Theroutineuseoflivethree-dimensional transesophageal echocardiography in mitral valve surgery: clinical experience

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1 European Journal of Echocardiography (2010) 11, doi: /ejechocard/jep173 Theroutineuseoflivethree-dimensional transesophageal echocardiography in mitral valve surgery: clinical experience Jeng Wei, Ming C. Hsiung, Shen Kou Tsai*, Ching-Huei Ou, Chung-Yi Chang, Yi Cheng Chang, Kuo Chen Lee, Sung-How Sue, and Yi-Pen Chou Division of Cardiovascular Diseases, Cheng-Hsin General Hospital, No 45, Cheng Hsin St, Beitou, Taipei, Taiwan Received 4 July 2009; accepted after revision 13 October 2009; online publish-ahead-of-print 21 November 2009 Background Perioperative monitoring of mitral valve (MV) anatomy, function, and pathology is essential for surgical management of different MV disease. Aims To overcome the several potential pitfalls of two-dimensional transesophageal echocardiography (2D TEE) and offline 3D TEE. Methods Live 3D TEE was used to assess 73 patients (44 men and 29 women) with Carpentier type II MV regurgitation undergoing MV surgery perioperatively. Results The isolated segment most frequently involved was A2/P2, but A1or P1 rarely was involved in an isolated lesion or combined lesions. The agreement between 3D TEE finding and surgery was 88% (64/73). In nine patients, the live 3D TEE images revealed more segments or scallops with prolapse than the surgeon noted intraoperatively. Conclusions Live 3D TEE allows more sensitivity and was feasible identification of prolapse or flail of individual segments of MV leaflets during surgery. We conclude that live 3D TEE should be regarded as an important adjunct to the standard 2D TEE examination in making decisions about MV surgery Keywords Live 3D TEE Mitral valve Introduction Mitral valve (MV) has become more common in the last decade, constituting more than half of MV procedures. 1 3 Its feasibility depends on the location, extent, and mechanism of MV disease. Twodimensional transesophageal echocardiography (2D TEE) was routinely used for planning of MV surgery. However, in complex valvular pathologies, 2D TEE has several potential pitfalls with regard to spatial relationships and valvular morphological abnormalities. 4 7 In our previous study, we reported that 2D TEE less frequently correctly diagnosed mitral regurgitation (MR) due to prolapsed or ruptured chordae than live 3D TEE. 8 Recently introduced live real-time 3D TEE allows for online assessment of cardiac structures and novel views of complex cardiac abnormalities in MV anatomy. The aim of this study was to evaluate the feasibility and routine use of live 3D TEE for recognizing and locating MV lesions during surgery. Methods Study population From October 2007 to December 2008, a total of 73 patients (44 men and 29 women) diagnosed with Carpentier type II MR by standard 2D transthoracic echocardiography preoperatively were enrolled in this study. All patients underwent surgical correction with live 3D TEE monitoring perioperatively. The Ethics Committee of Cheng-Hsin General Hospital approved the study and informed consent was obtained from all patients. Patient characteristics are shown in Table 1. Echocardiographic examination Intraoperative 2D TEE and live real-time 3D TEE were performed with a 5.5 MHz new matrix array X7-2t transducer and a commercially available Philips ie33 ultrasound system after induction of * Corresponding author. Tel: þ ; fax: þ address: ch9198@chgh.org.tw Published on behalf of the European Society of Cardiology. All rights reserved. & The Author For permissions please journals.permissions@oxfordjournals.org.

2 Live 3D TEE in mitral valve surgery 15 anaesthesia and endotracheal intubation. Live 3D TEE was performed at the end of the comprehensive 2D TEE examination. Live 3D TEE can delineate the surgical view of online MV anatomy (Figure 1). Table 1 Patient characteristics (n 5 73) Age (years) 59 (19 81) a Weight (kg) 62 (42 113) a Height (cm) 160 ( ) a Aetiology Degenerative valve disease 33 pts (45%) Rheumatic valve disease 38 pts (52%) Barlow s disease 2 pts (3%) Pts, patients. a Mean (range). Figure 1 Left frame: surgical view of normal mitral valve during systole as viewed by surgeon from the left atrium. Right frame: the corresponding live 3D TEE image. Schematic diagram depicts the segments/scallops of the anterior mitral leaflet (AML): A1 anterolateral, A2 middle, A3 posteromedial and posterior mitral leaflet (PML): P1 anterolateral, P2 middle, P3 posteromedial. Ao, aorta. However, the evaluation of MV dysfunction is based on Carpentier s nomenclature. 9 The anterior mitral leaflet (AML) is divided into three segments: A1 (anetrolateral), A2 (middle), and A3 (posteromedial). Correspondingly, the posterior mitral leaflet (PML) is divided into three segments: P1 (anterolateral), P2 (middle), and P3 (posteromedial). Protrusion, billowing, or flail (including chordal rupture) of individual segments (six scallops) was noted. All images were recorded on videotape and acquired in digital cine-loop on magneto-optical disks. All segments were classified as normal, prolapsing (.3 mm beyond the annulus plane), or flail. 10 2D TEE and live 3D TEE images were analysed by two experts who were blind to the surgical findings. The surgeon identified individual segments/scallops of the MV by close inspection. All the MV specimens were sent for pathological examination. Degenerative mitral disease was defined when there was myxomatous change of leaflet tissue. 11 Results There was an excellent visualization of the MV for all segments/ scallops of both MV leaflets by live 3D TEE examination. Because the annulus of the MV is non-planar during systole, in MV prolapse, either the anterior or posterior leaflet protruded into the left atrium like a spoon (Figure 2). In patients with ruptured chordae tendineae the tip of the mitral leaflet protruded into the left atrium far away from the coaptation point during systole (Figures 3 and 4). Table 2 shows the anatomical (surgical finding) characteristics of the study population. The isolated segment most frequently involved was A2/P2, followed by A3/P3. On the other hand, A1or P1 rarely was involved in an isolated lesion or combined lesions. In nine patients, the live 3D TEE images revealed more segments or scallops with prolapse than the surgeon noted intraoperatively (Table 3). These segments were related to combine lesions with P2 or A2 (Figure 5). The agreement between 3D TEE and surgery was 88% (64/73). All MV operations were successful and the results were assessed and confirmed by 3D TEE (Figure 6) after patients were weaned from cardiopulmonary bypass. All patients recovered well except two whom had 33% Figure 2 Left frame: prolapse of the middle segment of the posterior mitral leaflet. 2D TEE shows bulging of PML (arrow). Middle frame: view in systole from the left atrium by live 3D TEE showing a large spoon-like leaflet in the P2 segment. Right frame: surgical view showing prolapse of the P2 segment with heart arrested and empty. Ao, aorta; LA, left atrium; LAA, left appendage; LV, left ventricle.

3 16 J. Wei et al. left ventricular ejection fraction (LVEF) preoperatively and needed intra-aortic balloon pump (IABP) support for 2 days in the ICU after surgery. The incidence of rheumatic valve disease (n ¼ 38, 52%) was slightly higher than that of degenerative valve disease (n ¼ 33, 45%). AML involvement (n ¼ 33, 45%) was more frequent than PML involvement (n ¼ 24, 33%) (Table 4). Figure 3 Ruptured chordae tendineae of the anteromedial segment of the anterior mitral valve leaflet (AML). Left upper frame: 2D TEE showing a large billowing leaflet of the AML with a small fragment of tissue (arrow). Left lower frame: live 3D TEE showing flail of the A3 segment and ruptured chordae tendineae (arrow). Right upper frame: live 3D TEE showing flail of the A3 segment like cobra head with a long chordae tendineae (arrow). Right lower frame: the surgeon inspected the MV from the left atrium demonstrating ruptured chordae tendineae at the A3 segment of the AML. Abbreviations as in Figure 1. Discussion Understanding the morphology and function of the MV is essential for surgical. Our study showed that live 3D TEE provides highly accurate online images for MV evaluation. Also, the classification of nine patients area of prolapse revealed by 3D TEE were missed by surgeon indicated that 3D TEE images have more sensitivity than that of surgical finding because the surgeon evaluates an immobile MV during bypass when the heart is arrested and empty, whereas 3D TEE assesses an online dynamic MV. A smaller area of prolapsing, especially if involving the A2 or P2 segment, might be missed by the surgeon during inspection when the heart is arrested. Even though such an area may be missed, it does not cause much of a hindrance for the results of. The results of this study add significantly to previously reported results indicating that the involvement of P1/A1 segments/scallops is rare and only found in combined lesions. The P1 segment was used for a standard as a reference point during the surgery. It may be controlled by a specific chordae in which a rare prolapse occurred but it remained unclear. Our results also may explain why the AML was more involved than the PML. This finding may due to Figure 4 Ruptured chordae tendineae of the middle segment of the anterior mitral valve leaflet (AML). Left frame: 2D TEE showing a bulging defect of the AML (arrow). Middle frame: the corresponding images viewed from left atrium (LA) by live 3D TEE showing flail of AML at the A2 segment with a visible long chordae tendineae (arrow). Right frame: the surgeon inspected the MV from the left atrium demonstrating ruptured chordae tendineae at the A2 segment of the AML. Abbreviations as in Figure 1. Table 2 Surgical findings in 73 patients with Carpentier s type II MR (October 2007 to December 2008) Segment/scallop Isolated lesions (n 5 42, total 42 Combined lesions (n 5 31, total 70 All, no. of seg. (%) segments), no. of seg. (%) segments), no. of seg. (%)... A1 1 (2%) 8 (11%) 9 (8%) A2 13 (31%) 17 (24%) 30 (27%) A3 9 (22%) 14 (20%) 23 (20%) P1 0 (0%) 4 (6%) 4 (4%) P2 13 (31%) 13 (19%) 26 (23%) P3 6 (14%) 14 (20%) 20 (18%) Abbreviations as in Figure 1.

4 Live 3D TEE in mitral valve surgery 17 Table 3 Comparison of different finding between surgery and live three-dimensional transesophageal echocardiography finding in nine patients with Carpentier s type II mitral regurgitation Live 3D TEE Mitral valve surgery No. of... pts Findings Operative findings... P2, P3 P2 MV Carpentier s ring 2 A2, A3 A2 MV Carpentier s ring 2 A3, P3 A3 MV Carpentier s ring 2 A1, A2 A2 MV Carpentier s ring 1 P1, P2 P2 MV Carpentier s ring 1 A1, A2, P1 A1, A2 MV Carpentier s ring 1 Abbreviations as in Figure 1; No. of pts, number of patients. Figure 5 Prolapse of the posterior mitral leaflet. Left frame: 2D TEE showing bulging of the PML (arrow). Right frame: view in systole from the left atrium by live 3D TEE showing a large spoon-like leaflet in the P2 and P3 segments (arrow) but only P2 was reported by surgeon when heart was arrested and empty. Abbreviations as in Figure 1. the incidence of rheumatic valve disease being higher in our case series. Posterior leaflet lesions were most frequently diseased in patient with degenerative valve disease, 2,3 especially involving the P2 segment. The detection of MV lesion location may be influenced by the change of blood pressure (BP), especially in 2D examination. 12 In our experience, use of the dopamine stress test to keep the patient s BP ^ 100 mmhg before surgery may be necessary in Figure 6 View of MV before and after surgery. Left upper frame: 2D TEE showing a protrusion of the posterior mitral leaflet (PML); the specific segment involved is hard to identify. Right upper frame: En face LA view by 3D TEE clearly delineating PML flail with chordae tendineae rupture (arrows) at the P1, P2, and P3 segments. Left lower frame: surgical view of MV from left atrium showing ruptured chordae tendineae at the P1, P2, and P3 segments (arrows). En face LA view with 3D TEE at early systole after surgery demonstrating that the AML and PML had good function and position after with annuloplasty (stars). Abbreviations as in Figure 1. Table 4 Clinical, echocardiographic, and surgical features in population (n 5 73) Mitral leaflet involved AML 34 pts (47%) PML 27 pts (37%) AML þ PML 12 pts (16%) Mitral regurgitation Prolapse 26 pts (36%) Ruptured chordae tendineae 29 pts (40%) Combined 18 pts (24%) Surgical procedure MV 30 pts (41%) MV replacement 43 pts (59%) LVEF (%) pts (93%),50 5 pts (7%) Pts, patients. patients with low cardiac output, not only for providing accurate anatomical information but also for predicting the outcome of recovery after surgery. There were five patients (7%) in this study with severe MR associated with low LVEF; three had

5 18 J. Wei et al. uneventful recovery with medication of dopamine infusion, whereas two (33% LVEF) needed IABP support postoperatively. This indicates that the late stage of MR results in low ejection fraction of the left ventricle; cardiac function restoration after complete MV surgical correction needs additional cardiac support. Therefore, to decrease the incidence of heart failure early surgical correction may be needed and encouraged for patients with severe MR due to flail leaflets. 13 Conventional 2D TEE is useful for guiding surgical analysis; live 3D TEE can show the surgeon a view of the MV perioperatively that is in even a more physiological state. 3D TEE allows visualization of the anatomic structure of the heart to be online and clearly identifies the valvular apparatus and its defects which mimic actual anatomy as viewed by the surgeon in situ. We conclude that 3D TEE should be regarded as an important adjunct to the standard 2D TEE examination in making decisions about MV. Therefore, live 3D TEE should become a new clinical standard for providing additional and complementary valvular morphological information. It may complement 2D TEE in patients with complex MV anatomy. Conflict of interest: none declared. References 1. Suri RM, Schaff HV, Dearani JA, Sundt TM III, Daly RC, Mullany CJ et al. Survival advantage and improved durability of mitral for leaflet prolapsed subset in the current era. Ann Thorac Surg 2006;82: Elkhorn G, Noirhomme P, Verhelst R, Rubay J, Dion R. Surgical of prolapsing anterior leaflet in degenerative mitral disease. J Heart Valve Dis 2000;9: Rankin JS, Sharma MK, Teaque SM, McLaughlin VW, Johnston TS, McRae AT. A new approach to mitral valve for rheumatic disease: preliminary study. J Heart Valve Dis 2008;17: Garcia-Orta R, Moreno E, Vidal M, Ruiz-Lopez F, Oyonarte JM, Lara J et al. Threedimensional versus two-dimensional transesophageal echocardiography in mitral valve. J Am Soc Echocardiogr 2007;20: Ma N, LI ZA, Meng X, Yang Y. Live three-dimensional transesophageal echocardiography in mitral valve surgery. Chin Med J 2008;20: Fabricius AM, Walther T, Falk V. Three-dimensional echocardiography for planning of mitral valve surgery: current applicability. Ann Thorac Surg 2004;78: Muller S, Muller L, Laufer G, Alber H, Dichtl W, Frick M et al. Comparison of three-dimensional imaging to transesophageal echocardiography for preoperative evaluation in mitral valve prolapse. Am J Cardiol 2006;98: Manda J, Kesanolla SK, Hsuing MC, Nanda NC, Abo-Salem E, Dutta R et al. Comparison of real time two-dimensional with live/real time three-dimensional transesophageal echocardiography in the evaluation of mitral valve prolapse and chordae rupture. Echocardiography 2008;25: Carpentier AF, Lessana A, Relland JYM, Belli E, Mihaileanu S, Berrebi AJ et al. The physio-ring : an advanced concept in mitral valve annuloplasty. Ann Thorac Surg 1995;60: Pepi M, Tamborini G, Maltagliati A, Galli CA, Sisillo E, Salvi L et al. Head-to-head comparison of two- and three-dimensional transthoracic and transesophageal echocardiography in the location of mitral valve prolapse. J Am Coll Cardiol 2006;12: Newcomb AE, David TE, Lad VS, Bobiarski J, Armstrong S, Maganti M. Mitral valve for advanced myxoma degeneration with posterior displacement of the mitral annulus. J Thorac Cardiovasc Surg 2008;136: Mukai S, Nomura M, Sugino Y, Yasunaka H, Ozaki M. The usefulness of intraoperative three-dimensional transesophageal echocardiography analysis for evaluation of mitral valve prolapse. Circ Control 2003;24: Ling LH, Enriquez-Sarano M, Seward JB, Orszulak TA, Schaff HV, Bailey KR et al. Early surgery in patients with mitral regurgitaion due to fail leaflet. Circulation 1997;96: