Quantitative Analysis of Mitral Valve Apparatus in Mitral Valve Prolapse Before and After Annuloplasty: A Three-Dimensional Intraoperative Transesophageal Study

Background: Intraoperative real-time three-dimensional transesophageal echocardiography has been shown useful in the evaluation of the mitral valve (MV) apparatus, and dedicated commercial software allows its quantitative assessment. The aims of this study were to (1) quantify the effects induced by prolapse on MV anatomy in the presence of fibroelastic deficiency (FED) or Barlow's disease (BD), (2) assess the effect of surgery on the MV apparatus, and (3) investigate the potential role of three-dimensional transesophageal echocardiography in surgical planning. Methods: Fifty-six patients (29 with FED, 27 with BD) undergoing MV repair and annuloplasty were studied immediately before and after surgery. Also, 18 age-matched patients with normal MV anatomy, undergoing coronary artery bypass, were included as a control group. Three-dimensional transesophageal echocardiographic data sets were acquired and analyzed to quantify several MV annulus and leaflet parameters using dedicated software. Results: MV prolapse and regurgitation were associated with a markedly enlarged annulus (area, 12.0 +/- 3.2 cm(2) in FED and 15.4 +/- 3.8 cm(2) in BD) and leaflets compared with controls (area, 7.5 +/- 2.1 cm(2)), while annular height (4.5 +/- 1.3 mm in controls, 4.0 +/- 1.3 mm in FED, 5.3 +/- 1.6 mm in BD) and the mitral aortic angle (136 +/- 12 degrees in controls, 141 +/- 12 degrees in FED, 137 +/- 11 degrees in BD) were similar. Patients with BD showed greater values than those with FED. MV repair and annuloplasty led to a significant undersizing of leaflet and annular areas (4.0 +/- 1.1 cm(2) in FED, 4.9 +/- 1.3 cm(2) in BD), diameters, and height (2.6 +/- 1.1mmin FED, 3.4 +/- 1.4 mm in BD) compared with controls. Coaptation length remained in the normal range (30 +/- 5 mm in controls, 24 +/- 6 6mmin FED, 28 +/- 6mmin BD). Differences between BD and FED were reduced but still present after surgery. Conclusions: Intraoperative three-dimensional transesophageal echocardiography allows quantitative evaluation of the MV apparatus in the presence of FED or BD and could be useful for immediate assessment of the surgical procedure. (J Am Soc Echocardiogr 2011;24:405-13.)