Use of real-time 3-dimensional transthoracic echocardiography in the evaluation of mitral valve disease.

Three-dimensional (3D) echocardiography (3DE) provides unique orientations of the mitral valve (MV) not obtainable by routine 2-dimensional echocardiography. However, this modality has not been adopted in routine clinical practice because of its cumbersome and time-consuming process. The recent introduction of a full matrix-array transducer has enabled online real-time 3DE (RT3DE) and rendering. This study was designed to: (1) determine the clinical use of RT3DE in patients with MV pathology and in a control group selected for their good acoustic windows (protocol I); and (2) to investigate the feasibility of imaging the MV apparatus in a large group of consecutively imaged patients to determine the acoustic window or perspective from which the MV leaflets, commissures, and orifice are best visualized (protocol II). In protocol I, 65 patients were selected based on MV pathology and good 2-dimensional echocardiography image quality. Protocol II included 150 patients who were consecutively imaged using RT3DE. Images were viewed online (protocol I) and offline on a digital review station (protocol II). RT3DE visualization of the MV apparatus was graded based on the percentage of leaflet dropout and definition. In protocol I, 78% of patients had adequate 3D MV reconstructions with complete visualization of the anterior mitral leaflet (AML) in 84% versus the posterior mitral leaflet (PML) in 77%. The mitral leaflets, commissures, and MV orifice were well seen in 98%; however, the submitral apparatus was only observed in 76% of the patients. RT3DE: (1) correctly identified the prolapsed/flailed scallop in 6 of 8 patients; (2) obtained en face orientation of the MV orifice in 9 of 11 patients with mitral stenosis, allowing accurate measurements of the orifice area and evaluation of the immediate effects of balloon mitral valvuloplasty; and (3) allowed postoperative evaluation of MV repair and the integrity of the struts of a bioprosthetic leaflet. In protocol II, 70% of patients had adequate RT3DE with complete visualization of the AML noted in 55% versus 51% for PML. The mitral leaflets, commissures, and MV orifice were observed in 69%. Irrespective of acquisition window, the AML was best seen from a ventricular perspective. In contrast, the PML was optimally examined from a parasternal window. Both the medial and lateral commissures were equally assessed from either imaging window. In conclusion, RT3DE of the MV is feasible in a large majority of patients. Using different MV acquisitions RT3DE provides important clinical information such as: (1) identification of a prolapsed/flail scallop; (2) measurement of stenotic valve areas; (3) evaluation of MV leaflet integrity postrepair; and (4) identification of a MV perforation. In general the AML is better visualized than the PML. The parasternal window is the optimal approach to visualize both AML and PMLs.