Real-time three-dimensional transesophageal echocardiography: improvements in intraoperative mitral valve imaging.
BACKGROUND
Successful surgical repair of a regurgitant mitral valve (MV) is dependent on a comprehensive assessment of its complex anatomy. Although there is limited evidence of the feasibility and accuracy of intraoperative real-time 3-dimensional transesophageal echocardiography (RT3DTEE) in MV surgery, its use is increasing worldwide. We designed this prospective observational study of patients with mitral regurgitation to test initial findings on the accuracy of RT3DTEE images in the diagnosis of MV prolapse and chordal rupture relative to 2D imaging and to assess the potential of RT3DTEE for visualizing leaflet clefts.


METHODS
TEE-certified anesthesiologists examined 62 consecutive patients undergoing MV surgery by acquiring a full standard set of 2D TEE sections and 3D zoom recordings. Offline, 2D and 3D images were presented independently and in randomized order to 2 expert interpreters. Accuracy was determined using the surgical findings as the "gold standard."


RESULTS
Surgical inspection identified 52 cases of MV prolapse (MVP). RT3DTEE correlated stronger with the surgical findings than 2D TEE for detection and localization of MVP (difference in proportions=33.9%, P<0.001) and chordal rupture (difference in proportions=25.8%, P<0.001). The superiority of RT3DTEE was significant for scallops A2, P1, P2 in MVP and A2, P2 in chordal rupture (all P<0.05). In 22 patients, leaflet clefts were also surgically repaired, and RT3DTEE was feasible in accessing them (κ=0.65, confidence interval [0.44, 0.81]).


CONCLUSIONS
Although 2D TEE is currently the standard tool for intraoperative imaging in MV surgery, RT3DTEE improves the visualization of MV pathology and increases the accuracy of interpretation by facilitating spatial orientation. Further investigations, particularly those aimed at establishing its cost effectiveness, are indicated.
Department of Pediatrics, Research Training Group 1126, Heidelberg University, Neckarstaden 18, 69117 Heidelberg, Germany. maximilian.hien@med.uni-heidelberg.de
Maximilian Dominik
MD
Hien
Helmut
H
Rauch
Artur
A
Lichtenberg
Raffaele
R
De Simone
Marc
M
Weimer
Oriana Amanda
OA
Ponta
Christian
C
Rosendal
D000368:Aged; D006348:Cardiac Surgical Procedures / Q000379:methods*; D002315:Cardiopulmonary Bypass; D002815:Chordae Tendineae / Q000000981:diagnostic imaging / Q000601:surgery; D003627:Data Interpretation, Statistical; D004452:Echocardiography; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal / Q000379:methods*; D005260:Female; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging*; D008944:Mitral Valve Insufficiency / Q000000981:diagnostic imaging*; D008945:Mitral Valve Prolapse / Q000000981:diagnostic imaging / Q000601:surgery; D016343:Monitoring, Intraoperative / Q000379:methods*; D015588:Observer Variation; D011446:Prospective Studies