3D TEE for Evaluation of Commissural Opening Before and During Percutaneous Mitral Commissurotomy
Edward A. Gill, MD*,
Michael S. Kim, MD,
John D. Carroll, MD
The report by Messika-Zeitoun et al. (1) evaluating the association of commissural opening (CO) after percutaneous mitral commissurotomy (PMC) with improved long-term clinical outcomes shows the utility of combining CO with other echocardiography parameters in the post-procedure assessment of PMC. Their findings also validate the longstanding but inadequately data-supported (2) practice of using echocardiographic assessment of CO as a guide for evaluation and treatment of patients with severe mitral stenosis.
Although 2-dimensional echocardiography remains the standard imaging modality for evaluating mitral stenosis, we agree with the investigators that the advent of 3-dimensional (3D) transthoracic echocardiography (TTE) and 3D transesophageal echocardiography (TEE) harbor the potential to revolutionize the noninvasive evaluation and invasive management (i.e., PMC) of severe mitral stenosis. Before the development of real-time 3-dimensional (RT3D) imaging, the use of 3D echocardiography in evaluating mitral stenosis was limited to offline reconstruction of gated 3D images acquired using 2-dimensional echocardiography before PMC. Although offline reconstruction helped to clarify the presence and extent of commissural fusion, it could be used for neither procedural guidance nor as a mechanism for immediate feedback on procedural results. After the introduction of RT3D TTE in 2002, it became obvious that this technological advancement would serve as a useful tool to enhance our understanding and evaluation of mitral commissural fusion by providing "depth" to the mitral valve through the application of the "elevation" dimension (i.e., the third dimension). Furthermore, as opposed to the gated technique, RT3D imaging allowed visualization of the mitral valve throughout an unlimited number of cardiac cycles. Finally, the same evaluation could be performed before and after PMC as well as during the balloon inflation. Indeed, using the technology during PMC procedures, we noted several dramatic demonstrations of commissural splitting shown with pre- and post-procedure RT3D TTE (Fig. 1).
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Figure 1 Transthoracic 3-Dimensional Images From the Parasternal Short-Axis View at the Leaflet Tips
(A) The valve before percutaneous mitral commissurotomy with the commissures still fused. (B) The open commissures with the additional elevation dimension providing enhancement to appreciate the length of commissural splitting.
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The advent of RT3D TEE in November 2007, however, represented the next frontier in the evaluation of mitral stenosis and allowed for optimal 3D imaging of the mitral commissures in virtually all patients. As a result, we have now transitioned to routinely using RT3D TEE to both pre-procedurally evaluate mitral stenosis (i.e., assessing commissural fusion) and assess the immediate results (i.e., assessing CO) of PMC (Fig. 2). Additionally, the enhanced imaging provided by RT3D TEE has provided an improved confidence in adopting the approach to PMC of proceeding with increased Inoue balloon inflations until one or both commissures are split, while exercising caution to stop earlier should progressive mitral regurgitation develop.
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Figure 2 Examples of Real-Time 3-Dimensional Transesophageal Imaging
(A, C) The mitral orifice from the ventricular side before and after percutaneous mitral commissurotomy. As in Figure 1, C shows the opening of the commissures as a result of the procedure. (B) A view of the mitral orifice from the left atrial side. Further, the balloon catheter is seen within the left atrium as the operator moves it toward the mitral orifice.
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In summary, we agree with Messika-Zeitoun et al. (1) that 3D echocardiography, but particularly RT3D TEE, offers tremendous potential in assessing commissural fusion in mitral stenosis and CO after PMC, although further evaluation of this novel imaging modality is clearly needed before widespread adoption is achieved. Nonetheless, our positive experiences in using RT3D echocardiography in both the evaluation and the treatment of mitral stenosis have led to our laboratory incorporating it as a mainstay in the evaluation and percutaneous treatment of severe mitral stenosis.
* Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Harborview Medical Center, Box 359748, 325 Ninth Avenue, Seattle, Washington 98104 (Email: eagill{at}u.washington.edu).
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REFERENCES
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- Messika-Zeitoun D, Blanc J, Iung B, et al. Impact of degree of commissural opening after percutaneous mitral commissurotomy on long-term outcome J Am Coll Cardiol Img 2009;2:1-7.[Abstract/Free Full Text]
- Fatkin D, Roy P, Morgan JJ, Feneley MP. Percutaneous balloon mitral valvotomy with the Inoue single-balloon catheter: commissural morphology as a determinant of outcome J Am Coll Cardiol 1993;21:390-397.[Abstract]
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