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Table of Contents
Year : 2011  |  Volume : 14  |  Issue : 2  |  Page : 91-96
Real-time three-dimensional echocardiographic assessment of mitral valve: Is it really superior to 2D transesophageal echocardiography?

1 Department of Anaesthesiology and Intensive Care Medicine II, Heart Center Leipzig, University of Leipzig, Leipzig, Germany
2 Department of Anaesthesia and Intensive Care Medicine, Medical Faculty, University of Leipzig, Leipzig, Germany
3 Research Student, Department of Anaesthesiology and Intensive Care Medicine II, Heart Center, Leipzig, University of Leipzig, Leipzig, Germany
4 Department of Cardiac Surgery, University of Leipzig, Leipzig, Germany

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Date of Submission02-Nov-2010
Date of Acceptance11-Mar-2011
Date of Web Publication25-May-2011


Aim of our study was to investigate the feasibility of use and possible additional value of real-time 3D transesophageal echocardiography (RT-3D-TEE) compared to conventional 2D-TEE in patients undergoing elective mitral valve repair. After ethical committee approval, patients were included in this prospective study. After induction of anesthesia, a comprehensive 2D-TEE examination was performed, followed with RT-3D-TEE. The intraoperative surgical finding was used as the gold standard for segmental analysis. Only such segments which were surgically corrected either by resection or insertion of artificial chords were judged pathologic. A total of 50 patients were included in this study; usable data were available from 42 of these patients . Based on the Carpentier classification, the pathology found was type I in 2 (5%) patients, type II in 39 (93%) patients and type IIIb in 1 (2%) patient. We found that 3D imaging of complex mitral disease involving multiple segments, when compared to 2D-TEE did not show any statistically significant difference.RT-3D-TEE did not show any major advantage when compared to conventional 2D-TEE for assessing mitral valve pathology, although further study in a larger population is required to establish the validity of this study.

Keywords: Real time 3D TEE, minimally invasive mitral valve repair, 2D TEE

How to cite this article:
Mukherjee C, Tschernich H, Kaisers UX, Eibel S, Seeburger J, Ender J. Real-time three-dimensional echocardiographic assessment of mitral valve: Is it really superior to 2D transesophageal echocardiography?. Ann Card Anaesth 2011;14:91-6

How to cite this URL:
Mukherjee C, Tschernich H, Kaisers UX, Eibel S, Seeburger J, Ender J. Real-time three-dimensional echocardiographic assessment of mitral valve: Is it really superior to 2D transesophageal echocardiography?. Ann Card Anaesth [serial online] 2011 [cited 2022 Jan 20];14:91-6. Available from:

   Introduction Top

The frequency of mitral valve (MV) repair has increased in recent years, due to the advancement of surgical techniques. Surgical MV repair is the method of choice for the treatment of most cases of mitral regurgitation (MR). [1] A detailed preoperative echocardiographic examination of the mitral valve anatomy is imperative for proper planning and satisfactory outcome of surgery. Real-time 3D transesophageal echocardiography (RT-3D-TEE) is a mode of echocardiography which is recently introduced and considered a beneficial tool for intraoperative assessment of cardiac disease. [2] RT-3D-TEE helps to acquire images in a more precise and effective manner in comparison to its 2D counterpart. [3] In our study, we hypothesized that RT-3D-TEE would bring additional information when compared to 2D-TEE. Therefore, we aimed at :

  1. Establishing the feasibility of using real-time 3D echo in MV surgery
  2. Comparing its findings with those of intraoperative 2D-TEE and surgical findings
  3. Comparing online analysis with offline analysis

   Materials and Methods Top

Patients with an established diagnosis of moderate-to-severe mitral regurgitation scheduled for mitral valve repair were included in this prospective study after obtaining their written informed consent and after approval by the local ethics committee.

Echocardiographic examination

After complete anesthetic preparation for cardiac surgery, a comprehensive 2D-TEE examination, subsequently followed by 3D-TEE assessment, was performed. For image acquisition, the iE33 ultrasound system (Philips, Netherlands) with the matrix probe X7/2t was used. Accor. As per the institution protocol, standard views recommended by Society of Cardiovascular Anesthesiologists/ American Society of Echocardiography SCA/ASE guidelines [4] were acquired. For MV assessment, basal short axis transgastric view, midesophageal (ME) 4- and 5-chamber (Ch) views, ME commissural view, ME 2-Ch view were acquired as per recommendations of Lambert et al.,[5] with an additional ME long axis (LAX) view. It enabled us to visualize all scallops of the mitral valve, elucidating the pathology involved. For the online 2D evaluation, the echocardiographer assessed each segment of the mitral valve as either normal or pathologic. Then the same echocardiographer was involved in the 3D evaluation.

The 3D views were obtained after completion of detailed 2D examination. The sequence of 3D examination, as performed in our institute, was followed: The authors started with the "live 3D zoom" mode, which produces an "en face" view of the mitral valve. The view acquired was then rotated to reproduce the "surgical view," from the left atrium with the aorta on top [Figure 1]. This view enabled visualization of all the 3 scallops as well as the 2 commissures, namely anterolateral and posteromedial commissures. From ME 4-Ch view at 0 degrees in 2D, a "3D full volume" in B-mode was acquired, followed by "3D color full volume" acquisition, both by suspending ventilation to prevent artifacts. Subsequently "live 3D mode" was obtained and rotated so that only the A2 and P2 scallops of the mitral valve were displayed. From this position, the probe was either withdrawn (A1, P1) or advanced (A3, P3).
Figure 1: "En face," or surgical, view of the mitral valve with aortic valve on top showing prolapse of P3 scallop

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For the online 3D evaluation, the echocardiographer used the "en face" view of the mitral valve to assess each segment of the mitral valve individually.

The intraoperative 2D and RT-3D echo findings were compared to the surgical findings after surgical exposure, which was considered the gold standard for evaluation of the pathology involved. The segments which underwent surgical correction, either by insertion of neo-chordae and preservation of the native mitral valve leaflet (loop technique) or by resection, were considered pathologic.

Carpentier classification of mitral valve disease was used to describe the valve pathology, as per the movement of the leaflets, with type I for normal, type II for excessive and type III for restrictive (type IIIa, functional; and type IIIb, functional) movement.

The time frame to perform the above-described examination was recorded by the anesthesia nurse in the operating room.

A year after the online examination, the same echocardiographer was also involved in performing offline analysis based on real-time 3D-TEE digitally archived images using either the "full volume" mode or the live 3D zoom mode and the 2D-TEE examination. Another echocardiographer was also involved in performing the offline analysis of real-time 3D stored data sets. Wherever required, cropping was performed using 6 standard orthogonal planes along the 3 axes (x, y and z) for optimal visualization of the scallops. The echocardiographers performing the examination were board certified and had 5 or more years of experience in intraoperative TEE.

The analysis of all the scallops and anterior and posterior commissures was divided into 4 stages:

  1. Comparing 2D online and 3D offline analyses to see if 3D-TEE offline is superior to 2D online TEE
  2. Comparing 3D online and 3D offline analyses to see if there are any discrepancies
  3. Comparing 2D online with 2D offline analyses to see if the echocardiographer who performed the online analysis has more information regarding valve pathology
  4. Comparing 2D online analyses with 3D online analyses


The results were computed and analyzed using McNemar test for significance testing. Performances of online 2D and online 3D were tested by determination of the agreement of the 2D and 3D assessments with the gold standard, viz., intraoperative surgical findings. The effect of 3D was calculated using a stratified exact logistic regression model.. The effect size was calculated as log-odds ratio, where positive values indicate the advantage of the 3D assessment over 2D-TEE (better agreement with gold standard, viz., surgical findings). Calculations were performed using the software package LogXact 8.0.0 (Cytel Inc.). Case numbers to achieve significance of the findings were calculated using PASS 2008 (version 08.0.5, NCSS).

   Results Top

In this prospective study, 50 patients undergoing minimally invasive mitral valve repair were enrolled from February 2008 to April 2008. To minimize bias, online analysis was performed during the operation, whereas offline analysis of the digitally stored data was performed from April to September 2010. As per New York Heart Association (NYHA) classification, the patients were divided into Class I (18%), Class II (63%) and Class III/ IV (19%).

Patient demographics and com orbidities are shown in [Table 1]. 2D TEE and RT-3D-TEE examinations were performed in all patients, and the findings were verified by comparing them with the surgical findings. Patients with poor image quality were excluded. Eight patients with Barlow`s disease and a short left atrium, where the entire mitral valve could not be recorded in one view, had to be excluded. Usable data for accurate comparison and documentation were available from 42 patients.
Table 1: Patient demographics with associated comorbidities

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Based on Carpentier classification, the pathology found was type I in 2 (5%) patients, type II in 39 (93%) patients and type IIIb in 1 (2%) patient with both modalities, 2D and RT-3D-TEE.

Analyses of 2D online in comparison with analyses of 3D offline showed no significant differences in detecting pathological segments of the mitral valve [Table 2].
Table 2: Comparison between 2D online and 3D offline analyses

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Additionally 3D online versus 3D offline analyses showed no significant differences [Table 3]. Comparison of 2D online with 2D offline showed a positive trend for online analyses in identifying the pathology in most of the scallops, although no statistical significance could be demonstrated [Table 4].
Table 3: Comparison between 3D online and 3D offline analyses

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Table 4: Comparison between 2D online and 2D offline analyses

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When 3D online analyses was compared to 2D online analysis, no statistically significant difference could be demonstrated using the McNemar test [Table 5]. With the stratified exact logistic regression model, there was no effect seen for the 3D-TEE as a better predictor in evaluating the pathologic segments of the mitral valve [Table 6]. The number of patients necessary to derive significance can also be seen in [Table 6].
Table 5: Comparison between 3D online and 2D online analyses

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Table 6: Effect and additional information of real-time 3D echocardiography compared to 2D transesophageal echocardiography in assessment of different scallops

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3D images were acquired quicker (3±2 minutes) than 2D images (8±2 minutes).

   Discussion Top

The study shows that RT-3D-TEE is feasible in patients undergoing elective mitral valve repair, except in those patients with a highly mobile and severely enlarged valve in combination with a short distance between the echo transducer and the mitral valve.

Although MV repair is the procedure of choice for patients with mitral valve prolapse, residual mitral regurgitation is associated with poor long-term outcome. [6] Hence it is imperative to have an optimal repair, since MV replacement is considered to have worse long-term outcomes. [7],[8] Several studies in the past showed the benefits of using 3D echocardiography for assessment of the mitral valve morphology. [9],[10],[11] In contrast to these studies, we could not find any statistically significant difference in detecting involved segments in our study population. The differences between the echocardiographic findings and the surgical findings could be explained by the different physiological conditions. The surgical exploration was considered the "gold standard." The validity is also questionable as the surgeons visualize the heart in a nonphysiological state. Ahmed and colleagues have shown that there might be a difference between the surgical inspection and the echocardiographic finding, especially in nonpronounced prolapses. [12]

Grewal et al.[13] had 2 different echocardiographers performing the 2D and 3D views, and the results were analyzed at a later time. Because it was an offline analyses, the echocardiographers had assessed the stored loops and had not performed the TEE examination themselves, at that point of time. This should not be of consequence in the 3D data set since the entire valve is visualized. However, with online 2D-TEE, the information may get lost because the recorded sequences may not represent the entire valve.

Previous data showed that 2D examination was accurate in diagnosing prolapse of P2 segments. [10],[12] The sensitivity varied from 78% to 95%; and specificity, from 85% to 96%. [14],[15],[16],[17] Our patient population included not only those of solitary prolapse of P2 segment but also patients with more complex myxomatous valve pathology, including bi-leaflet prolapse or multisegment prolapse with or without flail leaflets. The 2D data from our study showed similar results, with online analyses sensitivity of 97% and specificity of 82% in the region of P2 scallop, with an accuracy of 93%. The findings by Delabays et al.[18] showed a 93% agreement with the surgical findings when compared to TEE. We share this opinion, that RT-3D-TEE examination has a high sensitivity and specificity in diagnosis, specifically in those cases with complex MV pathology. However, our data also clearly shows that also a standardized 2D examination performed by an experienced examiner is able to explore MV morphology and the underlying patho-mechanism at a high level of sensitivity and specificity. This might serve as an explanation why statistical testing failed to reveal significant differences for the comparison of single segments.

Therefore, we had hypothesized that 3D offline will reveal better correlation with the pathology involved compared to 2D online. We could show in our study that there is a mild tendency that 3D offline analyses is superior to online 2D TEE, but our study failed to detect a significant difference. The number of patients needed to derive significance varies between 200 and 1,600 depending on the individual segments involved. This reflects that the additional value of 3D-TEE in intraoperative assessment of the mitral valve pathology is clinically insignificant if the 2D-TEE is performed by an experienced echocardiographer.

Limitations of our study

Our study design had a bias that both the echocardiographers were involved in the online 2D-TEE examination before they started the online 3D-TEE examination. So we cannot rule out that the 3D online analyses was prejudiced when comparing its findings to the online 2D-TEE findings, although we can argue that the results of the offline analyses performed 1 year later revealed similar findings.

   Conclusion Top

Our study demonstrated that, contrary to previous literature findings, real-time 3D-TEE examination did not have any significant advantage in identifying the diseased scallops when compared to 2D-TEE results in patients undergoing minimally invasive mitral valve repair. Further studies in a larger population are required to validate the findings of this study.

   References Top

1.Seeburger J, Borger MA, Doll N, Walther T, Passage J, Falk V, et al. Comparison of outcomes of minimally invasive mitral valve surgery for posterior, anterior and bileaflet prolapsed. Eur J Cardiothorac Surg 2009;36:532-8.  Back to cited text no. 1
2.Veronesi F, Corsi C, Sugeng L, Mor-Avi V, Caiani EG, Weinert L, et al. A study of functional anatomy of aortic-mitral valve coupling using 3D matrix tranesophageal echocardiography. Circ Cardiovasc Imaging 2009;2:24-31.  Back to cited text no. 2
3.Pepi M, Tamborini G, Maltagliati A, Galli CA, Sisillo E, Salvi L, et al. Head-to-head comparison of two- and three-dimensional transthoracic and transesophageal echocardiography in the localization of mitral valve prolapse. J Am Coll Cardiol 2006:482524-30.  Back to cited text no. 3
4.Shanewise JS, Cheung AT, Aronson S, Stewart WJ, Weiss RL, Mark JB,et al. ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography. Anesth Analg 1999;89:870-84.  Back to cited text no. 4
5.Lambert AS, Miller JP, Merrick SH, Schiller NB, Foster E, Muhiudeen-Russell I, et al. Improved evaluation of the location and mechanism of mitral valve regurgitation with a systematic transesophageal echocardiography examination. Anesth Analg 1999;88:1205-12.  Back to cited text no. 5
6.Suri RM, Schaff HV, Dearani JA, Sundt TM 3rd, Daly RC, Mullany CJ, et al. Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era. Ann Thorac Surg 2006;22:819-26.  Back to cited text no. 6
7.Thourani VH, Weintraub WS, Guyton RA, Jones EL, Williams WH, Elkabbani S, et al. Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement. Circulation 2003;108:298-304.  Back to cited text no. 7
8.Gammie JS, Sheng S, Griffith BP, Peterson ED, Rankin JS, O'Brien SM, et al. Trends in mitral valve surgery in the United States: Results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg 2009;87:1431-7; discussion 1437-9.  Back to cited text no. 8
9.Kronzon I, Sugeng L, Perk G, Hirsh D, Weinert L, Garcia Fernandez MA, et al. Real-time 3-dimensional transesophageal echocardiography in the evaluation of post-operative mitral annloplasty ring and prosthetic valve dehiscence J Am Coll Cardiol 2009;53:1543-7.  Back to cited text no. 9
10.Manda J, Kesanolla SK, Hsuing MC, Nanda NC, Abo-Salem E, Dutta R, et al. Comparison of real time two-dimensional with live/real time three-dimensional transesophageal echocardiography in the evaluation of mitral valve prolapse and chordae rupture. Echocardiography 2008;25:1131-7.  Back to cited text no. 10
11.Hirata K, Pulerwitz T, Sciacca R, Otsuka R, Oe Y, Fujikura K, et al. Clinical utility of new real time three-dimensional transthoracic echocardiography in assessment of mitral valve prolapse. Echocardiography 2008;25:482-8.  Back to cited text no. 11
12.Agricola E, Oppizzi M, Pisani M, Maisano F, Margonato A. Accuracy of real-time 3D echocardiography in the evaluation of functional anatomy of mitral regurgitation. Int J Cardiol 2008;127:342-9.  Back to cited text no. 12
13.Ahmed S, Nanda NC, Miller AP, Nekkanti R, Yousif AM, Pacifio AD, et al. Usefulness of transesophageal three-dimensional echocardiography in the identification of individual segment/scallop prolapse of the mitral valve. Echocardiography 2003;20:203-9.  Back to cited text no. 13
14.Grewal J, Mankad S, Freeman WK, Click RL, Suri RM, Abel MD, et al. Real-time three-dimensional transesophageal echocardiography in the intraoperative assessment of mitral valve disease. J Am Soc Echocardiogr 2009;22:34-41.  Back to cited text no. 14
15.Grewal KS, Malkowski MJ, Kramer CM, Dianzumba S, Reichek N. Multiplane transesophageal echocardiographic identification of the involved scallop in patients with flail mitral valve leaflet: Intraoperative correlation. J Am Soc Echocardiogr 1998;11:966-71.  Back to cited text no. 15
16.Foster GP, Isselbacher EM, Rose GA, Torchiana DF, Akins CW, Picard MH. Accurate localization of mitral regurgitant defects using multiplane transesophageal echocardiography. Ann Thorac Surg 1998;65:1025-31.  Back to cited text no. 16
17.Stewart WJ, Currie PJ, Salcedo EE, Klein AL, Marwick T, Agler DA, et al. valuation of mitral leaflet motion by echocardiography and jet direction by Doppler color flow mapping to determine the mechanisms of mitral regurgitation. J Am Coll Cardiol 1992;20:1353-61.  Back to cited text no. 17
18.Delabays A, Jeanrenaud X, Chassot PG, Von Segesser LK, Kappenberger L. Localization and quantification of mitral valve prolapse using three-dimensional echocardiography. Eur J Echocardiogr 2004;5:422-9.  Back to cited text no. 18

Correspondence Address:
Joerg Ender
Department of Anaesthesiology and Intensive Medicine II, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, 04289 Leipzig
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0971-9784.81562

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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