Preoperative Scallop-by-scallop Assessment of Mitral Prolapse using 2D-transthoracic Echocardiograph
Preoperative Scallop-by-scallop Assessment of Mitral Prolapse using 2D-transthoracic Echocardiography
Background: This study was conducted to assess the accuracy of harmonic imaging 2D-transthoracic echocardiography (2D-TTE) segmental analysis compared to surgical findings, in degenerative mitral regurgitation (MR).
Methods: Seventy-seven consecutive patients with severe degenerative MR were prospectively enrolled. Preoperative 2D-TTE with precise localization of prolapsing or flailing scallops/segments was performed. All patients underwent mitral valve surgical repair. Surgical reports (SR), including valve description, were used as references for comparisons. A postoperative control 2D-TTE was performed.
Results: Out of 462 scallops/segments studied, surgical inspection identified 102 prolapses or flails (22%), 92 of which had previously been detected by 2D-TTE (90.2% sensitivity, 100% specificity). Agreement between preoperative 2D-TTE segmental analysis and SR was 97.8% (k = 0.93; p < 0.0001). Sixty-nine out of 77 2D-TTE reports were completely concordant with SR (89.6% diagnostic accuracy). None of the 8 non-concordant 2D-TTE reports were in complete disagreement with SR. P2 scallop was always involved in posterior leaflet prolapse or flail and was described correctly by 2D-TTE in 68 out of 69 patients (98,7% agreement, k = 0,93; 98.5% sensitivity). The anterior leaflet was involved in 14 patients (18%); A2 segment was involved in all of those cases and was correctly detected by 2D-TTE in 13 (98,7% agreement, k = 0,95; 92,8% sensitivity). Antero-lateral and postero-medial para-commissural prolapse or flail had a lower prevalence (14% and 10% respectively), with 2D-TTE sensitivity respectively of 64% and 50%.
Conclusions: 2D-TTE, performed by an experienced echo-lab, has very good diagnostic accuracy in localizing the scallops/segments involved in degenerative MR, particularly for the middle ones (P2-A2), which represent almost the totality of prolapses. More invasive, time consuming and expensive exams should be reserved to selected cases.
Echocardiographic mitral valve (MV) prolapse is defined as single or bileaflet systolic prolapse at least 2 mm beyond the parasternal long-axis annular plane, with or without leaflet thickening. The prevalence is estimated at 2-3%, and it is equally distributed between men and women.
MV prolapse assessment follows Carpentier's widely recognised nomenclature.
The most important complication of mitral valve prolapse is severe mitral regurgitation (MR), which may result from either progressive myxomatous degeneration or chordal rupture with leaflet flail. MV repair is the preferred method of treatment over MV replacement, if surgically feasible. This strategy preserves left ventricular function and decreases risk of hemolysis, thromboembolism, and hemorrhage (due to anticoagulation therapy). Suitability for MV repair can be predicted preoperatively by echocardiography, assessing mitral annular calcification and extension of valvular degeneration. Therefore to plan surgical repair a segmental analysis of the prolapsing valve is essential.
Both transthoracic echocardiography (2D-TTE) and transesophageal echocardiography (2D-TEE) are valid methods in the identification of MV prolapse or flail. Several studies have demonstrated that functional assessment of MR by 2D-TEE and 3D imaging is a strong determinant of valve reparability and postoperative outcome with significant incremental value over 2D-TTE. However, the advent of new beam formers and harmonic imaging has immensely improved the quality of 2D-TTE; thus, the diagnostic accuracy of 2D-TTE in the evaluation of the MV needs to be re-examined. Recently Monin et al. showed that functional assessment of MR by 2D-TTE can accurately predict valve reparability in patients undergoing surgery for severe MR, pointing out that in most cases preoperative 2D-TEE is not mandatory.
We have evaluated the accuracy of 2D-TTE in the assessment of prolapsing or flailing scallops/segments in a series of consecutive patients that underwent surgical repair for MR. The aim of the study was to assess, through a scallop-by-scallop analysis, the agreement between 2D-TTE and surgical report descriptions of MV scallops/segments, and the sensitivity and specificity of 2D-TTE in identifying prolapsing or flailing scallops/segments. We also evaluated the total concordance of 2D-TTE with surgical report for each patient; reports were classified as "concordant" or "non-concordant", where "non-concordant" meant incomplete agreement or disagreement.
Abstract and Background
Abstract
Background: This study was conducted to assess the accuracy of harmonic imaging 2D-transthoracic echocardiography (2D-TTE) segmental analysis compared to surgical findings, in degenerative mitral regurgitation (MR).
Methods: Seventy-seven consecutive patients with severe degenerative MR were prospectively enrolled. Preoperative 2D-TTE with precise localization of prolapsing or flailing scallops/segments was performed. All patients underwent mitral valve surgical repair. Surgical reports (SR), including valve description, were used as references for comparisons. A postoperative control 2D-TTE was performed.
Results: Out of 462 scallops/segments studied, surgical inspection identified 102 prolapses or flails (22%), 92 of which had previously been detected by 2D-TTE (90.2% sensitivity, 100% specificity). Agreement between preoperative 2D-TTE segmental analysis and SR was 97.8% (k = 0.93; p < 0.0001). Sixty-nine out of 77 2D-TTE reports were completely concordant with SR (89.6% diagnostic accuracy). None of the 8 non-concordant 2D-TTE reports were in complete disagreement with SR. P2 scallop was always involved in posterior leaflet prolapse or flail and was described correctly by 2D-TTE in 68 out of 69 patients (98,7% agreement, k = 0,93; 98.5% sensitivity). The anterior leaflet was involved in 14 patients (18%); A2 segment was involved in all of those cases and was correctly detected by 2D-TTE in 13 (98,7% agreement, k = 0,95; 92,8% sensitivity). Antero-lateral and postero-medial para-commissural prolapse or flail had a lower prevalence (14% and 10% respectively), with 2D-TTE sensitivity respectively of 64% and 50%.
Conclusions: 2D-TTE, performed by an experienced echo-lab, has very good diagnostic accuracy in localizing the scallops/segments involved in degenerative MR, particularly for the middle ones (P2-A2), which represent almost the totality of prolapses. More invasive, time consuming and expensive exams should be reserved to selected cases.
Background
Echocardiographic mitral valve (MV) prolapse is defined as single or bileaflet systolic prolapse at least 2 mm beyond the parasternal long-axis annular plane, with or without leaflet thickening. The prevalence is estimated at 2-3%, and it is equally distributed between men and women.
MV prolapse assessment follows Carpentier's widely recognised nomenclature.
The most important complication of mitral valve prolapse is severe mitral regurgitation (MR), which may result from either progressive myxomatous degeneration or chordal rupture with leaflet flail. MV repair is the preferred method of treatment over MV replacement, if surgically feasible. This strategy preserves left ventricular function and decreases risk of hemolysis, thromboembolism, and hemorrhage (due to anticoagulation therapy). Suitability for MV repair can be predicted preoperatively by echocardiography, assessing mitral annular calcification and extension of valvular degeneration. Therefore to plan surgical repair a segmental analysis of the prolapsing valve is essential.
Both transthoracic echocardiography (2D-TTE) and transesophageal echocardiography (2D-TEE) are valid methods in the identification of MV prolapse or flail. Several studies have demonstrated that functional assessment of MR by 2D-TEE and 3D imaging is a strong determinant of valve reparability and postoperative outcome with significant incremental value over 2D-TTE. However, the advent of new beam formers and harmonic imaging has immensely improved the quality of 2D-TTE; thus, the diagnostic accuracy of 2D-TTE in the evaluation of the MV needs to be re-examined. Recently Monin et al. showed that functional assessment of MR by 2D-TTE can accurately predict valve reparability in patients undergoing surgery for severe MR, pointing out that in most cases preoperative 2D-TEE is not mandatory.
We have evaluated the accuracy of 2D-TTE in the assessment of prolapsing or flailing scallops/segments in a series of consecutive patients that underwent surgical repair for MR. The aim of the study was to assess, through a scallop-by-scallop analysis, the agreement between 2D-TTE and surgical report descriptions of MV scallops/segments, and the sensitivity and specificity of 2D-TTE in identifying prolapsing or flailing scallops/segments. We also evaluated the total concordance of 2D-TTE with surgical report for each patient; reports were classified as "concordant" or "non-concordant", where "non-concordant" meant incomplete agreement or disagreement.
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