Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse.

Mitral valve prolapse has been diagnosed by two-dimensional echocardiographic criteria with surprising frequency in the general population, even when preselected normal subjects are examined. In most of these individuals, however, prolapse appears in the apical four-chamber view and is absent in roughly orthogonal long-axis views. Previous studies of in vitro models with nonplanar rings have shown that systolic mitral annular nonplanarity can potentially produce this discrepancy. However, to prove directly that apparent leaflet displacement in a two-dimensional view does not constitute true displacement above the three-dimensional annulus requires reconstruction of the entire mitral valve, including leaflets and annulus. Such reconstruction would also be necessary to explore the complex geometry of the valve and to derive volumetric measures of superior leaflet displacement. A technique was therefore developed and validated in vitro for three-dimensional reconstruction of the entire mitral valve. In this technique, simultaneous real-time acquisition of images and their spatial locations permits reconstruction of a localized structure by minimizing the effects of patient motion and respiration. By applying this method to 15 normal subjects, a coherent mitral valve surface could be reconstructed from intersecting scans. The results confirm mitral annular nonplanarity in systole, with a maximum deviation of 1.4 +/- 0.3 cm from planarity. They directly show that leaflets can appear to ascend above the mitral annulus in the apical four-chamber view, as they did in at least one view in all subjects, without actual leaflet displacement above the entire mitral valve in three dimensions, thereby challenging the diagnosis of prolapse by isolated four-chamber view displacement in otherwise normal individuals. This technique allows us to address a uniquely three-dimensional problem with high resolution and provide new information previously unavailable from the two-dimensional images. This new appreciation should enhance our ability to ask appropriate clinical questions relating mitral valve shape and leaflet displacement to clinical and pathologic consequences.

[1]  J. Barlow,et al.  Late systolic murmurs and non-ejection ("mid-late") systolic clicks. An analysis of 90 patients. , 1968, British heart journal.

[2]  Robert F. Sproull,et al.  Principles in interactive computer graphics , 1973 .

[3]  F.A.C.S. F.R.C.S Eng. F.R.C.S. ED. Wallace A. McAlpine M.D..  Heart and Coronary Arteries , 1975, Springer Berlin Heidelberg.

[4]  R. Schatz,et al.  Mitral Valve Prolapse: Two‐dimensional Echocardiographic and Angiographic Correlation , 1976, Circulation.

[5]  S. Savran,et al.  Prevalence of clinical mitral-valve prolapse in 1169 young women. , 1976, The New England journal of medicine.

[6]  R. Jeresaty.  Sudden death in the mitral valve prolapse-click syndrome. , 1976, The American journal of cardiology.

[7]  B. Brundage,et al.  Left Ventricular Volume from Paired Biplane Two‐dimensional Echocardiography , 1979, Circulation.

[8]  R. Jones,et al.  Two dimensional echocardiography in mitral, aortic and tricuspid valve prolapse. The clinical problem, cardiac nuclear imaging considerations and a proposed standard for diagnosis. , 1980, The American journal of cardiology.

[9]  Mild mitral regurgitation and the mitral prolapse fiasco. , 1980, American heart journal.

[10]  H. Barnett,et al.  Further evidence relating mitral-valve prolapse to cerebral ischemic events. , 1980, The New England journal of medicine.

[11]  J. Morganroth,et al.  Apical cross-sectional echocardiography. Standard for the diagnosis of idiopathic mitral valve prolapse syndrome. , 1981, Chest.

[12]  C. Tei,et al.  Size and Motion of the Mitral Valve Annulus in Man: I. A Two‐dimensional Echocardiographic Method and Findings in Normal Subjects , 1981, Circulation.

[13]  A. Feinstein,et al.  A controlled evaluation of the risk of bacterial endocarditis in persons with mitral-valve prolapse. , 1982, The New England journal of medicine.

[14]  [Two dimensional echocardiographic diagnosis of mitral valve prolapse syndrome in presumably healthy young students]. , 1982, Journal of cardiography.

[15]  E A Geiser,et al.  Dynamic three-dimensional echocardiographic reconstruction of the intact human left ventricle: technique and initial observations in patients. , 1982, American heart journal.

[16]  W. Kannel,et al.  Mitral valve prolapse in the general population. 2. Clinical features: the Framingham Study. , 1983, American heart journal.

[17]  K Kato,et al.  Value for measuring left ventricular volume , 2003 .

[18]  N. Nanda,et al.  Ejection fraction determination without planimetry by two-dimensional echocardiography: a new method. , 1983, Journal of the American College of Cardiology.

[19]  J. Weiss,et al.  Accuracy of Volume Determination by Two‐dimensional Echocardiography: Defining Requirements Under Controlled Conditions in the Ejecting Canine Left Ventricle , 1983, Circulation.

[20]  W. Moritz,et al.  An Ultrasonic Technique for Imaging the Ventricle in Three Dimensions and Calculating Its Volume , 1983, IEEE Transactions on Biomedical Engineering.

[21]  C. G. Blomqvist,et al.  Three-dimensional echoventriculography. , 1983, American heart journal.

[22]  M. Quiñones,et al.  Quantification of Left Ventricular Volumes by Two‐dimensional Echocardiograph: A Simplified and Accurate Approach , 1983, Circulation.

[23]  A. Weyman,et al.  Prevalence of mitral valve prolapse in normal children. , 1985, Journal of the American College of Cardiology.

[24]  W. Moritz,et al.  A new three-dimensional echocardiographic method of right ventricular volume measurement: in vitro validation. , 1986, Journal of the American College of Cardiology.

[25]  J. E. Snyder,et al.  Real-time orthogonal mode scanning of the heart. I. System design. , 1986, Journal of the American College of Cardiology.

[26]  G T Herman,et al.  Dynamic three-dimensional reconstruction of the left ventricle from two-dimensional echocardiograms. , 1986, Journal of the American College of Cardiology.

[27]  I. Cohen.  Two-dimensional echocardiographic mitral valve prolapse: evidence for a relationship of echocardiographic morphology to clinical findings and to mitral annular size. , 1987, American heart journal.

[28]  P. Kligfield,et al.  Diagnosis and classification of severity of mitral valve prolapse: methodologic, biologic, and prognostic considerations. , 1987, American heart journal.

[29]  R A Levine,et al.  The relationship of mitral annular shape to the diagnosis of mitral valve prolapse. , 1987, Circulation.

[30]  J. Krivokapich,et al.  Reassessment of echocardiographic criteria for diagnosis of mitral valve prolapse. , 1988, The American journal of cardiology.

[31]  Reconsideration of echocardiographic standards for mitral valve prolapse: lack of association between leaflet displacement isolated to the apical four chamber view and independent echocardiographic evidence of abnormality. , 1988, Journal of the American College of Cardiology.