Vintage Drawing Instrument Set

The Role of 3-dimensional
Echocardiography in the Evaluation of
Mitral Valve Diseases
Dr. Astrid Apor
Semmelweis University Budapest
3DE, as the ultrasound shows
the reality
Advantages of 3DE
Improved understanding of…
• valvular morphology
• graphic reconstruction
quantitative analysis
• realistic representation
of the valve for surgeons
• pathomechanism of
regurgitation
• quantification of severity
Mitral valve apparatus
Chordae tendineae
Mitral annulus
Size
Shape
Sphincteric function
Mitral annulus
Contraction of the mitral
annulus
Contraction

Decrease of the
annular area
Annular dilatation
Normal:
Syst. area: 4.4cm²
Diast. area: 7cm²
Contraction: ~36%
Remodelling:
Syst. area: 9cm²
Diast. area: 10cm²
Contraction: ~15%
Mitral annulus calcification
Mitral leaflets
Mitral leaflets
Mitral leaflets
ME Four Chamber View
Systematic characterization of the
mitral valve by 3D Salcedo et al. JASE 2009
Biplane real time: 25-28Hz, 30-35msec, color doppler
Narrow sector: 24-37Hz, 33-40msec no color
Large sector gated: 20-25Hz, 35-50msec color doppler
Wide sector focused : 5-15Hz, 160msec, no color
Volume-rendering
En face, en bottom
Close up view
iCrop
3D methods of analysis
1, Thresholding, postprocessing
2, Cropping
3, Measuring
4, Modelling
MPR
multiplanar reconstruction
Segmental analysis
multiplanar reconstruction
Analysis of scallops
24
Ogara et al. JACCI 2008
Mitral leaflets
A1
P1
A2 A3
P2
P3
Assessment of pathomechanism of MR
inaccuracy of 2DE
2D TEE 120°
2D TEE 0°
correct identification correct identification
of scallops
of scallops
A2P2
A1P1
A3P3
69%
14%
5.6%
50%
47%
5.6%
Mahmood, J Cardiothorac Vasc Anesth 2012
Mitral valve quantification
3D parameters of the mitral leaflets
3D curvilinear length
3D surface area
Height of prolapse/ Depth of tenting
Volume of prolapse/tenting
Planning of valve repair
Dynamic model of the valve
Adaptation of the valve
3D leaflet surface area
increases during stress
Acute: +15% elongation
=distensibility
Chronic: +35%
=expansion
Zone of coaptation
Reduction of coaptational
zone
Zone of coaptation
Etiology of MR
•
•
•
•
•
•
•
•
•
•
•
Congenital: cleft
Degenerative (myxomatous, fibroelastic)
Rheumatic
Endocarditis
Ischaemia (local / global remodelling of the LV,
ischaemia/infaectio/rupture of the papillary muscles)
Calcific degeneration
Traumatic injury
DCM (LV remodelling, anular dilatation)
HOCM (SAM)
RCM
Endomyocardial fibroelastosis
Carpentier classification of MR
Normal mobillity
Increased mobility
excessive motion
Decreased mobility
restrictive motion
Carpentier I
Mitral clefts
Carpentier II
Myxomatous valve disease
Myxomatous valve disease I.
Barlow disease
Barlow disease
Younger patients  60 years
Long-standing murmur
Redundancy of leaflets
Thickening of leaflets
Billowing
Severe annular dilatation
Thickened, elongated chordae
prolapse
Multiscallop involvement
Complex lesion
Myxomatous valve disease II.
Fibroelastic Deficiency FED
Myxomatous valve disease II.
Fibroelastic Deficiency FED
Older patient  60 years
New onset murmur
Leaflet thickening at
prolapse
Anterior leaflet spared
Chordal rupture
Few scallops are affected
Moderate annular dilatation
Simple lesion
Easy to repair
Differentiation between Barlow disease
and FED (Fibroelastic deficiency)
Types of myxomatous
Mitral valve disease
3D TEE
Height of billowing > 1mm
Normal
Degenerative MVP
Billowing volume > 1.15ml
FED
Barlow: length of anterior leaflet: > 36mm
Barlow
46
Chandra, Circ. CV Imaging 2011
Carpentier IIIb
Functional mitral regurgitation
Tethering forces
Annular dilatation
Local / global
remodelling of LV
Dislocation of papillary
muscles
Closing forces
Systolic disfunction
Dyssynchronia
Annulus
sphincteric action
Remodelling of the LV
Functional mitral regurgitation
Functional mitral regurgitation
FMR
Hypodynamic,
enlarged annulus
Leaflet tethering
Incomplete coaptation
Normal valve anatomy
Regional / global
LV remodelling
Functional mitral regurgitation
Chronic tethering

Coaptation zone
Mitral regurgitation
Leaflet adaptation

Leaflet surface area
Mitral regurgitation
Dal-Bianco et al. Circulation 2009
Functional mitral regurgitation
systole
MR flow rate in time
Tenting volume in time
Song et al. Am J Cardiol 2006
Quantification of MR
Can 3DE help?
Vena contracta width
Flow convergence method
Doppler volumetric
method
3D vena contracta area
AROA
3D PISA
3D derived areas
3D volumes
3D volumetric color flow
Assessment of severity of MR
Limitations of conventional methods
VENA CONTRACTA
Geometric assumption:
circular orifice
QUANTITATIVE
DOPPLER
• Geometric assumption:
mitral annular area
LVOT area
• Not valid in AR
• Sample volume location
• Multiple measurements
• Time consuming
PISA
• Geometric assumption:
hemispheric
- irregular orifices
- eccentric jets
- multiple jets
• PISA shape affected by
- aliasing velocity
- alignment
- distance from orifice
- flow constraintment
• Cyclic variation in time
• Interobserver variability
Irregularity of the regurgitant
orifice
Shape of 3D VCA ~ EROA
FMR
FMR
Multiple jets
Vena Contracta Anatomical
orifice
3D en face view
vena contracta
area
PISA
Quantitative
Doppler
3D PISA
3D volumetric
surface
flow measurements
62
Hemielliptic model
Quantification of the severity of MR
vena contracta area
Quantification of the severity of MR
vena contracta area
The method is validated
Limitations: spatial, temporaly resolution, system settings
3D VCA limitations
• Temporal resolution: largest ERO missed
• Stitch artifacts, reconstructed images
• Spatial resolution (beam width, angle of
acquisition)
• Delineation of the jet, axis of the jet
• Aliasing of color flow data
• Off-line analysis, processing time
AROA
3D anatomical regurgitant orifice area
Chandra, Am J Physiol Heart Circ Physiol 2011
3D characterization of PISA
FUTURE
3 dimensional
hemielliptical
PISA surface calculation
Automated 3D
PISA surface recognition
Kahlert JASE 2008
Automated 3D PISA surface recognition
90x90 volume
40 vps
PISA 3D surface

MR quantification
Automated 3D PISA surface recognition
Cobey et al. JCVTA 2012
Volumetric color flow quantification
Stroke volume, MR,
ASD, VSD, PFO
Thavendiranathan et al. JASE 2012
3D TEE in Mitral Valve Repair
The role of 3DE before MV repair
Neochorda implantation
Papillary muscle replacement
Ring selection
Technique
of repair
Suitability for MV repair
Complexity of repair
Assessment of
MR pathomechanism
MR quantification
Indication for surgery
3D in myxomatous valve disease
3D vena contracta area
3D appearance of MR
3D LV function
Aortico-mitral
angle
Indication for surgery?
Risk of SAM?
3D axes of annulus
annulus height
annular dynamics
3D length of leaflets
3D surface of leaflets
volume of prolapse
coaptation zone area
Commissurepapillary
muscle distances
Ruptured chordae
Feasibility for repair?
Which annuloplasty ring?
Which surgical method?
MR pathomechanism
origin of the jet
MR pathomechanizmus
How to characterize the lesion by 3DE
Is the coaptation maintained?
YES
NO
Where is the coaptation?
Below the annulus
↓
Depth of coaptation
6-8mm
Tenting?
Billowing?
Marginal prolapse?
Above the annulus
↓
Segmental analysis
Height of prolapse
Volume of prolapse
Pseudo cleft?
Length of coaptation?
3.2-6.5mm
Flail (ruptured chordae)
or
Overturned scallop
(elongated chordae)
MV prolapse: scallop by scallop analysis
prolapse+secondary tenting
Thickness
of scallop
(mm)
Billowing
Prolapse
height (mm)
Billowing
Prolapse
Volume
(ml)
Marginal
prolapse
Chordal
elongation
Overturned
scallop
Flail
2
Tent 4
Tent 0.1
+
+
0
0
2
Tent 4
Tent 0.1
0
0
0
0
2
Tent 5
Tent 0.1
0
0
0
0
2
3
0.1
0
+
+
0
5
8
0.6
0
3
4
0.2
0
+
+
0
AL
C
0
-
-
-
-
-
-
PM
C
0
-
-
-
-
-
-
A1
A2
A3
P1
P2
P3
+
Prolapse score: 3/8, Prolapse volume: 0.9ml, Prolapse height: 8mm
Biomechanical simulation of
mitral valve function
3D TEE dataset
Geometrical information
annulus, leaflets, chordae
Geometrical information
annulus, leaflet motion
Virtual valve model
annulus, leaflet
model
papillary muscle
model
Model of
chordae
Simulation of valve function
anular
motion
Pressure gradients
leaflet stress
chordal stressz
contact pressure
Biomechanical simulation of
mitral valve function
FED
stress distribution on the leaflets
Rim, JACC CVI 2013
Biomechanical simulation of
mitral valve function
BARLOW
stress distribution on the leaflets
Rim, JACC CVI 2013
Suitability for mitral valve repair
PATHOLOGY
Surgeon
Predictors of suitability for repair
estimation of the complexity of repair
•
•
•
•
•
•
•
•
•
•
Type of myxomatous degeneration
Number of prolapsing scallops (>3), bileaflet prolapse
Anterior or commissural prolapse
Height of prolapse
3D surface of anterior leaflet
Angle of posterior leaflet
Severe annular dilatation (>50mm)
Extensive calcification
Severe, central jet
Thinning of leaflet
83
Chickwe, European Journal of Cardio-Thoracic Surgery 2012
New 3D parameters of mitral valve
quantification
dynamicity of parameters…
Annulus
• AP, CC diameter
• height
• 3D area, circumference
• ellipticity
• contraction
Leaflets
• surface area, 3D length
• angle of non-planarity
• prolapse / tenting height,
volume
• zone/length of coaptation
• Length of chordae
• aortico-mitral angle
• Intertrigonal distance
Mitral leaflets
Anterior leaflet area
→ size of the ring
→ complexity of repair
Length of scallops
→ leaflet augmentation
Leaflet area,
height, volume
of prolapse
→ extent of resection
Total leaflet area= 1.4 x annular area
Anterior leaflet area= 1.5 x posterior leaflet area
Anterior length= 2.3 x posterior leaflet length
Mitral annulus
• Saddle shaped:
height/ long diameter>15%
ellipticity: 130°
• Systolic contraction:~ 25%
height 
AP diameter
systolic „folding”
Mitral annuloplasty
objective: reestablishment of coaptation
Size, shape, contractility of
annulus
Amount of mobile
leaflet tissue
Risk of SAM
Aortico-mitral
angle
Anterior/posterior
leaflet length
(<1.3)
Coaptationseptum distance
(<25mm)
88
Ring sizing
Length of anterior leaflet
Intercommissural diameter
Intertrigonal distance
Visual assessment
3DE measurements
Intertrigonal distance
Intertrigonal distance: 35mm
Ring sizing with
dedicated software (Ring Tool, TomTec)
• Digital model of the
ring
• Superimposition of
ring model onto the
3D loops of the
valve
„ fit on the ring”
Ender, EJE 2011
Ring selection
Flat↔Saddle shaped
Saddle shaped ↔ flat ring
effect on coaptation
The saddle ring more profoundly augments coaptation length, than the flat ring.
Vergnat et al, Ann Thor Surg 2011
Premeasure of the length of arteficial
chordae
3D multiplanar reconstruction
Shorter CPB time
Shorter aortic
cross-clamp time
Improving results
Huang, J Cardiothoracic Surg 2013
Planning of papillary muscle
relocation
New position of
papillary muscles
Truncated cone model of valve geometry
Fattouch et al, J Trorac Cardiovasc Surg 2012
Individualized technique of
repair
Individualized, annular-valvular-ventricular,
complex mitral valve repair!
Interactive surgical simulator for
mitral valve repair
predicted
valve shape
Image
processing
segmentation
meshing
model
Interactive
valve
simulator
Surgeon
evaluation
Surgical plan
Virtual surgery
Tenenholz et al.2011
Interactive surgical simulator for
mitral valve repair
Virtual surgery
Tenenholz et al.2011
Success rate of durable mitral
repair
At least 25 MV repair/year with 90% success rate, mortality < 1%
Thank you for your patience!
Let’ s do it with 3D!
Quantification of mitral stenosis
• MVA (valve area)
Planimetry
PHT
Continuity equation
• Valve Resistance
1333 x TMPG x Q
• TMPG
(transmitral pressure
gradient)
• PASP
(pulmonary artery
systolic pressure)
Limitation of 2D planimetry
• Funnel-shaped orifice
Rheumatic mitral stenosis
Indications of 3DE in valvular heart
diseases
EAE/ASE Recommendations 2012