Multimodality imaging assessment of mitral annular disjunction in mitral valve prolapse.

OBJECTIVE: Mitral annular disjunction (MAD) is an abnormality linked to mitral valve prolapse (MVP), possibly associated with malignant ventricular arrhythmias. We assessed the agreement among different imaging techniques for MAD identification and measurement. METHODS: 131 patients with MVP and significant mitral regurgitation undergoing transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) were retrospectively enrolled. Transoesophageal echocardiography (TOE) was available in 106 patients. MAD was evaluated in standard long-axis views (four-chamber, two-chamber, three-chamber) by each technique. RESULTS: Considering any-length MAD, MAD prevalence was 17.3%, 25.5%, 42.0% by TTE, TOE and CMR, respectively (p<0.05). The agreement on MAD identification was moderate between TTE and CMR (κ=0.54, 95% CI 0.49 to 0.59) and good between TOE and CMR (κ=0.79, 95% CI 0.74 to 0.84). Assuming CMR as reference and according to different cut-off values for MAD (≥2 mm, ≥4 mm, ≥6 mm), specificity (95% CI) of TTE and TOE was 99.6 (99.0 to 100.0)% and 98.7 (97.4 to 100.0)%; 99.3 (98.4 to 100.0)% and 97.6 (95.8 to 99.4)%; 97.8 (96.2 to 99.3)% and 93.2 (90.3 to 96.1)%, respectively; sensitivity (95% CI) was 43.1 (37.8 to 48.4)% and 74.5 (69.4 to 79.5)%; 54.0 (48.7 to 59.3)% and 88.9 (85.2 to 92.5)%; 88.0 (84.5 to 91.5)% and 100.0 (100.0 to 100.0)%, respectively. MAD length was 8.0 (7.0-10.0), 7.0 (5.0-8.0], 5.0 (4.0-7.0) mm, respectively by TTE, TOE and CMR. Agreement on MAD measurement was moderate between TTE and CMR (ρ=0.73) and strong between TOE and CMR (ρ=0.86). CONCLUSIONS: An integrated imaging approach could be necessary for a comprehensive assessment of patients with MVP and symptoms suggestive for arrhythmias. If echocardiography is fundamental for the anatomic and haemodynamic characterisation of the MV disease, CMR may better identify small length MAD as well as myocardial fibrosis.

Echocardiographic Assessment of the Tricuspid Annulus: The Effects of the Third Dimension and Measurement Methodology.

BACKGROUND: Evaluation of the tricuspid annulus is crucial for the decision making at the time of left heart surgery. Current recommendations for tricuspid valve repair are based on two-dimensional (2D) transthoracic echocardiography (TTE), despite the known underestimation compared with three-dimensional (3D) echocardiography. However, little is known about the differences in 3D tricuspid annular (TA) sizing using TTE versus transesophageal echocardiography (TEE). The aims of this study were to (1) compare 2D and 3D TA measurements performed with both TTE and TEE and (2) compare two 3D methods for TA measurements: multiplanar reconstruction (MPR) and dedicated software (DS) designed to take into account TA nonplanarity. METHODS: Seventy patients underwent 2D and 3D TTE and TEE. Two-dimensional images were used to measure TA diameter from apical four-chamber, right ventricular-focused (TTE), and midesophageal four-chamber (TEE) views. Three-dimensional full-volume data sets were analyzed using both MPR and DS, to obtain major and minor axes, perimeter, and area. Intertechnique agreement was assessed using Bland-Altman analysis. RESULTS: Measurements on 2D TTE and TEE, which were view dependent, underestimated TA major dimensions in all views compared with 3D values, irrespective of the 3D method. MPR and DS measurements were significantly different, with DS resulting in larger values for all parameters, irrespective of approach. No differences were found between 3D TTE and 3D TEE for both MPR and DS. CONCLUSIONS: Our findings highlight the need for methodology that respects the 3D geometry of the tricuspid annulus, including its nonplanarity, which cannot be accurately assessed from 2D images and is not equally taken into account by different 3D measurement methodologies. Accordingly, a 3D cutoff value for TA enlargement needs to be established and is likely to be larger than the guideline-recommended 2D-based 40-mm cutoff. Importantly, noninvasive 3D TTE can be used instead of 3D TEE because TA measurements are not different.

Comprehensive Assessment of Mitral Valve Geometry and Cardiac Remodeling With 3-Dimensional Echocardiography After Percutaneous Mitral Valve Repair.

MitraClip is a validated treatment for significant mitral regurgitation (MR) in high-risk patients. Aims of the study were to evaluate immediate changes in mitral valve (MV) geometry induced by MitraClip and correlations between baseline geometry and cardiac remodeling. Eighty patients who underwent MitraClip for primary (48%) or secondary (52%) MR were enrolled. Intraoperative transesophageal echocardiographic 3D images were acquired immediately before and after the procedure for MV annulus (MVA) morphology analysis. Transthoracic 3D echocardiography was performed preoperatively and at 6 months follow-up (6MFU). Patients were classified on the basis of MR reduction (ΔMR) at 6MFU as Optimal (ΔMR ≥ 2) or Suboptimal (ΔMR < 2). An optimal result was reached in 60 (75%) patients, whereas 20 subjects showed a ΔMR< 2 at 6MFU. The Optimal showed significantly smaller baseline MVA (antero-posterior diameter 4.05 ± 0.59 vs 4.43 ± 0.68 cm; anterolateral-posteromedial diameter 4.38 ± 0.56 vs 4.70 ± 0.73 cm; MVA circumference 14.1 ± 1.7 vs 15.1 ± 2.3 cm; and 3D area 14.8 ± 3.9 vs 17.4 ± 5.3 cm2), lower sphericity index and nonplanar angle compared with Suboptimal. A value of antero-posterior diameter ≥4.44cm was identified (receiver-operating characteristic curve) as a possible cut-off for preoperative identification of Suboptimal patients. Postoperatively, MitraClip induced reduction of MVA flattening (nonplanar angle), sphericity index, and size (as expressed by antero-posterior diameter, MVA circumference and area). At 6MFU, the Optimal showed significant decrease in left ventricular volumes and pulmonary artery systolic pressure. In conclusion, MitraClip induces remarkable changes in MVA geometry and favorable left ventricular remodeling is detected in patients with optimal mid-term outcome; a preprocedural antero-posterior diameter <4.44cm seems to be a potential predictor of mid-term optimal result.

Technological Advancements in Echocardiographic Assessment of Thoracic Aortic Dilatation: Head to Head Comparison Among Multidetector Computed Tomography, 2-Dimensional, and 3-Dimensional Echocardiography Measurements.

PURPOSE: The aim of this study was to evaluate the feasibility and accuracy of 2-dimensional (2D) and 3-dimensional (3D) transthoracic echocardiography (2DTTE, 3DTTE) versus multidetector computed tomography (MDCT) in patients with ascending aortic (AA) dilation. MATERIALS AND METHODS: Fifty consecutive patients with AA dilation were evaluated by 2DTTE, X-plane (XP) 3DTTE, and MDCT. Aorta diameters were measured at aortic annulus, aortic root (SIN), sinotubular junction, AA, aortic arch before the prebrachiocephalic artery (PRE), and before left subclavian artery (INTRA). Leading edge-to-leading edge (L-L) and inner-to-inner (I-I) measurements were compared with MDCT data. RESULTS: Feasibility, quality of imaging, and accuracy was high with all echocardiographic methods. Specifically for MDCT maximum SIN diameter, the best correlation and agreement was obtained using XP maximum diameter at 3DTTE (MDCT: 44.8±7.4 mm vs. XP: 44.4±7.4 mm; r=0.975; bias=-0.4 mm). The same was true for AA maximum diameter at MDCT (MDCT: 46.6±8.1 mm vs. XP: 47.5±8.1 mm; r=0.991; bias=0.1 mm). For aortic arch the best correlation and agreement with MDCT were as follows: 2DTTE L-L diameter for arch PRE (MDCT: 37.9±5.3 mm vs. TTE: 36.6±4.5 mm; r=0.927; bias=-0.9 mm) and MDCT minimum diameter with XP minimum diameter for arch INTRA (MDCT: 28.2±5.0 mm vs. TTE 28.8±4.7 mm; r=0.939; bias=-0.3 mm). CONCLUSION: In patients with aortic dilatation or aneurysm, new techniques (mainly 2D-3D probes allowing XP views) facilitate accuracy of aortic measurements at different sites of the vessel and allow standardization of analysis to better compare with MDCT.

Comparison of accuracy of aortic root annulus assessment with cardiac magnetic resonance versus echocardiography and multidetector computed tomography in patients referred for transcatheter aortic valve implantation.

The evaluation of the aortic root in patients referred for transcatheter aortic valve implantation is crucial. The aim of the present study was to compare the accuracy of cardiac magnetic resonance (CMR) evaluation of the aortic annulus (AoA) with transthoracic and transesophageal echocardiography and multidetector computed tomography (MDCT) in patients referred for transcatheter aortic valve implantation. In 50 patients, maximum diameter, minimum diameter and AoA, length of the left coronary, right coronary, and noncoronary aortic leaflets, degree (grades 1 to 4) of aortic leaflet calcification, and distance between AoA and coronary artery ostia were assessed. AoA maximum diameter, minimum diameter, and area by CMR were 26.4 ± 2.8 mm, 20.6 ± 2.3 mm, 449.8 ± 86.2 mm(2), respectively. The length of left coronary, right coronary, and noncoronary leaflets by CMR were 13.9 ± 2.2, 13.3 ± 2.1, and 13.4 ± 1.8 mm, respectively, whereas the score of aortic leaflet calcifications was 2.9 ± 0.8. Finally, the distances between AoA and left main and right coronary artery ostia were 16.1 ± 2.8 and 16.1 ± 4.4 mm, respectively. Regarding AoA area, transthoracic and transesophageal echocardiography showed an underestimation (p <0.01), with a moderate agreement (r: 0.5 and 0.6, respectively, p <0.01) compared with CMR. No differences and excellent correlation were observed between CMR and MDCT for all parameters (r: 0.9, p <0.01), except for aortic leaflet calcifications that were underestimated by CMR. In conclusion, aortic root assessment with CMR including AoA size, aortic leaflet length, and coronary artery ostia height is accurate compared with MDCT. CMR may be a valid imaging alternative in patients unsuitable for MDCT.

Aortic annulus area assessment by multidetector computed tomography for predicting paravalvular regurgitation in patients undergoing balloon-expandable transcatheter aortic valve implantation: a comparison with transthoracic and transesophageal echocardiography.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a valid alternative to surgery in high-risk patients with severe aortic stenosis. Aortic annulus (AoA) sizing is crucial for TAVI success. The aim of the study was to compare AoA dimensions measured by multidetector computed tomography (MDCT) vs those obtained with transthoracic (TTE) and transesophageal echocardiography (TEE) for predicting paravalvular aortic regurgitation (PVR) after TAVI. METHODS: Aortic annulus maximum diameter, minimum diameter, and area were assessed using MDCT and compared with TTE and TEE diameter and area for predicting PVR after TAVI in 151 patients (45 men, age 81.2 ± 6.4 years). RESULTS: Aortic annulus maximum, minimum diameter, and area detected by MDCT were 25.04 ± 2.39 mm, 21.27 ± 2.10 mm, and 420.87 ± 76.10 mm(2), respectively. Aortic annulus diameter and area measured by TTE and TEE were 21.14 ± 1.94 mm and 353.82 ± 64.57 mm(2) and 22.04 ± 1.94 mm and 384.33 ± 67.30 mm(2), respectively. A good correlation was found between AoA diameters and area evaluated by MDCT vs TTE and TEE (0.61, 0.65, and 0.69 and 0.61, 0.65, and 0.70, respectively), with a mean difference of 3.90 ± 1.98 mm, 0.13 ± 1.67 mm, and 67.05 ± 55.87 mm(2) and 3.0 ± 2.0 mm, 0.77 ± 1.70 mm, and 36.54 ± 56.43 mm(2), respectively. Grade ≥2 PVR occurred in 46 patients and was related to male gender, higher body mass index, preprocedural aortic regurgitation, and lower mismatch between the nominal area of the implanted prosthesis and AoA area detected by MDCT. CONCLUSIONS: Mismatch between prosthesis area and AoA area detected by MDCT is a better predictor of PVR as compared with echocardiography mismatch. Specific MDCT-based sizing recommendations should be developed.

Feasibility and accuracy of a routine echocardiographic assessment of right ventricular function.

The evaluation of right ventricular (RV) systolic function is important for its clinical and prognostic value but difficult to obtain due to RV complex anatomy. Aims of this study were to evaluate the feasibility of a routine use of RV fractional shortening area (FSA), systolic excursion (TAPSE) and peak systolic velocity (PSV) of tricuspidal annular motion in a large series of cases (900 pts), to determine the values in normal subjects (150) and in patients (750) with different pathologies and to correlate these indexes to clinical and echo-Doppler variables. FSA (50.3+/-10% vs 54.6+/-9% p<0.01), TAPSE (20.2+/-5 vs 24.7+/-4 mm, p<0.01) and PSV (16.2+/-4 vs 20+/-4 cm/s, p<0.01) were lower in patients than in normals, correlated positively to left ventricular ejection fraction and negatively to the pulmonary pressure. The values of 17 mm for TAPSE, 12 cm/s for PSV and 37% for FSA identified patients with high specificity. The values in subgroups of pathological patients were evaluated and compared.

Feasibility and diagnostic accuracy of quantitative assessment of mechanical prostheses leaflet motion by transthoracic and transesophageal echocardiography in suspected prosthetic valve dysfunction.

Transthoracic (TTE) and transesophageal echocardiography (TEE) are the standard techniques for the evaluation of prosthetic valve function. However, quantitative evaluation of leaflet(s) motion is not routinally carried out, although leaflet(s) opening and closing angle measurements are important information to recognize prosthetic dysfunction. For this purpose, cinefluoroscopy is considered the "gold standard" technique. The aim of this study was the evaluate the diagnostic accuracy of TTE and TEE in the quantitative assessment of leaflet motion in patients with mechanical protheses. One hundred-eleven patients with mitral (single disk 18; bileaflet 48) and aortic (single disk 22; bileaflet 23) prostheses, were referred to TTE, TEE, and cinefluoroscopy for electrical cardioversion of atrial fibrillation (n = 40) or suspected prosthesis dysfunction (n = 71). Echocardiographic evaluation included leaflet(s) opening and closing angle measurements; results were compared with cinefluoroscopy. For mitral prostheses, opening and closing angles were correctly identified by TTE in 85% and by TEE in 100% of patients, regardless of prosthetic valve type, with a good concordance with cinefluoroscopy. For aortic prostheses, opening angles were correctly identified by TTE and TEE, respectively, in 40% and 77% of patients with single-disk and in 13% and 35% of patients with bileaflet prostheses. Both TTE and TEE were rarely able to identify closing angles. In conclusion, quantitative evaluation of mitral leaflet(s) motion may be accurately achieved with TTE and TEE, leading to increased diagnostic efficacy of prosthetic valve dysfunction. In the aortic position, TTE and TEE allow a quantitative evaluation of leaflet(s) dynamics only in a minority of patients and cinefluoroscopy still remains the first-choice technique.