Usefulness of multiplane transesophageal echocardiography to improve the assessment of severity of mitral regurgitation.

This study was designed to examine the accuracy of multiplane transesophageal echocardiography (TEE) color Doppler measurements in comparison to monoplane or biplane measurements in estimating the severity of mitral regurgitation (MR). Multiplane TEE potentially increases diagnostic accuracy of transesophageal examinations; it is unknown if multiplane is more accurate in assessing the severity of MR than monoplane or biplane TEE. Left ventricular cineangiograms of 91 patients with MR (40 no or mild, 30 moderate, and 21 severe) were compared with systolic pulmonary venous flow reversal and transesophageal color Doppler measurements: jet area and length in the transverse and longitudinal plane, maximal and average of those 2 planes (biplane), and maximal and average of 11 different planes (multiplane). Flow reversal (16 patients) identified severe MR with a specificity of 96% and a sensitivity of 62%; these were 96% and only 10% to 43%, respectively, for color Doppler measurements. In the absence of flow reversal, multiplane maximal jet area predicted severe MR with a sensitivity of 88% and a specificity of 75%, which were 85% and 76%, respectively, for no or mild MR; this did not differ significantly from results obtained by monoplane or biplane measurements. Color Doppler measurements of eccentric jets were not reliable for identification of severe MR. Systolic pulmonary venous flow reversal identifies 2 of 3 patients with severe MR with a high accuracy. In patients without flow reversal, multiplane color Doppler TEE is very capable of assessing MR severity, but biplane and monoplane TEE are equally accurate.

Biplane transesophageal color-flow Doppler imaging in assessing severity of mitral regurgitation: influence of hemodynamic circumstances and mechanism of regurgitation.

OBJECTIVE: To determine the value of biplane transesophageal echocardiography in the assessment of severity of mitral regurgitation compared with left ventricular angiography. DESIGN: Prospective study of consecutive patients. SETTING: Two university hospitals, one community hospital. PARTICIPANTS: Thirty-seven patients with angiographically proven mitral regurgitation. INTERVENTION: Transthoracic and biplane transesophageal echocardiography. In 19 patients, transesophageal echocardiography was performed during general anesthesia. MEASUREMENTS AND MAIN RESULTS: The largest mitral regurgitation jet area and longest jet as obtained with Doppler color-flow mapping from transthoracic and biplane transesophageal echocardiography and pulsed-Doppler pulmonary venous flow characteristics. Sensitivity and 100-minus-specificity were plotted to constitute receiver operating characteristics (ROC) curves. Areas under ROC curve for transverse, longitudinal, and biplane jet area were 0.77, 0.75, and 0.81, and for jet length, 0.82, 0.84, and 0.88, respectively; this was for biplane jet area in conscious patients; 0.99 compared with 0.72 in anesthetized patients (p < 0.05). CONCLUSIONS: Biplane measurements identified severe mitral regurgitation slightly more reliably than the transverse or longitudinal measurements alone. In conscious patients, jet area was an excellent test for estimating severity of mitral regurgitation. In anesthetized patients, a combination of biplane jet area and length and of systolic pulmonary venous flow reversal accurately predicted angiographic severity of mitral regurgitation. In anesthetized patients, the optimal cut-off value for jet area to distinguish between moderate and severe mitral regurgitation was lower than in conscious patients. In the total population, regardless of hemodynamic and technical variations, a combination of biplane jet area and length and of systolic pulmonary venous flow reversal accurately predicted the severity of mitral regurgitation.

Value of systolic pulmonary venous flow reversal and color Doppler jet measurements assessed with transesophageal echocardiography in recognizing severe pure mitral regurgitation.

We evaluated the value of color and pulsed Doppler transesophageal echocardiographic parameters and of V waves in estimating the severity of mitral regurgitation (MR) in 62 consecutive patients (38 men and 24 women, aged 39 to 80 years) with angiographically proven chronic pure MR (15 grade I/II, 47 grade III/IV). Twenty patients were examined before cardiac surgery under general anesthesia. Sensitivity, specificity, and positive and negative predictive values of systolic pulmonary venous flow reversal for the presence of grade III/IV MR were 87%, 93%, 98%, and 64%, respectively, these were for jet areas > or = 8.0 cm2--66%, 100%, 100%, and 48%, for jet lengths > or = 50 mm--70%, 87%, 94%, and 48%, for enlarged V waves--86%, 38%, 83%, and 43%, and for either flow reversal or a jet area > or = 8.0 cm2--96%, 93%, 98%, and 88%. We conclude that a combination of measurements improved the negative predictive value considerably, which is of importance in a population with a high pretest probability of severe MR. Enlarged V waves are not reliable in predicting severe MR. The optimal cutoff value for jet area and jet length was lower in anesthesized patients than in conscious patients; in anesthesized patients, sensitivity, specificity, and positive and negative predictive values of jet area > or = 5.0 CM2 for grade III/IV MR were 67%, 100%, 100%, and 50%, respectively; these were 87%, 100%, 100%, and 71% for flow reversal. Because the results of mitral repair are often evaluated with transesophageal echocardiography during surgery, our findings have clinical implications for evaluation of severe MR in anesthesized patients: pulmonary venous flow direction is the first-choice measure; jet area can be used when a low cutoff point is chosen.

Additional value of biplane transesophageal echocardiography in assessing the genesis of mitral regurgitation and the feasibility of valve repair.

To determine the additional diagnostic value of biplane transesophageal echocardiography (TEE) in patients undergoing mitral valve surgery, we studied 48 patients with severe mitral regurgitation. Transesophageal echocardiographic video recordings were reorganized in separate transverse and longitudinal sections to allow independent evaluation. Mechanism of mitral regurgitation and anatomic abnormalities of the mitral valve were assessed by all 3 transesophageal echocardiographic modalities and were related to surgical findings. Biplane TEE detected increased leaflet mobility with a sensitivity of 91% and a specificity of 84%, and restricted leaflet mobility with a sensitivity of 100% and a specificity of 97%. Biplane TEE was accurate in the diagnosis of most of the anatomic abnormalities associated with these mechanisms. However, the sensitivity for detecting subvalvular abnormalities (including papillary muscle abnormalities) was poor, and measurement of the annular diameter had a poor correlation with annular dilatation. Although the yield of biplane TEE was better than either transverse or longitudinal TEE alone, the differences did not reach statistical significance, because of the size of the patient group. The surgical procedure (either valve repair or replacement) was correctly predicted with transverse TEE in 71%, with longitudinal TEE in 69%, and with biplane TEE in 79% of the patients. All 3 transesophageal echocardiographic modalities are very capable of assessing the anatomic abnormalities and mechanism of mitral regurgitation, as well as predicting the feasibility of valve repair.