J Cardiovasc Imaging.  2019 Jul;27(3):187-199. 10.4250/jcvi.2019.27.e29.

A Modified Echocardiographic Classification of Mitral Valve Regurgitation Mechanism: The Role of Three-dimensional Echocardiography

• de Groot-de Laat LE
• McGhie J
• Ren B
• Frowijn R
• Oei FB
• Geleijnse

• KMID: 2456854
• DOI: http://doi.org/10.4250/jcvi.2019.27.e29

Abstract

In this report, we provide an overview of a new, updated echocardiographic classification of mitral regurgitation mechanisms to provide a more comprehensive and detailed assessment of mitral valve disorders. This is relevant to modern mitral valve repair techniques, with special attention to the added value of 3D-echocardiography.

Keyword

Mitral regurgitation; Mechanism; Echocardiography; Three-dimensional echocardiography

MeSH Terms

Classification*
Echocardiography*
Echocardiography, Three-Dimensional*
Mitral Valve Insufficiency*
Mitral Valve*

Figure

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  Figure 1 Mitral valve perforation in the medial part of the anterior leaflet, identified with 2D grayscale (A, see arrowhead), 2D color (B), and with 3D echo from the left atrial (surgical) view (C, see arrowhead).

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  Figure 2 Three-dimensional echocardiographic surgical view of an anterior mitral valve leaflet cleft seen from the left atrial (surgical) view (A, see asterisk) and left ventricular view (B, see asterisk).

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  Figure 3 Three-dimensional echocardiographic surgical view reconstruction of the mitral annulus with software from Philips QLAB (A) and TomTec (B).

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  Figure 4 Type II-A mitral valve prolapse due to fibro-elastic deficiency with chordal rupture (A, see arrowhead). Acute flail mitral valve leaflet prolapse due to antero-lateral papillary muscle rupture (B, see arrowhead) and postero-medial papillary muscle rupture (C: gray-scale, see arrowhead, D: color Doppler, E: 3D image, see arrowhead).

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  Figure 5 Type II-B billowing mitral valve leaflets due to chordal elongation seen with 2D transthoracic (A), 2D trans-esophageal (B), and 3D echocardiography (C: surgical view). Diffuse redundant and thickened leaflet tissue known as myxomatous Barlow's disease is seen with trans-esophageal echocardiography without (D: type II-B) and with chordal ruptures (E: type II-C).

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  Figure 6 Mitral valve prolapse site identification with trans-esophageal commissural view 2D imaging (left column), color-imaging (middle column), and 3D imaging (right column). Seen are prolapses (asterisks and arrowheads) of the P1 (top row A-C), P2 (middle row D-F), and P3 (bottom row G-I) scallops.

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  Figure 7 Three-dimensional echocardiographic surgical view of mitral prolapse extent: small P2 prolapse (A), broad P2 prolapse (B), and P2-P3 prolapse (C). The sites of prolapse are indicated with arrowheads.

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  Figure 8 Mitral valve restriction seen with 2D trans-thoracic gray scale and color imaging in rheumatic disease with systolic and diastolic restriction (A, B, and C show the 3D surgical view with reduced valve opening) in dilated cardiomyopathy with symmetric systolic restriction (D and E) and ischemic cardiomyopathy (F and G) with asymmetric systolic restriction. In the bottom panel (H), 3D echocardiographic virtual models are seen from the commissure-to-commissure view. The 3D tenting area and tethering angle of segment P3 (arrow-line) may predict recurrent mitral regurgitation after annuloplasty. AC denotes anterior commissure and PC denotes posterior commissure. Reproduced with permission from Bouma et al.37)

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  Figure 9 Influence on the severity of trans-esophageal assessment of mitral regurgitation by peri-operative blood pressure changes (A) and general anesthesia (B: significant mitral regurgitation in the outpatient clinic, C: minimal mitral regurgitation under general anesthesia).

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  Figure 10 Mitral regurgitation due to systolic anterior motion (see arrowheads) in hypertrophic cardiomyopathy (A) and after mitral valve annuloplasty (B: gray-scale and C: color Doppler).

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  Figure 11 Three-dimensional echocardiography showing mitral ring dehiscence (A) and replacement with a mechanical prosthesis (B). The lower panel shows localization of smaller paravalvular leakage after implantation of a mechanical prosthesis by the origin of the 3D color Doppler jet (C, arrowhead), facilitating wire passage (D, arrowhead) and thus placement of a closure device.

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