Utility Of Real Time Three-dimensional Transesophageal Echocardiography (RT-3D TEE) In The Intra-operative Assessment Of Mitral Valve Repair

Background and ObjectiveOver the past several decades, advancements in echocardiography have significantly contributed to its utility as an invaluable diagnostic tool for monitoring cardiac performance. Two-dimensional transthoracic echocardiography (2D TTE) and two-dimensional transesophageal echocardiography (2D TEE) have been demonstrated to be useful in evaluating the pathology of cardiac structures, but they do have certain hindrances, and its accuracy with which specific mitral valve (MV) scallop involvement is identified is expertise-dependent, and the sensitivity and specificity tend to decrease with more complex multisegment and bileaflet disease. Real time three-dimensional transesophageal echocardiography (RT-3D TEE) is less time-consuming than 2D TEE and was superior in defining specific MV pathology according to previous reports.The feasibility and the clinical utility of RT-3D images in the assessment of native valves, especially the MV, was recently demonstrated in several clinical investigations. The goal of our study was 1) to determine its potential clinical utility by establishing its accuracy for diagnosing MV pathology compared with findings obtained by direct inspection and 2) to evaluate the function of MV postoperatively. MethodsTwenty-one consecutive adult patients (16male,5 female, mean age 52±11 years) with established diagnosis of mitral regurgitation (MR) scheduled for surgical correction were enrolled. Intraoperative 2D and 3D TEE were performed. All the 3D images were compared with findings obtained from direct surgical inspection. Post-operative RT-3D TEE was performed immediately to evaluate outcomes of mitral annuloplasty.ResultsSuperb 3D-TEE en face views of the MV were obtained in all patients. Correct diagnoses of MV pathology in agreement with the surgical findings were made in 18 of 21 patients (85.7%), however in the remaining 3 patients, the diagnoses were incorrect despite good image quality. In one, RT-3D TEE diagnosed prolapse of A2 segment and P2 scallop, which was not confirmed at surgery, but MV degeneration and annular dilatation were observed. In another one, RT-3D TEE revealed prolapse of P3 scallop, while at surgery prolapse involved P2 and P3 with ruptured chordae. In the rest one, surgically detected prolapse of P2 was missed by RT-3D TEE. On the other hand with 2D TEE, the diagnoses correlated poorly with surgical findings. Only 11 patients were accurately diagnosed (52.4%).In some patients,2D TEE was able to identify the MVP, but it had difficulty in defining the exact location of the prolapsed segment or scallop. The severity of MR decreased significantly after surgery. MV repair was successful in all patients except one(4.8%), in whom moderate to severe MR was still present and MV replacement was conducted subsequently as an alternative.ConclusionRT-3D TEE provides excellent imaging of MV components, including the anterior and posterior leaflets, as well as annulus and subvalvular structures, which can be especially helpful in planning the most appropriate surgery strategy. What's more, RT-3D TEE offers exact anatomic characteristics of mitral annuloplasty rings and bands, providing additional information for the evaluation of surgical outcomes.