1

SREE CHITRA TIRUNAL INSTITUTE FOR

MEDICAL SCIENCES AND TECHNOLOGY

TRIVANDRUM, KERALA

PROJECT REPORT

Submitted during the course of

DM Cardiology

Dr. NILESH P. PATEL DM Trainee

DEPARTMENT OF CARDIOLOGY

Jan 2012 – Dec 2014

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DECLARATION

I, Dr Nilesh P. Patel, hereby declare that the project in this book was undertaken by me

under the supervision of the faculty, Department of Cardiology, Sree Chitra Tirunal Institute

for Medical Sciences and Technology.

Thiruvananthapuram Dr Nilesh P. Patel,

Date DM Trainee

Forwarded

The candidate, Dr Nilesh P. Patel, has carried out the minimum required project.

Thiruvananthapuram Prof. Dr Thomas Titus

Date Head of Department of Cardiology

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TITLE

The incremental value of three dimensional transesophageal

echocardiography in predicting the outcome of balloon mitral

valvotomy

Investigators

Dr Nilesh P Patel, Senior resident, Department of cardiology

Dr Venkateshwaran S., Assitant Professor, Department of cardiology

Dr Harikrishan S., Addtional. Professor, Department of cardiology

Dr Sivasankaran S., Professor, Department of cardiology

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INDEX

Page no.

Introduction 5

Aims and objectives 8

Review of literature 9

Materials and methods 22

Results 30

Discussion 43

Limitations 54

Conclusions 55

References 56

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INTRODUCTION

Rheumatic fever and rheumatic heart disease is a major problem in developing

countries like India, though the developed countries have documented a decline

(1). The mitral valve is the most commonly and severely affected (65%–70% of

patients) by a rheumatic process by stenosis and/or regurgitation (2). Percutaneous

balloon mitral valotomy (BMV) was introduced in 1984 by Inoue et al. (3) for the

treatment of selected patients with mitral stenosis. BMV is a minimally invasive,

nonsurgical procedure, a safe and effective therapeutic modality in selected

patients with mitral stenosis (4, 5) and is equivalent to or even better than surgical

commissurotomy (6, 7). With successful BMV, there is generally a twofold

increase in the mitral valve area and an associated dramatic fall in transmitral valve

gradient, left atrial pressure, and pulmonary artery pressure (8, 9). These

hemodynamic benefits are associated with postprocedural improvement in the

patients’ symptoms and exercise tolerance (10). The safety and success of BMV

techniques are mostly dependent on the selection of patients. There are multiple

predictors of the outcome, including age, functional class, previous

commissurotomy, preprocedure mitral valve area, valve anatomy, and balloon size

used (11). Morphology of the mitral valve is considered as the main predictor of a

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successful BMV and hence mitral valve evaluation by echocardiography is of

crucial importance (11).

Sophisticated and precise imaging is needed for a complex dynamic structure like

the mitral valve, especially when we embark on an interventional procedure like

balloon valvulotomy and repair, to aid the operator and to optimize the outcome

(12).

Effective performance and interpretation of two dimensional (2D)

echocardiography requires one to mentally integrate the collected images into a

three dimensional (3D) reconstruction of the cardiac anatomy. Two dimensional

echocardiographic reconstruction is limited by the echo window and operator

experience. Three dimensional volume data sets on the other hand, are less

operator dependent. Three dimensional echocardiography could be the best way of

assessing cardiac anatomy and plan interventions. The ability to accurately localize

the smallest orifice has essentially made 3D echocardiography the Gold standard

for the assessment of rheumatic mitral stenosis (13).

The close proximity of the transducer to the mitral valve and the higher

transmission frequencies used in real-time 3D transesophageal echocardiography

(3DTEE) allow high resolution images of the mitral valve independent of the

quality of transthoracic acoustic windows and may provide additional information

to that obtained by 3DTTE (14,15). MVA planimetry is feasible in the majority of

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patients with rheumatic mitral stenosis (RhMS) using 3DTEE, with excellent

reproducibility, and compares favorably with established methods (38). 3DTEE

allows excellent assessment of commissural fusion and sub-valvular pathology

(38).

Transesophageal echocardiography is done at our centre prior to BMV. The

present study was planned to study the incremental value of 3DTEE on outcome of

BMV in such patients.

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AIMS AND OBJECTIVES

1. To evaluate three dimensional anatomy of the mitral valve in mitral stenosis

and to correlate it with outcome of balloon mitral valvotomy.

2. To compare mitral valve area (MVA) by 2D transthoracic echocardiography

(MVA2D, MVAPHT), 3D transtransesophageal echocardiography

(MVA3D) and Gorlin method in the catheterization laboratory (MVA

Gorlin).

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REVIEW OF LITERATURE

The need to identify patients with mitral stenosis who could improve with

commissurotomy was the impetus for Edler to work with Hertz to utilize the

ultrasound for the generation of pictures of the Mitral valve (15). Henry in 1975 for

the first time planimetered the mitral valve orifice, a measurement hitherto not

available without cardiac catheterization (48). The difficulties in clearly imaging

the smallest mitral valve orifice in a diseased valve were partly overcome with the

advent of Doppler echocardiography using methods like the continuity equation

and the pressure half time (48). The ability to accurately localize the smallest

orifice has essentially made three 3D echocardiography the Gold standard for the

assessment of rheumatic mitral stenosis (46). Though invasive, 3D trans-

oesophagealechocardiography (TEE) done simultaneously during pre procedural

evaluation to rule out left atrial thrombi, gives the best pictures to study the mitral

valve (50). The pictures generated by the advanced machines are not only pretty,

but have a major role in the management of the mitral valve abnormalities (51).

Though calcification cannot be recognized the 3D TEE, this modality stands as the

best measure in calcific highly echogenic valves and in people with poor echo

windows. Transesophageal matrix array probes generate the best quality images

because of the proximity, higher frequency and frame rates (52). The major

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advances that can happen in this field could be the tissue characterization (similar

to virtual histology used in intravascular ultrasound), since calcification cannot be

precisely estimated by these reflected voxels (53).

Surgical as well as interventional approaches to management of mitral valve

disease also are largely based upon data from transthoracic echocardiography

(TTE). Transesophageal echocardiography (TEE) is a major tool to optimize the

outcome of interventions in the catheterization laboratories (54). Graded dilatation

of the stenotic mitral valve is now possible by imaging the splitting of the fused

commissures at the time of balloon valvuloplasty to optimize results and minimize

mitral regurgitation (55). Sophisticated and precise imaging is needed for a

complex dynamic structure like the mitral valve, especially when we embark on an

interventional procedure like balloon valvuloplasty and repair, to aid the operator

and to optimize the outcome (56).

The mitral valve apparatus is a complex three dimensional structure consisting of

the leaflets, the mitral annulus, the chordae tendinae, the papillary muscles and the

left ventricle itself. Effective performance and interpretation of 2D

echocardiography requires one to mentally integrate the collected images into a

three dimensional reconstruction of the cardiac anatomy. Two dimensional

echocardiographic reconstruction is limited by the echo window and operator

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experience. Three dimensional volume data sets on the other hand, are less

operator dependent. Real time three dimensional echocardiography (RT3DE) is

therefore the best way of assessing cardiac anatomy and plan interventions.

3DTEE, as mentioned above, due to its more proximity to mitral valve compared

to transthoracic technique may give a more accurate measurement and

morphological assessment of the mitral valve. The electrocardiographic gating and

limitation of respiratory movement needed for the earlier machines are now

overcome by volumetric RT3DE (50). Commercially available echocardiography

systems generally have the following options to work on three dimensional

imaging both for Transthoracic as well as Transesophageal probes:

Full volume acquisition

Single beat full volume acquisition (Siemens)

Live 3D echo

3D zoom

Full volume colour Doppler acquisition

Data acquired may be analyzed by using several software platforms such as

QLAB (Phillips)

Multi plane rendering (MPR)

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I slice (computer aided slicing of the data set into multi-frame

formats)

Mitral valve quantification (MVQ)

Three dimensional echocardiography in rheumatic mitral stenosis

Mitral valve area:

To identify the best therapeutic strategy in patients with rheumatic mitral valve

stenosis, clinical data and accurate measurements of mitral valve area are needed.

Doppler based methods are heavily influenced by heart rate, cardiac rhythm,

haemodynamic status and angle of incidence. Hence methods based on direct

planimetry of the anatomical valve orifice are more reliable (51). Some workers

have concluded that the mitral valve area estimated with 3DTEE is significantly

less as compared to 2D echo and Doppler methods. Because 2D planimetry tends

to overestimate MVA, 3DTEE should be considered for accurate MVA

assessment, especially in patients with a large left atrium (57). Measurement of

mitral valve area by planimetry of the orifice on 2D short axis images has several

limitations namely as illustrated in figure 1:

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Figure 1 fallacies of measuring the mitral valve area by 2 dimensional echocardiography;

Theplanimetered valve area could be any of the three values A, B, or C depending on the angle

of the ultrasound, whereas the true orifice plane is along the red line.

Orthogonality of the imaging plane with the mitral orifice is assumed

but not granted

Level at which the 2D plane intersects the funnel formed by the

stenotic mitral orifice cannot be controlled by the echocardiographer

The angle between the lines of the true mitral valve tip and the echo

beam-to- mitral valve tip measured in the parasternal long axis view

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on 2D echo was found to be an independent variable resulting in

overestimation of mitral valve area by 2 D echo (57).

Direct planimetry of mitral valve area from 2D echocardiographic images,

therefore, may overestimate of the valve orifice area due to imaging and

measurement in an oblique plane. Using the 3D dataset, it is possible to obtain

sections of the stenotic mitral valve that are exactly orthogonal to the orifice and at

its narrowest point. As a result, compared to all other echo Doppler methods for

assessing residual mitral valve orifice area, RT-3DE has the best agreement with

invasive methods (14). Figure 2 and 3 illustrates the planimetry of mitral valve

using I slice and MPR planimetry.

Figure 2 A Multi-plane rendering of a 3 D data set frozen in diastole to measure the smallest

mitral valve area. Two orthogonal planes are aligned along the valve orifice so that the third

plane measures the exact orifice. Figure 2 B Multi-plane rendering of the colour volume data set

of the mitral valve frozen in systole to estimate the regurgitant orifice prior to balloon mitral

valvotomy.

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Figure 3 Estimation of mitral valve area by I slice : using computer manipulation in the

software provided (Q Lab) multiple planes aligned along the valve can be selected in multiple

frame formats of varying thickness and each of these plane can individually, zoomed ,reviewed

and frozen in diastole to measure the exact valve area.

Mitral valve anatomy

Results of percutaneous BMV are dependent on the mitral valve anatomy (57).

Three dimensional echocardiographic features can differentiate rheumatic from

nonrheumatic causes for mitral stenosis as well (Table 1) (60). Several prognostic

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scores are used such as the Wilkins score, which rely on the anatomical details of

the mitral valve leaflets such as mobility, thickening, and subvalvar apparatus

pathology is better assessed using RT-3DE (58). Other scores applicable for 2D

echocardiography are modified Wilkins score (66), Reid score (67), Nobuyoshi

score (68), Cormier score (69) etc. Most commonly used score is Wilkins score,

has many limitations like inability to differentiate nodular fibrosis from

calcification, assessment of commissural involvement is not included, doesn’t

account for uneven distribution of pathologic abnormalities and relative

contribution of each variable, frequent underestimation of sub-valvular disease. A

3D echocardiography based scoring system has also been recently proposed (Table

2) (59). Compared to Wilkins score new 3D scoring allows visualization and

assessment of the whole length of both leaflets through single image plane,

describes calcification at the commissural parts of leaflet by a higher score than the

middle leaflets calcification because it was proved that calcification of

commissures is one of the strong predictors of outcome after BMV as it affects the

degree of commissural splitting, includes chordal separation over and above

thicknes, applied using both transthoracic and transesophageal approaches because

the image orientation and interpretation are not different. Simultaneous assessment

of associated other valvular lesions is an integral part of three dimensional

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assessment which has a direct influence on the optimal management of the clinical

problem (61).

Table: 1 Anatomical characteristic of the different etiological types of mitral

stenosis

Table 2 Mitral valve score based on real-time 3D echocardiography

Leaflets Normal=0, mild=1–2, moderate=3–4, severe >5

Sub-valvular pathology Normal=0, mild=1–2, moderate=3–5, severe >6

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Left atrial appendage

Left atrial appendage often is the site of thrombi in rheumatic mitral stenosis

especially in atrial fibrillation. Transesophageal echocardiography is generally

used to exclude a thrombus in the left atrial appendage prior to a BMV. Both

transthoracic and trans-esophageal 3D echocardiography has been utilized

extensively to understand the appendage pathology (63, 64). The anatomy of the

left atrial appendage is variable. Three dimensional echocardiography is a powerful

tool in evaluating the left atrial appendage and is extensively used in planning left

atrial appendage device closure procedures as well.

Procedural 3D TEE in the interventional catheterization laboratory

Real Time Live 3D echocardiography especially 3DTEE may also be used to guide

the various steps of the procedure such as transseptal puncture and assess the result

of the procedure and the need for additional dilatations (62). Live 3D

echocardiography can be invaluable in early detection and quantification of mitral

regurgitation during BMV and accurately determine its mechanism.

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3D TEE in Mitral Stenosis

In rheumatic mitral stenosis, there is extensive post inflammatory fibrosis,

asymmetric scarring, and calcification of the mitral valve leaflets and subvalvar

apparatus. The anatomy is significantly distorted rendering 2D transthoracic

imaging challenging. The orifice area should be planimetered at the leaflet tips as

discussed above, during their maximal separation in early to mid-diastole.

Planimetry measurements below the leaflet tips will overestimate the area. Two

dimensional planimetry is prone to erroneous overestimation of valve area due to

the technical difficulty in accurately establishing the plane of the leaflet tips in the

parasternal short axis view (Figure 1). Three dimensional echocardiography

overcomes this limitation by the ability to identify the plane of the leaflet tips.

Studies with head to head comparison of transthoracic 2D and 3D have shown that

3D planimetry correlates more closely with invasively derived area, both before

and after commissurotomy (26). Schlosshan and colleagues (38) compared the

mitral valve area (MVA) by 3DTEE with traditional 2DTTE methods. They

concluded that 3DTEE is feasible and provides reproducible, superior imaging of

the rheumatic mitral valve and commissural fusion in nearly all patients. MVA-3D

planimetry was significantly lower than MVA-2D planimetry and pressure half

time, but agreed closely with the continuity method. Min and colleagues (65)

confirmed that 2D planimetry significantly overestimated MVA by >0.2 cm2 in

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nearly half the patients. Two factors predicted area overestimation - left atrial

diameter > 49 mm and an angle of deviation of the ultrasound plane from the

leaflet tips ≥ 9.5°. 3DTEE may offer incremental value in patients with discrepant

clinical and 2D echocardiographic severity of mitral stenosis. However, the

primary role of 3DTEE in mitral stenosis is in BMV.

BMV is a long established treatment option for selected patients with symptomatic

mitral stenosis in the absence of significant mitral regurgitation. Patient selection is

based on clinical profile and favorable valve anatomy (26). An echocardiographic

assessment of the extent of commissural calcification, fusion, and involvement of

subvalvar apparatus is required. Commissural calcification may be the limitation

for 3D TEE, provides a superior description of commissural fusion (38) from the

LA and LV perspectives, and may identify the safest site for transeptal puncture

with respect to surrounding structures. Special care is taken to avoid the aorta

while allowing adequate room to maneuver the catheter and balloon tip coaxially

towards the mitral orifice, thereby helping in appropriate sizing as well. The

balloon is then positioned for inflation without damaging the subvalvar structures.

3DTEE is superior in the post valvuloplasty detection of commissural splitting and

leaflet tears (17).

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Newer developments in technology

Ongoing developments in 3D echocardiography include technological innovations

in transducer technology and expanding clinical applications. Automated surface

extraction and quantification, single-heartbeat full-volume acquisition,

Transesophageal real time 3D imaging, the ability to navigate within the 3D

volume and stereoscopic visualization of 3D images are some of the technological

advances that can be expected over the next several years. The Combination of the

excellent temporal resolution of echocardiography with the excellent spatial

resolution of magnetic resonance imaging may herald a new era of “hybrid

imaging” in the near future (70-72). Three-dimensional echocardiography of

colour Doppler flow for measuring stroke volume and cardiac output valvular heart

disease is under development and has the potential to serve as a powerful

noninvasive clinical tool, aiding physicians in the serial assessment of disease and

response to intervention.

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MATERIALS AND METHODS

Setting: Cardiology OPD and echocardiography Lab, Sree Chitra Institute for

medical sciences and technology.

Study period: January 2014 to July 2014

Study Design: Prospective Observational study

Patient Population: Twenty five consecutive patients referred to our institution for

management of Rheumatic mitral stenosis between January to July 2014 were

studied. As routine all patients underwent transthoracic echocardiography for

balloon mitral valvotomy (BMV) suitability. It is routine in our institute to rule out

left atrial thrombi by transesophageal echocardiography (TEE) at least within 7

days prior to BMV. In addition, at the time of TEE, we have acquired 3D of mitral

valve and analyzed it offline.

Selection of patients for the BMV was by treating physicians after clinical and

transthoracic echocardiographic evaluation.

Inclusion and exclusion criteria:

Patients with rheumatic severe mitral stenosis undergoing TEE to rule out LA clot

prior to BMV will be included. (Ideal study group)

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Age less than 18 years and pregnant females will be excluded from enrollment.

(Issues related to cooperation during TEE)

Patients with left atrial clot will be excluded for BMV and analysis.

Patients who cannot give consent were also excluded from the study.

ECHOCARDIOGRAPHIC EXAMINATION

2D echocardiography

Two-dimensional transthoracic echocardiography (2DTTE) used a commercial

ultrasound system (S5-1 probe and iE33; Philips Medical Systems, Andover, MA).

MVA using 2D planimetry (MVA2D) was performed on a parasternal short-axis

view. The gain was optimized to visualize the whole contour of the mitral valve

orifice. The mitral valve orifice was magnified. Systematic scanning from the apex

to the base of the left ventricle was performed to ensure that the smallest mitral

valve cross-sectional area was obtained at the leaflet tips. The image was paused

during early diastole at the time of greatest mitral valve leaflet separation. Mean

and peak trans mitral gradients and the time-velocity integral were obtained by

continuous-wave Doppler tracings through the mitral valve from the apical 4-

chamber view. MVA using pressure half-time (MVAPHT) was estimated using the

formula 220/pressure half-time in the absence of moderate aortic or mitral

regurgitation. Left ventricular outflow tract measurements were made in the

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parasternal long-axis view. Three cardiac cycles for patients in sinus rhythm and 5

representative cycles for patients with atrial fibrillation were measured, and their

results were averaged. Associated aortic valve diseases like aortic regurgitation as

well as aortic stenosis that may also require intervention were excluded from detail

evaluation of the aortic valve in apical five chamber view and parasternal long axis

view. Assessment of left ventricular size and function, right ventricular size and

function, pulmonary artery systolic pressure, left atrial size and area, and the

degree of mitral regurgitation severity were also made. The short-axis view of the

mitral valve orifice was used to grade semi quantitatively the degree of fusion of

the anterolateral (P1 and A1) and posteromedial commissures (P3 and A3) as a

partial fusion or complete fusion.

3D Transesophageal echocardiography

Patients who are planning for BMV were called 6 hours fasting state for TEE (3D)

on a specific date. After detail informed consent related to procedure, TEE was

done by consultant in the Echo lab as an outpatient procedure and image were

stored for analysis later. Patients underwent 3DTEE under local anesthesia within

one week prior to BMV. Images of 3DTEE data sets were acquired after ruling out

left atrial thrombi by 2DTEE. The acquisition was performed using a commercially

available matrix-array transducer and echocardiographic unit (X7-2 t probe and

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iE33; Philips Medical Systems). The same ultrasound platform was used for both

2D and 3D acquisitions.

Conventional 2D transesophageal echocardiography was performed to assess valve

morphology and functional information like associated mitral regurgitation, aortic

regurgitation and aortic stenosis. For 3DTEE image acquisition, the 2D image of

the mitral valve in the bi-commissural view was optimized, and then 3D “en face”

views of the mitral valve were obtained in real time using the 3D zoom mode. By

adjusting the mitral valve in the center of the screen, sector settings were optimized

for image and color resolution. MVA3D was determined offline on an Xcelera

workstation using dedicated Philips QLAB version 7.0 advanced quantification

software (Philips Medical Systems). Gain and brightness settings were optimized

offline to allow the best endocardial definition detection. Multiplanar

reconstruction of the mitral valve orifice was used to identify the plane at which

the mitral valve orifice was smallest (Fig. 4). First, the smallest orifice in the most

perpendicular plane was determined. This plane was then steered systematically in

small depths and angulations in 3D space to ensure that the truly smallest orifice

was obtained. Planimetry was performed en face at the cross-sectional plane in

early to mid-diastole during its greatest diastolic opening (Fig. 5). Final MVA3D

was considered the average value after calculating three times in different plane.

Similar to 2DTTE, the degree of commissural fusion was assessed semi

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quantitatively in the form of partial or complete fusion. 3D en face views of the

mitral valve were used to assess the commissures from the left atrial, left ventricle,

and lateral views.

Figure 4: Multiplanar Reconstruction of MV Orifice Showing Orthogonal Imaging Planes at the

Tips of the MV Leaflets

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Figure 5: Three-Dimensional Planimetry of the MVA Traced at the MV Leaflet Tips Using the

Short-Axis View Determined After Multiplanar Reconstruction

After 2D transthoracic echocardiograpghy, 2DTEE and 3DTEE evaluation as

above if the patient is suitable for balloon mitral valvotomy, patients were planned

for BMV within a week of echocardiographic evaluation.

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Calculation of mitral valve area in catheterization laboratory

Prior to balloon mitral valvotomy, all patients underwent hemodynamic assessment

of mitral stenosis in form of gradient across the mitral valve by simultaneous

measurement of pressure in left atria and Left ventricle. Cardiac output was also

calculated after assessment aortic saturation/mean systemic pressure and mixed

venous saturation/mean right atrial pressure. The stenotic orifice area is determined

from the pressure gradient and cardiac output with the formula developed by

Gorlin and Gorlin from the fundamental hydraulic relationships linking the area of

an orifice to the flow and pressure drop across the orifice.

Hemodynamic assessment for pulmonary hypertension was done by direct

measurement of pulmonary artery pressure.

After collecting the data as mentioned above from 2DTTE, 3DTEE and

catheterization in form of MVA2D, MVAPHT, MVA3D, MVA Gorlin and

commissural evaluation for fusion, sub-valvular pathology - data used in the final

analysis.

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MVA3D measurements were compared with MVA2D, MVAPHT, and MVACON.

All values used in the final analysis were obtained independently, blinded to the

results of the other MVA measurements.

Statistical analysis

Statistical analysis was done by IBM SPSS trial version. Measures of dispersion,

Mean & Standard deviation were used for measurements. MVA values obtained

different methods were compared using two tailed Student’s paired t tests. For

qualitative data, significance was tested by ANOVA and Fisher tests.

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RESULTS

Twenty five consecutive patients with rheumatic mitral stenosis who underwent

TEE prior to BMV, were included in the study. Mean age of patients was 36.2 ± 12

(range 20-60) years. Nineteen patients were women. Eighteen patients were in

New York Heart Association (NYHA) functional class II and 7 patients were in

NYHA functional class III. One lady had history of prior TIA. Out of 25 patients, 8

patients had mild PAH, 7 patients had moderate PAH and 5 patient has severe

PAH prior to BMV. Only one patient had a history of heart failure. Twenty

patients were in sinus rhythm, 4 patients were in atrial fibrillation and one patient

had low atrial rhythm. Twenty patients had QRS axis ≥+75° with the mean QRS

axis of total cohort was +83° ±18°. One patient had a history of closed mitral

valvotomy at age of 23 years, 19 years prior to current BMV and 3 patients had a

prior history of BMV.

2D Transthoracic Echocardiographic data

All patients underwent 2DTTE systemically for evaluation of mitral valve as well

as hemodynamics associated with mitral stenosis. Mean left atrial size was 43±7

cm. 4 patients had no mitral regurgitation, 11 patients had trivial mitral

regurgitation and 10 patients had mild mitral regurgitation. Assessment of aortic

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valve revealed trivial to mild aortic stenosis in 7. Aortic regurgitation was present

in total 12 patients which was graded as trivial in 5, mild in 6 and as moderate in

one. Mean of peak diastolic gradient across the mitral valve by continuous Doppler

was 28.4 mm Hg and mean of mean diastolic gradient across mitral valve was

18.32 mm Hg. The mean of planimetry (2D) Mitral valve area was 0.834 cm2 and

mean of mitral valve area by the pressure half time method was 0.918 cm2.

Tricuspid regurgitation was present in 22 patients, of which 13 patients had mild

and 9 patients had trivial tricuspid regurgitation. Thirteen patients had right

ventricular systolic pressure ≥ 40mmHg.

3D Transesophageal Echocardiographic data

Information collected during 3DTEE were mitral valve area, commissural fusion

and sub-valvular pathology. Mean 3D mitral valve area was 0.7568 cm2. Medial

commissures were fused partially in 12 patients and fully in 13 patients while

lateral commissures were fused partially in 8 patients and fully in 17 patients. Sub-

valvular pathology was present in 22 patients. Out of 22, 11 patients had mild, 9

had moderate and 2 had severe sub-valvular pathology. These morphologic

observations were by the consultant based on his experience and no volumetric

studies on the valvular or sub-valvular pathologies were done in the present study.

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The only quantitative measurement which can be validated obtained in this study

was the smallest orifice of the mitral valve.

Catheterization data during balloon mitral valvotomy

Mean Mitral valve area calculated by Gorlin’s method prior to balloon mitral

valvotomy was 0.858 cm2 and after balloon mitral valvotomy was 1.53 cm2. Mean

mitral valve gradient by catheterization was 15.8 mm Hg prior to BMV and it was

reduced to 6 mm Hg after BMV. During catheterization pulmonary hypertension

was assessed in 16 patients and mean pulmonary artery pressure was 37.15 mmHg

prior to BMV and it was reduced to 26.85 mm Hg after BMV.

Predischarge evaluation of mitral valve by 2DTTE after BMV

Prior to discharge all patients underwent for evaluation by 2DTTE for mitral valve

as well as any complication due to the procedure. No complication noted in form

of pericardial effusion, vegetation, thrombi or residual atrial septal defect in any

patient. There was no increase in significant mitral regurgitation in any patients.

Post BMV mean mitral valve area was found to be 1.57 cm2 by planimetry

(MVA2D) and 1.56 cm2 by pressure half time (PHT) method. Mean peak mitral

valve gradient was found to have 12.32 mm Hg and mean of mean mitral valve

gradient was 5.76 mm Hg after BMV.

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Balloon mitral valvotomy outcome

MVA3D better correlated with 2DMVA than MVAPHT or MVA Gorlin. Success

of BMV was defined as ≥50% increase in 2DMVA by TTE from the baseline

without significant increase in mitral regurgitation. Total 8 patients did not have

successful BMV. The mean age of these patients was 41.37 years. 7 patients were

female. 1 patient was in NYHA class III and 7 patients were in NYHA class II. 5

patients had mild PAH, 2 patients had moderate PAH and one patient did not have

PAH. Out of 8 patients, 3 patients had rhythm other than sinus, 2 had atrial

fibrillation and one had low atrial rhythm. Mean QRS axis +79.37°. Two patients

had a past history of intervention for mitral stenosis, one had balloon mitral

valvotomy and the other had closed mitral valvotomy (CMV). Patient with CMV

had a 41% increase in MVA after BMV, he had CMV 19 years back. Patient with

BMV in the past had 28% increase in MVA after BMV. The mean LA size was

46.75mm. Baseline measurements for mean MVA2D, MVAPHT, MVA3D and

MVA Gorlin was 1.03 cm2, 0.96 cm2, 0.87 cm2 and 0.94 cm2 respectively in

these 8 patients group. Post BMV mean measurements for MVA2D, MVAPHT

and MVA Gorlin was 1.47 cm2, 1.48 cm2 and 1.45 cm2 respectively. Other valve

lesions were present in the form of moderate aortic stenosis and moderate aortic

regurgitation in one patient, mild aortic regurgitation in 3 patients. Three patients

34

had mild sub-valvular pathology and 3 patients had moderate sub-valvular

pathology. Among the patients who did not have successful BMV 2 patients had

both medial and lateral commissures fused, 2 patients had both commissures

partially fused. Three patients had lateral commissure fused and medial

commissure partially fused. One patient had medial commissure fused and lateral

commissure partially fused.

Out of various variables only baseline MVA2D and baseline MVA3D were

significantly associated with the success of balloon mitral valvotomy. Sub-valvular

pathology and commissural fusion by 3DTEE was not associated with the success

of balloon mitral valvotomy.

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Table 3: Various baseline variables and its significance for successful BMV

results

Variables BMV failure

n=8

BMV

successful

n=17

p

value

MVA3D (cm2) 0.871±0.130 0.703±0.190 .039

MVA2D (cm2) 1.031±0.133 0.741±0.170 .001

Mean Mitral valve gradient (mmHg) 16.63±7.09 19.12±6.22 0.38

LA size (mm) 46.75±6.29 42.00±7.89 0.15

Commissural fusion (3D) PF 2 1 0.53

F/PF 4 10

F 2 6

Sub-valvular pathology (3D) Nil/mild 5 9 0.65

Mod/severe 3 8

PAH Nil/mild 6 7 0.10

Mod/severe 2 10

Aortic valve disease + 4 3 0.46

- 4 14

Past history of mitral valve

intervention

+ 2 2 0.17

- 6 15

Atrial fibrillation + 3 1 0.13

- 5 16

36

Assessment of MVA

MVA3D was compared with MVA2D, MVAPHT and MVA Gorlin. MVA3D

measurements were significantly lower compared with MVAPHT (mean

difference: 0.161 ± 0.25; n = 25, p 0.004) and MVA Gorlin (mean difference:

0.100 ± 0.18; n = 25, p 0.013). MVA3D was also smaller compared to MVA2D

but this was not significant (mean difference: 0.077 ± 0.20; n = 25, p 0.073).

Correlation between MVA3D and conventional methods

MVA3D demonstrated the best correlation with MVA2D (ICC 0.472), followed by

MVA Gorlin (ICC 0.457). The correlation was not good with MVAPHT (ICC

0.246). Agreement between methods is summarized in Table 5. Bland-Altman

plots and correlations comparing paired observations between methods are shown

in Figures 6-8. (INTRACLASS CORRELATION COEFFICIENT – ICC)

Table 4 Mean of MVA (various methods) with Standard deviation

MVA 2D Pre MVA PHT Pre MVA 3D Pre MVA 2D Post

MVA PHT

Post

MVA GOR

Pre MVA Gor Post

Mean .8340 .9180 .7568 1.5680 1.5552 .8576 1.5332

Std. Error of Mean .04159 .03360 .03853 .05101 .04827 .03316 .05701

Median .8700 .9000 .8000 1.6000 1.5000 .8700 1.5000

Std. Deviation .20795 .16800 .19265 .25505 .24134 .16579 .28507

Range .80 .60 .64 1.11 1.10 .76 1.15

Minimum .50 .60 .39 1.09 1.10 .44 .95

Maximum 1.30 1.20 1.03 2.20 2.20 1.20 2.10

37

Table 5 Co-relation Between Different Methods and MVA3D

Method Mean +/- SD p value Correlation

Coefficient

MVA 2D 0.077 +/- 0.20

0.073 0.472

(Significant)

MVA PHT 0.161 +/- 0.25 0.004 0.246 (0.903 Not Significant)

MVA Gor 0.100 +/- 0.18 0.013 0.457 (0.017

Significant)

Figure 6: Correlation graph between MVA 2D & MVA 3D (r 0.472)

38

Figure 7: Correlation graph between MVA PHT & MVA 3D (r= 0.246)

Figure 8: Correlation graph between MVA Gorlin & MVA 3D (r = 0.457)

39

Assessment of commissural fusion by 3DTEE

Commissural fusion of the medial and lateral commissures were assessed by an

experienced operator and classified into 4 groups. Group A had partial fusion of

both the commissures. Group B had partial fusion of medial commissures with

complete fusion of the lateral commissure. Group C had the reverse of B. Group D

had both the commissures fully fused. Mean MVA 3DTEE was 1.01 ± 0.02cm2,

0.79 ± 0.17 cm2, 0.80 ± 0.14 cm2 and 0.60 ± 0.15 cm2 in Group A, B, C and D

respectively.

Table 6: Relation between degree of commissural fusion and mean 3DMVA

MVA3D

cm2

Lateral commissures

P 0.004 Partially fused

(PF)

Fused (F)

Medial

commissures

PF

1.01 ± 0.02

n 3 Gr A

0.79 ± 0.17

n 9 Gr B

F 0.80 ± 0.14

n 5 Gr C

0.60 ± 0.15

n 8 Gr D

Assessment of sub-valvular pathology

In our study, we have evaluated sub-valvular pathology by 3DTEE and according

to visual impression it was classified in mild, moderate and severe sub-valvular

pathology. Total 11 patients had mild, 9 patients had moderate and 2 patients had

40

severe sub-valvular pathology. No significant chordal thickening or shortening

could be imaged in 3 patients. Mean MVA 3DTEE measurements in above groups

also correlate with their sub-valvular pathology. Table 7 showing mean MVA

according to mild, moderate and severe sub-valvular pathology is as below.

Significantly decrease in mean MVA 3D with increase in sub-valvular pathology

(p = 0.002).

Table 7: Relation between severity of sub-valvular pathology and 3DMVA

Mean

MVA3D

cm2

Sub-valvular pathology (p 0.002)

Nil (n=3) Mild (n=11) Moderate (n=9) Severe (n=2)

1.02 ± 0.01 0.79 ± 0.17 0.70 ± 0.13 0.45 ± 0.08

Success of BMV and its relation with commissural fusion

In our study, we defined a success of BMV as a 50% increase in MVA without

significant increase in mitral regurgitation. With this definition 8 patients did not

have a 50% increase in 2DMVA compared to baseline. We had also evaluated the

factors affecting the success of BMV like subvalular pathology and commissural

fusion and its effect on the success of the BMV. Group A commissural fusion had

a 67% increase in MVA2D and 64% increase in MVA Gorlin compared to

41

baseline. Group B commissural fusion had a 56.88% increase in MVA2D and

56.33% increase in MVA Gorlin compared to baseline. Group C commissural

fusion had a 51% increase in MVA2D and 55% increase in MVA Gorlin compared

to baseline. Group D commissural fusion had a 47% increase in MVA2D and 54%

increase in MVA Gorlin compared to baseline.

Table 8: Relation between degree of commissural fusion and percentage of

gain in MVA after balloon mitral valvotomy

2D Gorlin 2D Gorlin 2D Gorlin 2D Gorlin

67 64 56.88 56.33 51 55 47 54.37

% Gain in

MVA

after

BMV

Gr A Gr B Gr C Gr D

Success of BMV and its relation with sub-valvular pathology

We had evaluated the success of BMV according to severity of subvalular

pathology also. In a patient who did not have a significant sub-valvular pathology

shown a 72.33% increase in 2DMVA and a 62.33% increase in MVA Gorlin from

baseline. In patient who had mild sub-valvular pathology had a 52.55% increase in

2DMVA and 54.55% increase in MVA Gorlin from baseline. In patient who had

moderate sub-valvular pathology had a 50.44% increase in 2DMVA and a 58%

increase in MVA Gorlin from baseline. In patient who had severe sub-valvular

pathology had a 50.5% increase in 2DMVA and a 47.5% increase in MVA Gorlin

from baseline.

42

Table 9: Relation between degree of sub-valvular pathology and percentage of

gain in MVA after balloon mitral valvotomy

Gain in MVA

after

BMV (%)

Nil Mild Moderate Severe

2D

Gorlin 2D

Gorlin

2D

Gorlin 2D

Gorlin

72.33 62.33 52.55 54.55 50.44 58 50.5 47.5

43

DISCUSSION

Schlosshan et al., 2011 was the first study that evaluated the reliability and

feasibility of 3DTEE technology for MVA measurements and the assessment of

commissural fusion in patients with moderate to severe RhMS. It showed MVA

planimetry is feasible in the majority of patients with RhMS using 3DTEE, with

excellent reproducibility, and compares favorably with established methods.

Three-dimensional transesophageal echocardiography allows excellent assessment

of commissural fusion (38).

In our study, we have included total 25 patients for 3DTEE evaluation who are

planned for 2DTEE otherwise to rule out left atrial thrombus prior to the

therapeutic procedure in the form of balloon mitral valvotomy. We could able to

evaluate mitral valve anatomy at a same time of 2DTEE in all the patients without

any feasibility issue.

The findings were that 3DTEE: 1) provides excellent images of the mitral valve

leaflets in the majority of patients; 2) permits accurate MVA planimetry in all

patients and 3) demonstrates assessments of commissural fusion in all patients.

44

MVA measurements

MVA measurements play a major role in the management of RhMS. MVA

determines the hemodynamics in RhMS and classifies it in mild, moderate and

severe obstruction at the mitral valve level along with transmitral gradient.

Methods that provide sufficient accuracy and low variability are therefore

desirable. MVA assessments by planimetered methods are recommended as a

reference standards, because they are relatively unaffected by hemodynamic

changes (34).

In present study MVA3D was compared with MVA2D, MVAPHT and MVA

Gorlin. MVA3D measurements were significantly lower compared with MVAPHT

(mean difference: 0.161 ± 0.25; n = 25, p 0.004) and MVA Gorlin (mean

difference: 0.100 ± 0.18; n = 25, p 0.013). MVA3D was also smaller compared to

MVA2D but this was not significant (mean difference: 0.077 ± 0.20; n = 25, p

0.073). In Schlosshan et al., (38) MVA3D measurements were significantly lower

compared with MVAPHT (mean difference: -0.23 ± 0.28 cm2; n 39, p < 0.0001),

finding matching with our study. However, in Schlosshan et al., MVA3D

measurements were significantly lower compared with MVA2D (mean difference:

-0.16 ± 0.22; n 25, p < 0.005), but in our study MVA2D measurements was only

correlated with the MVA3D measurements. In Schlosshan et al., MVA3D

45

measurements were marginally greater than MVACON (mean difference: 0.05 ±

0.22 cm2; n 24, p = 0.82) that we had not evaluated in our study.

In 2009, Zamorano et al (39) showed accuracy of 3DTTE planimetry is superior to

the accuracy of the invasive Gorlin's method for the mitral valve area (MVA)

measurements when a median value obtained from two-dimensional planimetry,

pressure half-time, and proximal isovelocity surface area method is used as the

gold standard. 3DTTE improves MVA measurement, particularly in less

experienced operators compared with experienced operators. Augusto L Plama et

al. (41) Showed Echo is an adequate method for the assessment and calculation of

MVA before and after BMV providing accurate values when compared to the

established method MVA calculation obtained by Gorlln's formula. Mean MVA

Gorlin was 1.73 cm2, whereas the mean value obtained by 3DTTE was 1.72 cm2.

There was a significant correlation between MVA obtained by Gorlin's formula

and 3D Echo pre valvuloplasty (r: 0.7638; P < 0.001) and post-valvuloplasty (r:

0.6659; P

46

correlated well with the mitral area determined by 2-dimensional echocardiography

(r = 0.98) and by pressure half-time (r = 0.90). MVA in normal controls on 3DTTE

correlated well with MVA on 2-dimensional echocardiography (r = 0.94) and

pressure half-time (r = 0.91). Other two studies, Sebag IA et. al (36) and Binder

TM et al (37) also showed the same results.

It is well known that MVAPHT can be affected by several hemodynamic factors

like heart rate, left ventricular end diastolic pressure, associated valvular lesions

like mitral or aortic valve regurgitation as well as the rhythm of the patient at the

time of measurement. In our study, 20% of the patients had rhythm other than

sinus, 6 patients had mild aortic regurgitation and one patient had moderate degree

of aortic regurgitation. 11 patients had trivial mitral regurgitation and 10 patients

had mild mitral regurgitation that may affect the measurement of MVAPHT but

not the planimetry measurement of mitral valve area by 2D or 3D

echocardiography. These factors in our study may have affected the accuracy of

MVAPHT. Omer et al. (40) showed that MVA calculated with both the PISA and

PHT methods correlated well with MVA calculated with the planimetry method.

However, the PISA rather than PHT is recommended for patients with MS and

extreme atrioventricular compliance values because PHT is affected by changes in

atrioventricular compliance.

47

3DTEE may provide lower values for MVA compared with MVA2D because of

inferior lateral resolution. However, other investigators have demonstrated that

MVA measured with 3DTTE, which has an inferior lateral resolution compared

with 2DTEE, show superior accuracy compared with traditional 2D and Doppler

methods when compared with MVA derived from the Gorlin formula used as the

gold standard.

The geometry and complex structure of the mitral valve in RhMS make it difficult

to determine the correct MVA with 2D echocardiography. Importantly, controlled

sectioning of the mitral valve funnel orifice in a second plane is not possible. This

may lead to inaccurate measurements whereby the smallest and most perpendicular

views is not measured, and MVA is significantly overestimated (42). Three-

dimensional echocardiography offers the advantage that the mitral valve tips can

be viewed in three orthogonal planes. This allows accurate identification and

verification of the narrowest part of the mitral valve orifice for planimetry of the

smallest MVA. Previous studies have suggested that 3DTTE provides superior

accuracy and reproducibility in the assessment of MVA in patients with RhMS

(43-45). However, suboptimal image quality is an important limitation of 3DTTE

(46).

48

3DTEE – Technical issues

In 2008, Sugeng L et al. showed 3DTEE is excellent for visualization of the mitral

valve (85% to 91% for all scallops of both MV leaflets), interatrial septum (84%),

left atrial appendage (86%), and left ventricle (77%) in a study of 211 patients.

3DTEE provides superior image quality and resolution of the mitral valve

compared with 3DTTE (14). Earlier studies using offline reconstructed 3DTEE

technology suggested that 3DTEE may allow more accurate and reproducible

assessment of the mitral valve and MVA in patients with RhMS (47, 17, 18). In

accordance with other studies, we used 3D zoom mode to acquire real-time 3D

images of the mitral valve over 1 heart beat (19). The 3D zoom mode was

preferred over the multiple-beat wide-angle acquisition full-volume mode because

there are no limitations related to arrhythmias and breathing. Full-volume mode

provides higher temporal resolution (up to 30 to 40 Hz) at a cost of inferior lateral

resolution compared with zoom mode. Because of the relatively small mitral valve

annulus in RhMS, the sector width of the pyramidal dataset can be narrowed down,

allowing the acquisition of high-quality 3D images of the mitral valve at higher

frame rates than achievable in other mitral valve pathologies, in which the annular

size often requires a larger sector size (20). In the present study, we achieved a

mean frame rate of >16 Hz and were able to acquire consistently high-quality real-

time 3D images of the mitral valve. This allowed real-time, en face evaluation of

49

the mitral valve apparatus from multiple angles, providing detailed visualization of

the mitral valve leaflets, sub-valvular structures, and commissures. 3DTEE was

particularly useful for the MVA assessment of eccentric mitral valve orifices and

the characterization of the shape and distribution of the mitral valve orifice.

We have included the patients who were evaluated for MVA assessment by all

three modalities, i.e 2DTTE, 3DTEE and Gorlin’s methods. So our study is

difficult to answer related to feasibility of 3DTEE compared to 2DTTE, but our

observation suggests there was not a single patient in whom 3DTEE evaluation

was not possible for any reason. So we can claim from the study that 3DTEE was

definitely feasible in all patients with RhMS. Previous studies Schlosshan et al (38)

showed 95% feasibility in a cohort of 41 patients, 2 patients were not feasible

because of excess calcification of the mitral valve.

Commissural assessment

In David Messika-Zeitoun et al (45) the degree of commissural fusion was

underestimated with 2DTTE in 19% of patients compared with 3DTEE in a cohort

of 60 patients of RhMS. The detailed visualization of the mitral valve

commissures in RhMS with 3DTEE constitutes a major advantage over 2D

echocardiographic methods. In Schlosshan et al (38) 3DTEE provided detailed

morphological evaluation and accurate assessment of commissural fusion in all

50

patients. In contrast, commissural assessment was possible in only 60% using

2DTTE (38). In Schlosshan et al commissural fusion was classified in minimal,

partial and complete fusion, but the exact definition of commissural fusion

classification was not applied in any study. All evaluations for commuters were

depended on morphology analysis by the investigator. So we, in our study

commissures were evaluated as either complete fusion or partial fusion. It was

feasible to evaluate commissure in all patients in our study. The mitral valve

commissures traverse several different 2D planes and thus are ideally suited to be

visualized by 3DTEE. This can be readily appreciated by viewing the commissures

from the atrial, ventricular, and lateral perspective. Commissural calcification is an

important predictor of outcome after BMV (21). In our institute, we consider

commissural calcification as a contraindication for balloon mitral valvotomy.

Commissural calcification is difficult to visualize by 3DTEE, as current 3D images

represent a 3D surface rendition of the mitral valve. In surgical specimens, mitral

valve calcification is often found to be endothelialized rather than located on the

surface of the commissures. 3D imaging is good at demonstrating protruding bulk,

while 2D imaging, which is cross-sectional, permits better characterization of the

calcification. This highlights how 2D and 3D methods are complementary.

Assessment of commissural morphology has been shown to provide additional

predictive value above other components of mitral valve anatomy in patients

51

considered for BMV (22–25). Zamorano J et al. and Langerveld J et al. showed

that the morphological assessment of the rheumatic mitral valve before BMV using

3DTTE may be more accurate and reliable than 2D methods (26, 47). Splitting of

the commissures is the principal mechanism that leads to increased MVA and

hemodynamic improvement after BMV. In C L Reid et al .(27), 1987 MVA was

smaller in patients with calcification (2.1 ± 0.2 cm2) compared with those without

(2.7 ± 0.5 cm2; p =0. 10) and in those with sub-valvular disease (2.0 ± 0.6 cm2)

compared with those without (2.9 ± 0.9 cm2; p = .03) after BMV.BMV is therefore

unlikely to increase MVA if commissural fusion is minimal or if the commissures

are rigid because of the presence of calcium. The improved visualization of the

commissures with 3D echocardiography may thus be superior to conventional 2D

techniques in predicting outcomes after BMV.

We have classified commissural fusion in only two types, i.e. fused or partially

fused. So we will get total 4 groups of patients. Group A had partial fusion of both

the commissures. Group B had partial fusion of medial commissures with complete

fusion of the lateral commissure. Group C had the reverse of B. Group D had both

the commissures fully fused. Mean MVA3DTEE was 1.01 ± 0.02 cm2, 0.79 ± 0.17

cm2, 0.80 ± 0.14 cm2 and 0.60± 0.15 cm2 in Group A, B, C and D respectively.

These results were as per expected MVA in suggesting groups. Schlosshanet al.

52

(38) also showed patients in whom both commissures were fused had a lowest

MVA (0.48 ± 0.18 cm2) in all groups.

Commisural fusion was also associated with suboptimal result of BMV. As seen in

our study gain of mitral valve area highest in Group A was 67% by 2DMVA and

64% by MVA Gorlin while with increasing fusion of commissures as in Group B,

C and D gain of mitral valve area after BMV was 56.88%, 51%, 47% respectively

by 2DMVA method and 56.33%, 55% and 54.37% respectively by MVA Gorlin

method.

Reid CL et al (29) showed that increase in sub-valvular pathology from mild to

severe, was associated with less increase in mitral valve area after balloon mitral

valvotomy. In our study also with no sub-valvular pathology is associated better

gain of mitral valve area compare to patient had sub-valvular pathology. Among

patients with sub-valvular pathology also gain of mitral valve area, both by

2DMVA and Gorlin method was decreasing proportionally with increase in sub-

valvular pathology.

Predictors of poor outcome of BMV

Prediction of the results is multifactorial. In addition to morphological factors,

preoperative variables (eg, age, functional class, history of surgical

commissurotomy, small mitral valve area, presence of mitral regurgitation before

http://www.ncbi.nlm.nih.gov/pubmed?term=Reid%20CL%5BAuthor%5D&cauthor=true&cauthor_uid=2766506

53

the procedure, pulmonary artery pressure, and severity of tricuspid regurgitation)

and procedural factors (eg, balloon size) can be independent predictors of

immediate outcome (30-33). In our study we, found baseline MVA2D and

MVA3D were only significant predictors for successful BMV. A smaller mitral

valve area associated with poor outcome BMV with p value 0.001 (MVA2D) and

0.039 (MVA3D). Past history of CMV/BMV, increased age, atrial fibrillation,

commissural fusion and associated aortic valve lesion were not predictors of poor

balloon mitral valvotomy results in our study.Prediction of successful BMV

outcome by other variables may not be applicable due to small sample size.

54

LIMITATIONS

Our study group was small and was a nonrandomized study for outcome

assessment. No objective definition was used to define or quantitate sub-valvular

pathology and commissural fusion. As an absolute gold standard for MVA

assessment is not established, final conclusion about accuracy of 3DTEE compared

to other methods for assessment of MVA remain controversial (73). 3DTEE itself

has some technical limitations. Zoom mode in usually associated with very low

frame rate, so image motion may not be smooth, and fine structures such as

chordae tendineae may not be well assessed (19,28). Severe calcific mitral valve

has more chance of tissue drop out during planimetry measurement. Current 3D

analysis software allows planimetry of the mitral valve orifice only in a single

carefully selected plane. In some patients, the mitral orifice may be curvilinear and

is not optimally represented by a single plane.

55

CONCLUSIONS

In the current study, baseline mitral valve area by 3DTEE or 2DTTE were the

predictors of BMV outcome. Commissural and sub-valvular pathology evaluations

with 3DTEE did not provide incremental value to standard two dimensional

echocardiography in predicting BMV outcome.

MVA3D by transesophageal echocardiography was correlated well with the

MVA2D transthoracic echocardiography, but was not correlated well with the

method which were affected by hemodynamics like pressure half time and Gorlin’s

method.

56

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