Transthoracic Echocardiographic

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Myron Hutchinson
6 years ago
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1 Transthoracic Echocardiographic Findings of Mitral Regurgitation Caused by Commissural Prolapse 1 Hyue Mee Kim, 1 Kyung-Jin Kim, 1 Hyung-Kwan Kim*, 1 Jun-Bean Park, 2 Ho-Young Hwang, 3 Yeonyee E. Yoon, 1 Yong-Jin Kim, 3 Goo-Young Cho, 2 Kyung-Hwan Kim, 1 Dae-Won Sohn, 2 Hyuk Ahn 1 Department Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea 2 Department of Cardiovascular Thoracic Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea 3 Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Kyunggi-do, Korea

mortality and better outcomes Accurate localization of

2 Introduction Mitral valve prolapse One of the main causes of MR Valve repair is recommended due to lower perioperative mortality and better outcomes Accurate localization of prolapsed or flail segment is important for the durability of the repaired valve.

Introduction Transthoracic echocardiography in MV prolapse First line imaging modality for assessment of MR Localization and quantification of

3 Introduction Transthoracic echocardiography in MV prolapse First line imaging modality for assessment of MR Localization and quantification of MR severity Two-dimensional and Doppler image However, the accuracy of localizing a prolapse segment is variable depending on the segment involved.

4 Introduction Commissural MR Lower prevalence, but significant risk factor for reoperation. No systematic data on the transthoracic echocardiography findings often misinterpreted or missed in the preoperative assessment. We sought to study To describe the characteristics of transthoracic echocardiography findings highly suggestive of commissural MR

5 Methods Study population

Methods Echocardiographic examination Within 1 month before the surgical procedure Severe MR: diagnosed based on current guideline recommendations Localization of the involved scallops and

6 Methods Echocardiographic examination Within 1 month before the surgical procedure Severe MR: diagnosed based on current guideline recommendations Localization of the involved scallops and commissures were assessed Surgical report Carpentier functional classification was adopted to localize prolapsed segments with the addition of 2 MV commissural segments. Using the surgical findings as the reference standard, Prolapsed segments were determined and compared with the TTE findings.

7 Results Clinical characteristics All AC prolapse PC prolapse P value (n=13) (n=23) Age (years) 56 ± ± 9 54 ± Male (%) 27 (75) 8 (62) 19 (83) 0.24 BSA (kg/m 2 ) 1.7 ± ± ± SBP (mmhg) 129 ± ± ± DBP (mmhg) 77 ± ± 8 75 ± Heart rate (bpm) 73 ± ± ± NYHA Fc III-IV (%) 9 (25) 3 (23) 6 (26) >0.99 Atrial fib (%) 7 (19) 4 (31) 3 (13) 0.23 Hypertension (%) 14 (39) 5 (39) 9 (39) 0.97 Diabetes mellitus (%) 5 (14) 2 (15) 3 (13) >0.99 CKD (%) CAD (%) 4 (11) 2 (15) 2 (9) 0.61 History of CVA (%) 0 0 0

8 Results Localization and frequency of commissural MR from surgical view Among 36 patients, - 25 (69.4%) patients showed isolated commissural prolapse - 11 (30.6%) patients showed partial involvement of an adjacent scallop. Correct diagnosis of commissural prolapse could be made in only 13 patients. Reflecting the diagnostic challenge of commissural MR

9 Results Comparison of echocardiographic findings (parasternal long) All AC prolapse PC prolapse P value (n=13) (n=23) Prolapsed segment seen (%) 18 (50.0%) 4 (30.8%) 14 (60.9%) 0.16 Integrity of leaflet margin maintained in patients in whom prolapsed segment seen (%) 13 (72.2%) 2 (50%) 11 (78.6%) 0.53 Acceleration flow seen on the LV side (%) 6 (16.7%) 4 (30.8%) 2 (8.7%) 0.16 Flow morphology or direction 0.68* V-shaped, double jet flow (toward anterior and posterior) 9 (25.0%) 3 (23.1%) 6 (26.1%) widely spreading into LA 7 (19.4%) 3 (23.1%) 4 (17.4%) toward anterior 3 (8.3%) 0 (0%) 3 (13.0%) toward central 2 (5.6%) 0 (0%) 3 (8.7%) toward posterior 10 (27.8) 6 (46.2%) 4 (17.4%) short regurgitant flow just below mitral valve 4 (11.1%) 0 (0%) 4 (17.4%) Indeterminate 1 (2.8%) 1 (7.7%) 0 (0%)

10 Results Comparison of echocardiographic findings (parasternal short) All AC prolapse PC prolapse P value (n=13) (n=23) Prolapsed segment seen (%) 21 (58.3%) 7 (53.8%) 14 (60.9%) 0.74 Acceleration flow seen (%) 28 (77.8%) 10 (76.9%) 18 (78.3%) >0.99 Flow morphology or direction 0.14* V-shaped, double jet flow 10 (27.8%) 4 (30.8%) 6 (26.1%) toward posterolateral 8 (22.2%) 3 (23.1%) 5 (21.7%) toward posteromedial 9 (25.0%) 5 (38.5%) 4 (17.4%) widely spreading 1 (2.8%) 0 (0%) 1 (4.3%) toward anterolateral 1 (2.8%) 0 (0%) 1 (4.3%) horizontal flow 2 (5.6%) 0 (0%) 2 (8.7%) Indeterminate 5 (13.9%) 1 (7.7%) 4 (17.4%)

11 Results Comparison of echocardiographic findings (bi-commissural 2 chamber view) All AC prolapse PC prolapse P value (n=13) (n=23) Prolapsed segment seen (%) 31 (86.1%) 10 (76.9%) 21 (91.3%) 0.33 Integrity of leaflet margin maintained in patients in whom prolapsed segment seen (%) 3 (9.7%) 1 (10.0%) 2 (9.5%) >0.99 Acceleration flow seen on the LV side (%) 33 (91.7%) 12 (92.3%) 21 (91.3%) >0.99 Flow morphology or direction 0.39* V-shaped, double jet flow 20 (55.6%) 7 (53.8%) 13 (56.5%) toward anterolateral 7 (19.4%) 2 (15.4%) 5 (21.7%) toward posteromedial 2 (5.6%) 3 (23.1%) 2 (8.7%) horizontal flow 6 (16.7%) 0 (0%) 3 (13.0%) Indeterminate 1 (2.8%) 1 (7.7%) 0 (0%)

Results Representative examples of color Doppler flow patterns A: a V-shaped, double jet flow originating from posteromedial commissure B: a small V-shaped, double jet flow originating form

12 Results Representative examples of color Doppler flow patterns A: a V-shaped, double jet flow originating from posteromedial commissure B: a small V-shaped, double jet flow originating form anterolateral commissure C: a regurgitant flow running obliquely from posteromedial commissure toward the anterolateral direction without adhering to the LA wall D: a regurgitant flow running horizontally from posteromedial commissure

Image from bi-commissural 2-chamber view: acceleration flow

13 Results A. Color Doppler image from the parasternal short axis: proximal flow convergence at the lateral side of the anterior MV B. Image from bi-commissural 2-chamber view: acceleration flow from lateral portion and runs obliquely toward the posteromedial portion of the LA C. Intraoperative saline test : similar findings observed in Echocardiography (A)

14 Conclusions Commissural prolapse-related MR The prolapsed site was more likely to be PC. Commissural involvement was frequently overlooked. The proximal acceleration flow on the LV side and the regurgitant flow patterns observed in the LA in the apical bi-commissural view is useful. TTE findings proposed this study could facilitate the detection of commissural MR and play an important role as the gatekeeper to preoperative TEE. Correct preoperative localization of prolapsed segments can be translated into good clinical outcomes with better surgical planning.

15 Thank you for your attention

ECHOCARDIOGRAPHY DATA REPORT FORM

ECHOCARDIOGRAPHY DATA REPORT FORM Patient ID Patient Study ID AVM - - Date of form completion / / 20 Initials of person completing the form mm dd yyyy Study period Preoperative Postoperative Operative 6-month f/u 1-year f/u 2-year f/u