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Saturday, 10 May, 2008


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  Technology Update
From ACC 2007

Percutaneous treatment of Mitral Valve Regurgitation


A team led by Karl-Heinz Kuck, cardiology director at Allgemeines Krankenhaus St. Georg, Hamburg, Germany evaluated one approach to non-surgical mitral repair, the Edwards MONARC™ system and reported on the preliminary findings at the ACC 07 Scientific Sessions.
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THE SOCIETY FOR MITRAL VALVE PROLAPSE SYNDROME


Mitral valve prolapse: now you see it; now you don't: recalling the discovery, rise and decline of a diagnosis


Weisse AB.
New Jersey Medical School, Springfield, NJ, USA.
Am J Cardiol. 2007 Jan 1;99(1):129-33.

Mitral valve prolapse has been recognized as a clinical entity for only the past 50 years, although the auscultatory findings of this condition had been recognized since the mid-19th century. On the evidence of only a few autopsies, it was concluded that the basis for these were pleuropericardial adhesions. Left ventricular angiographic studies performed in the 1960s clearly documented the true nature of the condition, although it was not until the advent of echocardiography that large numbers of patients began to be referred for evaluation by this new technique. Because of the wide variety of symptoms in patients with suspected mitral valve prolapse, similar to those with other conditions, many patients with the latter were referred for evaluation and diagnosed with mitral valve prolapse because of misleading M-mode and then 2-dimensional criteria. It is now recognized, with the use of improved, more restrictive echocardiographic criteria, that the prevalence of the disorder is much less than previously believed. No test has been devised that will prove 100% sensitive and 100% specific for any disorder. In conclusion, this sobering fact should encourage the use of all modalities available, including clinical skills, to make proper diagnoses when these may be in doubt.

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Mitral Valve Prolapse


  • Echocardiography is the most utilised imaging modality for diagnosis of mitral valve prolapse. Mmode and 2-D echocardiography frequently lead to false-positive and false-negative diagnoses due to the non-planar leaflet–annular relationships of the mitral valve.
  • Prolapse is generally defined as a displacement of a bodily part from its normal position or relations. By 3-D echocardiography it is possible to visualise the mitral valve en face from either the left atrium or the LV (1, 2).
  • In volume rendered images looking down in the left atrium, mitral valve prolapse is viewed as a convexity or bulge and often as a bright area compared with the rest of the mitral leaflet. Looking up in the LV mitral valve, prolapse appears as a spoon-like depression.
  • In patients with mitral valve prolapse and mitral regurgitation a crack due to noncoaptation can be identified (see Figure).

Mitral Valve Prolapse

Figure: (A) View of the Mitral Valve Prolapse as Seen from the Left Atrium. (B) Visualisation of a Crack due to Non-coaptation when the Whole Data Set is Turned a Crack (Arrow)

Excerpt from Three-dimensional Echocardiography in Mitral Valve Disease
1. Three-dimensional transaesophageal echocardiography in the diagnosis of mitral valve prolapse
2. Evaluation of mitral valve prolapse by four-dimensional echocardiography

Mitral Valve Prolapse


  • 3-D echocardiography allows accurate identification and quantification of the prolapse of individual scallops/segments of the mitral valve leaflets (see Figure).
  • Two intra-operative studies, conducted by Ahmed et al and Chauvel et al, confirmed that the topography of prolapsing scallops/segments shown by 3-D echocardiography was correct in 78% and 86%, respectively.
  • Contrary to 2-D echocardiography, 3-D echocardiography allowed measurements of the area and width of the prolapsed portion of the leaflet as well as measurements of the circumference of the posterior part of the mitral annulus.
  • This information could aid the surgeon in deciding the extent of valvular tissue resection (3, 4).

Mitral Valve Prolapse - Middle Segment

Figure: (A) Mitral Valve Prolapse of the Middle Segment of the Posterior Mitral Leaflet Viewed in Systole from the Left Atrium. (B) Measurement of the Area and Width of the Prolapsing Segment

Excerpt from Three-dimensional Echocardiography in Mitral Valve Disease
3. Usefulness of transaesophageal three-dimensional echocardiography in the identification of individual segment/scallop prolapse of the mitral valve
4. Usefulness of three-dimensional echocardiography for the evaluation of mitral valve prolapse: An intraoperative study
  Assessment of Carpentier type II mitral valve lesions
From The American Journal of Cardiology

Comparison of Three-Dimensional Imaging to Transesophageal Echocardiography for Preoperative Evaluation in Mitral Valve Prolapse


Mitral Valve Prolapse Article
  • Perioperative 3DIR clearly facilitates optimal valve repair
  • The more complex the lesion, the more valuable 3DIR is compared with TEE in determining underlying pathology
  • Prior to repair, the more specific 3DIR is compared with TEE
  • Extend each echocardiographic evaluation of type II mitral valve dysfunction to 3DIR
  • 3DIR may not always accurately detect the lesion if > 2 scallops are involved in a bileaflet defect

  Guidelines Watch
A round up of the latest Clinical Guidelines from the ACC

These guidelines attempt to deal with general issues of treatment of patients with heart valve disorders, such as evaluation of patients with heart murmurs, prevention and treatment of endocarditis, management of valve disease in pregnancy, and treatment of patients with concomitant coronary artery disease (CAD), as well as more specialized issues that pertain to specific valve lesions. The guidelines focus primarily on valvular heart disease in the adult, with a separate section dealing with specific recommendations for valve disorders in adolescents and young adults.

(1) ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

  Method Update

3DTEE to assess patients with Mitral Valve Prolapse undergoing surgical correction

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