dataset, being accurate in the same 17 cases out of 20 valves studied.


   4 Discussion
Top
 Abstract
 1 Introduction
 2 Methods
 3 Results
 4 Discussion
5 Limitations of the...
 6 Conclusions
 Appendix A. Abbreviation list
 References
 
Multiplane TOE plays a vital role in the assessment of reparability of the regurgitant mitral valve. In this study we observed a valuable incremental role of 3D echocardiography over TOE in the complete and accurate evaluation of mitral valve morphology prior to valve repair. We studied an unselected cohort of patients undergoing mitral reconstruction with a representative array of aetiologies typically encountered at a surgical centre.

We used a method of mitral valve analysis devised by Foster and colleagues19 to map TOE views onto a surgeon's view of the valve seen from the left atrial aspect. A systematic and rational approach was employed to map the mitral valve in 3D using a combination of en-face atrial and longitudinal views. The two echo modalities were compared for the adequacy of recognition of the eight Carpentier components10 of the valve applying a modified scoring system devised by Salustri et al.27 Using surgical findings as the gold standard, we also compared TOE with 3D for accuracy in the complete description of functional morphology of each leaflet component.

In this study 3D was superior in the recognition of all but the middle scallops of both valve leaflets. With simple middle segment mitral pathology TOE may suffice but with more complex valves 3D seems to offer more confidence in interpretation. Superiority of recognition was particularly striking for the commissural segments. This highlights the difficulties in conceptualising complex 3D anatomy from a two-dimensional image (examples of en-face 3D displays of "complex" mitral valve pathologies are demonstrated in Figs. 4 and 5Go). This study also showed that even when a segment was apparently recognised well with TOE (i.e. score=2), assessment of functional morphology was incorrect in a significant proportion (14%).


Figure 4
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  		Figure 4 Flail commissure. The figure demonstrates the ease of locating and diagnosing a flail posteromedial commissure by 3D (marked by arrow in D) as compared with TOE. Three TOE planes (A–C) were required to achieve a complete and confident visualisation of this valve morphology as opposed to one cut plane by 3D.

 


Figure 5
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  		Figure 5 Complex mitral valve morphology. In this complex valve there were multiple pathological segments including a flail P2, perforation and aneurysm in A3. The en-face view in 3D (A) shows the various segments in one reconstruction whereas even with multiple TOE views (B–D) the diagnosis was extremely difficult. The 3D en-face reconstruction of the valve in systole has the closure line demarcated by the dotted line. The flail segment of P2 is indicated. At the bottom right hand corner an aneurysmal segment with an adjacent perforation can be seen clearly. The TOE images show the aneurysm and perforation indicated by arrows.

 
In our experience 3D reconstruction is particularly useful in complex valves with large amounts of flail or redundant leaflet tissue where precise orientation of the imaging plane to the valve closure line is invaluable in identifying the underlying abnormality. The systematic method of analysis that we employed, combining both en-face and longitudinal views ensured that all parts of the valve leaflets were imaged. In combining these two sets of imaging planes we also minimised the risk of artifacts appearing as leaflet perforations. We have found that volume rendered longitudinal views are easier to interpret than the corresponding 2D anyplane images.

Even after excluding unrecognised segments from analysis, 3D was superior to TOE (95% vs 89%) in correctly describing and localising morphology. Inspection of "segmental" accuracy showed superiority of 3D for all anterior leaflet components and both commissures but not for the posterior leaflet. Thirty-six percent of our patients had anterior leaflet or commissural pathology. Three-dimensional echocardiography was superior not only in detecting common aetiologies such as flail and prolapsing segments, but also in detecting normality. This negative predictive accuracy of 3D may have a great impact in deciding the feasibility of repair. On pre-operative TOE assessment alone, reparable valves could be erroneously earmarked for replacement thereby influencing both the timing of intervention and also, in some institutions, the referral patterns to non-specialist surgeons. Moreover with the increasing interest in valve repair in truly asymptomatic patients it is essential that echocardiographic assessments are as accurate as possible.

The accuracy for both imaging modalities has been lower in our study compared with previous observations for both TOE19–23 and 3D.24–26 One explanation might be the use of surgical findings as the "gold standard" particularly for ischaemic MR patients. Segments that have appeared "tethered" on both echo modalities (10 patients) have appeared "normal" during surgical inspection of the arrested heart. Some studies have excluded such ischaemic patients from their analysis.22–25 Another reason for the lower accuracy rates might be the strict scoring protocol used to describe morphology. An accurate score in this study was only achieved by exact morphological description at the correct segmental location. A third explanation may lie in the fact that this study examined accuracy in greater detail (dividing the mitral valve into eight segments) than other surveys.20,22,25,26 Even when detailed segmental analysis has been undertaken, other studies have limited their assessment to a small sample size of regurgitant mitral valves.21,25,26 Whatever the reasons for lower accuracy rates in our study, both modalities have suffered our methodological attenuation equally. We feel that the incremental value of 3D over TOE is clinically more significant.


   5 Limitations of the study
Top
 Abstract
 1 Introduction
 2 Methods
 3 Results
 4 Discussion
 5 Limitations of the...
6 Conclusions
 Appendix A. Abbreviation list
 References
 
In this study we have restricted our evaluation to the morphology of the mitral leaflets, ruptured chordae and the defects of coaptation rather than the subvalvular apparatus. Other mitral valve components have been evaluated in 3D by other investigators.27,31,32 Secondly, we made no attempts at quantifying MR by TOE or 3D. The degree of MR in our cohort of patients had been semi-quantified as severe on the basis of TOE and angiography prior to referral for surgery. We were also mindful of the large proportion of patients having the 3D study under anaesthesia (65%) and the pitfalls of MR quantification under these circumstances.33,34 With improvements in colour Doppler reconstructive software, MR quantification will become a routine 3D application in the same way as its 2D counterpart. This may also enhance the appreciation of pathologies such as leaflet perforation by 3D.

The design of this study was to compare 3D with TOE. The operating surgeon in our study was unaware of the 3D findings at the time of the atriotomy. Whether additional 3D information could have altered the surgical outcome was not examined in this study but may have altered our pattern of referral of "complex" valves to specialist surgeons.


   6 Conclusions
Top
 Abstract
 1 Introduction
 2 Methods
 3 Results
 4 Discussion
 5 Limitations of the...
 6 Conclusions
Appendix A. Abbreviation list
 References
 
With ever-expanding surgical advances in valve reconstruction and the pressures on cardiologists to obtain more complete information on mitral leaflet morphology, TOE alone does not seem entirely satisfactory. TOE may be adequate for simple pathology in the middle of the posterior valve leaflet. But for anything more complex 3D will add confidence in interpretation and help to shorten the learning curve. The technique should be regarded as an important adjunct to TOE in decisions regarding mitral valve repair.


   Appendix A. Abbreviation list
Top
 Abstract
 1 Introduction
 2 Methods
 3 Results
 4 Discussion
 5 Limitations of the...
 6 Conclusions
 Appendix A. Abbreviation list
References
 

A1Lateral scallop of the anterior leaflet
A2Middle scallop of the anterior leaflet
A3Medial scallop of the anterior leaflet
P1Lateral scallop of the posterior leaflet
P2Middle scallop of the posterior leaflet
P3Medial scallop of the posterior leaflet
ALCAnterolateral commissure
PMCPosteromedial commissure
TOETransoesophageal echocardiography
3DThree-dimensional echocardiography
MRMitral regurgitation
LAALeft atrial appendage
LVLeft ventricle
LALeft atrium
AoAorta


   References
Top
 Abstract
 1 Introduction
 2 Methods
 3 Results
 4 Discussion
 5 Limitations of the...
 6 Conclusions
 Appendix A. Abbreviation list
 References
 

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