J Cardiovasc Ultrasound.  2012 Jun;20(2):69-76. 10.4250/jcu.2012.20.2.69.

Assessment of Mitral Valve Complex by Three-Dimensional Echocardiography: Therapeutic Strategy for Functional Mitral Regurgitation

• Yoshida K
• Obase K

• KMID: 2177368
• DOI: http://doi.org/10.4250/jcu.2012.20.2.69

Abstract

The mitral valve complex is consisted of annulus, leaflets, chordae tendineae, papillary muscle (PMs) and surrounding left ventricle. Functional mitral regurgitation (MR) results from left ventricular remodeling such as dilatation or distortion, which displaces the PMs and then tethers the mitral leaflets, restricting leaflet coaptation. Undersized annuloplasty, which has been widely accepted as a simple and effective procedure for functional MR, sometimes worsens the tethering of posterior leaflet and induces recurrent MR. In order to overcome such problems, several additional procedures to the simple annuloplasty have been produced. Three dimensional echocardiography plays an essential role to understand the geometry of mitral valve complex and contributes greatly to decision making of the surgical strategy in functional MR and its postoperative assessment.

Keyword

Mitral valve complex; 3D echocardiography; Functional mitral regurgitation

MeSH Terms

Chordae Tendineae
Decision Making
Dilatation
Echocardiography, Three-Dimensional
Heart Ventricles
Mitral Valve
Mitral Valve Insufficiency
Papillary Muscles
Ventricular Remodeling

Figure

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  Fig. 1 Mitral valve complex. The whole mitral valve complex geometry consisted of annulus, leaflets, chordae, papillary muscles and surrounding left ventricle. Mitral annulus shows a nonplanar saddle-shaped configuration in healthy individual. There are two peaks at the aortic insertion and posterior left ventricular wall and two low troughs closest to the apex located medially and laterally (Otto1) and Levine et al.2) with permission). LA: left atrium, LV: left ventricle.

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  Fig. 2 Mitral annulus configuration. Three dimensional echocardiography allowed us to visualize the dilatation and flattening of the mitral annulus in patients with ischemic mitral regurgitation and more deformation in anterior infarction compared to posterior infarction (Watanabe et al.23) with permission). MI: myocardial infarction.

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  Fig. 3 Visualizing the annular flattening and leaflet tenting. The reconstructed three-dimensional (3D) images by Real View allow us to understand the annular flattening or mitral leaflet tenting in patients with functional mitral regurgitation (MR) and it also can be quantitatively measured and analyzed in 3D spaces, which is impossible to do in two-dimensional images (Watanabe et al.22) with permission).

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  Fig. 4 Surgical procedures for subvalvular apparati or left ventricle. Undersized annuloplasty sometimes fails to ameliorate mitral regurgitation (MR) in patient with severely tethered mitral leaflet and worsen the tethering of posterior leaflet, resulting recurrent MR. In addition, undersized annuloplasty has a possibility to induce functional mitral stenosis. Therefore, additive procedures should be considered for patients with severely tethered valve. PM: papillary muscle.

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  Fig. 5 Papillary heads optimization method. In Papillary heads optimization method, the papillary muscle (PM) head for posterior leaflet was connected to the PM head for anterior leaflet by using a PTFE suture in each PM. After annuloplasty by a semi-rigid ring, its arms were re-suspended towards the mid-anterior mitral annulus and the sutures were passed through it and tied after the length adjustment. PTFE: polytetrafluoroethylene.

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  Fig. 6 Visualizing the submitral structure by transgastric approach. Visualizing submitral structure at mid systole from a three-dimensional dataset acquired by transgastric approach using QLAB (Philips Medical Systems, Andver, MA, USA), with coronal section (commissure-commissure direction) view (upper left), sagittal section (anterior-posterior leaflet direction) view of posterior papillary muscle (PPM) (upper right) and short axis view (lower left and right). APM: anterior papillary muscle, pp: PPM head for posterior leaflet, pa: PPM head for anterior leaflet.

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  Fig. 7 Pre- and postoperative observation of papillary heads optimization method. Postoperative connected papillary muscle head for anterior leaflet and for posterior leaflet of each papillary muscle by papillary heads optimization procedure is clearly visualized by three-dimensional transesophageal echocardiography with transgastric approach. PPM: posterior papillary muscle, APM: anterior papillary muscle, pp: PPM head for posterior leaflet, pa: PPM head for anterior leaflet, aa: APM head for anterior leaflet, ap: APM head for posterior leaflet.

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  Fig. 8 Quantitative analysis of submitral structure. With the aid of quantitative software, acquired three-dimensional volume dataset allows accurate measurement of the pre and postoperative distance between papillary muscle head and mid-anterior annulus and the tenting volume, etc. Vo: mid-anterior annulus point, pp: posterior papillary muscle (PPM) head for posterior leaflet, pa: PPM head for anterior leaflet, aa: anterior papillary muscle (APM) head for anterior leaflet, ap: APM head for posterior leaflet, PM: papillary muscle.

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