title: Visualization and measurement of mitral valve chordae tendineae using three-dimensional transesophageal echocardiography from the transgastric approach.
abstract: BACKGROUND
  The evaluation of the submitral apparatus is challenging from the conventional transesophageal approach. The aim of this study was to test the feasibility of using three-dimensional (3D) transesophageal echocardiographic (TEE) imaging from the transgastric approach to visualize the submitral apparatus and quantify the lengths of the chordae tendineae by using multiplanar reconstruction analysis.
  
  
  METHODS
  Twenty-two patients who had transgastric full-volume 3D TEE data sets before mitral valve surgery underwent surgical measurement of chordal length. A short-axis plane at the chordal level was extracted from the 3D data set to identify leaflet segments and the corresponding primary chords. Then, for each chord, the optimal plane was selected to visualize and measure the entire chordal length from its origin at the leaflet margin to the papillary muscle tips. Measurements were performed at the phase of the cardiac cycle when chordal length reached its maximum. Measured values were compared with surgical measurements using linear regression and Bland-Altman analyses.
  
  
  RESULTS
  One hundred forty-six primary chords were measured intraoperatively. Three-dimensional TEE imaging was able to measure the lengths of all these chords. The surgical and 3D TEE measurements (mean, 1.96 ± 0.56 vs 1.93 ± 0.50 cm, respectively) correlated highly (r = 0.93, P < .0001), with a minimal bias of 0.03 cm and narrow limits of agreement from -0.39 to 0.45 cm.
  
  
  CONCLUSIONS
  Transgastric 3D TEE imaging of the submitral apparatus allows visualization and accurate measurement of chordae tendineae lengths, which may be useful for planning mitral valve repair, including percutaneous transcatheter procedures.
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois; Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan. Electronic address: kikuko_obase@hotmail.com.
authors.forename: Kikuko
authors.initials: K
authors.lastname: Obase
authors.affiliation: Cardiovascular Surgery, University of Chicago, Chicago, Illinois.
authors.forename: Valluvan
authors.initials: V
authors.lastname: Jeevanandam
authors.affiliation: Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan.
authors.forename: Ken
authors.initials: K
authors.lastname: Saito
authors.affiliation: Department of Anesthesia & Critical Care, University of Chicago, Chicago, Illinois.
authors.forename: Kimberly
authors.initials: K
authors.lastname: Kesner
authors.affiliation: Department of Anesthesia & Critical Care, University of Chicago, Chicago, Illinois.
authors.forename: Aaron
authors.initials: A
authors.lastname: Barry
authors.affiliation: Department of Anesthesia & Critical Care, University of Chicago, Chicago, Illinois.
authors.forename: Andrew
authors.initials: A
authors.lastname: Hollatz
authors.affiliation: Department of Anesthesia & Critical Care, University of Chicago, Chicago, Illinois.
authors.forename: Farhan
authors.initials: F
authors.lastname: Farooqui
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Karima
authors.initials: K
authors.lastname: Addetia
authors.affiliation: Department of Anesthesia & Critical Care, University of Chicago, Chicago, Illinois.
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Roberts
authors.affiliation: Cardiovascular Surgery, University of Chicago, Chicago, Illinois.
authors.forename: Takeyoshi
authors.initials: T
authors.lastname: Ota
authors.affiliation: Cardiovascular Surgery, University of Chicago, Chicago, Illinois.
authors.forename: Husam H
authors.initials: HH
authors.lastname: Balkhy
authors.affiliation: Department of Cardiology, Kawasaki Medical School, Kurashiki, Japan.
authors.forename: Kiyoshi
authors.initials: K
authors.lastname: Yoshida
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Victor
authors.initials: V
authors.lastname: Mor-Avi
authors.affiliation: Section of Cardiology, Department of Medicine, University of Chicago, Chicago, Illinois.
authors.forename: Roberto M
authors.initials: RM
authors.lastname: Lang
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D002815:Chordae Tendineae / Q000000981:diagnostic imaging*; D019560:Echocardiography, Three-Dimensional / Q000379:methods*; D017548:Echocardiography, Transesophageal / Q000379:methods*; D005260:Female; D006801:Humans; D007089:Image Enhancement / Q000379:methods; D007090:Image Interpretation, Computer-Assisted / Q000379:methods*; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000000981:diagnostic imaging*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D013270:Stomach
keywords: 3D transesophageal echocardiography; Mitral valve chordae tendineae; Multiplanar reconstruction; Submitral apparatus; Transgastric view