title: Functional anatomy of mitral regurgitation: accuracy and outcome implications of transesophageal echocardiography.
abstract: OBJECTIVE
  This study was performed to determine the accuracy and outcome implications of mitral regurgitant lesions assessed by echocardiography.
  
  
  BACKGROUND
  In patients with mitral regurgitation (MR), valve repair is a major incentive to early surgery and is decided on the basis of the anatomic mitral lesions. These lesions can be observed easily with transesophageal echocardiography (TEE), but the accuracy and implications for outcome and clinical decision-making of these observations are unknown.
  
  
  METHODS
  In 248 consecutive patients operated on for MR, the anatomic lesions diagnosed with TEE were compared with those observed by the surgeon and those seen on 216 transthoracic echocardiographic (TTE) studies, and their relationship to postoperative outcome was determined.
  
  
  RESULTS
  Compared with surgical diagnosis, the accuracy of TEE was high: 99% for cause and mechanism, presence of vegetations and prolapsed or flail segment, and 88% for ruptured chordae. Diagnostic accuracy was higher for TEE than TTE for all end points (p < 0.001), but the difference was of low magnitude (<10%) except for mediocre TTE imaging or flail leaflets (both p < 0.001). The type of mitral lesions identified by TEE (floppy valve, restricted motion, functional lesion) were determinants of valve repairability and postoperative outcome (operative mortality and long-term survival; all p < 0.001) independent of age, gender, ejection fraction and presence of coronary artery disease.
  
  
  CONCLUSIONS
  Transesophageal echocardiography provides a highly accurate anatomic assessment of all types of MR lesions and has incremental diagnostic value if TTE is inconclusive. The functional anatomy of MR defined by TEE is strongly and independently predictive of valve repairability and postoperative outcome. Therefore, the mitral lesions assessed by echocardiography represent essential information for clinical decision making, particularly for the indication of early surgery for MR.
authors.affiliation: Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA.
authors.forename: M
authors.initials: M
authors.lastname: Enriquez-Sarano
authors.forename: W K
authors.initials: WK
authors.lastname: Freeman
authors.forename: C M
authors.initials: CM
authors.lastname: Tribouilloy
authors.forename: T A
authors.initials: TA
authors.lastname: Orszulak
authors.forename: B K
authors.initials: BK
authors.lastname: Khandheria
authors.forename: J B
authors.initials: JB
authors.lastname: Seward
authors.forename: K R
authors.initials: KR
authors.lastname: Bailey
authors.forename: A J
authors.initials: AJ
authors.lastname: Tajik
mesh_terms: D000368:Aged; D003661:Decision Support Techniques; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology; D012680:Sensitivity and Specificity; D015996:Survival Rate; D016896:Treatment Outcome