Usefulness of real-time three-dimensional echocardiography for evaluation of myectomy in patients with hypertrophic cardiomyopathy

Qin, Jian Xin; Shiota, Takahiro; Asher, Craig R.; Smedira, Nicholas G.; Shin, Joon Han; Agler, Deborah A.; Nash, Patrick J.; Greenberg, Neil L.; Lever, Harry M.; Lytle, Bruce W.; Thomas, James D.

doi:10.1016/j.amjcard.2004.06.043

Cited by 29 publications

(19 citation statements)

References 20 publications

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“…We showed that the LVOT area is not exclusively circular but often assumes a more ellipsoid-like shape which means that data derived from the measurement of its longitudinal axis -usually the smaller diameter -consequently result in a smaller area. Dynamic reduction of the LVOT area during systole in hypertrophic cardiomyopathy patients with systolic anterior motion of the anterior mitral valve leaflet has been demonstrated [18][19][20]. Our results suggest that dynamic changes are also detectable in normal individuals.…”

Section: Discussionsupporting

confidence: 50%

Direct measurement of left ventricular outflow tract by transthoracic real-time 3D-echocardiography increases accuracy in assessment of aortic valve stenosis

Khaw

Bardeleben

Strasser

et al. 2009

International Journal of Cardiology

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Section: Discussionsupporting

confidence: 50%

Direct measurement of left ventricular outflow tract by transthoracic real-time 3D-echocardiography increases accuracy in assessment of aortic valve stenosis

Khaw

Bardeleben

Strasser

et al. 2009

International Journal of Cardiology

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“…The minimal LVOT area was abnormally small in HCM40 and showed better inverse correlation with maximal LVOT velocity ( r =−0.95) than 2D SAM-septal distance ( r =−0.83) 25. LVOT area was also useful to assess therapeutic success 40,41. While confirming this relation between minimal systolic LVOT area and gradient, this study further uses 3D data to explore the mechanism of SAM at the valvular and subvalvular levels on the basis of the comprehensive geometric relationships tying together individual components contributing to SAM-septal contact.…”

Section: Discussionmentioning

confidence: 89%

Section: Discussionmentioning

confidence: 99%

In Vivo Measurement of Mitral Leaflet Surface Area and Subvalvular Geometry in Patients With Asymmetrical Septal Hypertrophy

et al. 2010

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Background-Analyzing the determinants of systolic anterior motion of the mitral valve and consequent left ventricular outflow tract (LVOT) obstruction in patients with asymmetrical septal hypertrophy requires a comprehensive 3-dimensional analysis of mitral leaflet (ML) area, papillary muscle (PM) geometry, and the distribution of left ventricular hypertrophy. Methods and Results-Real-time 3-dimensional echocardiography was performed in 47 patients with asymmetrical septal hypertrophy and 32 normal controls. Patients included 20 with resting LVOT obstruction (group I) and 27 without (group II). Customized software (Omni 4D) provided a validated measure of ML surface area, LVOT area, mitral annular area and nonplanarity, LVOT hypertrophy index by topography (percent area with wall thickness Ͼ16 mm), and 3-dimensional PM positions relative to annulus. ML area was more than twice as large in group I than normal and 1.4 times normal in group II (PϽ0.001). Group I patients were also characterized by higher LVOT hypertrophy index and medial and anterior displacements of both PMs, resulting in a shorter inter-PM distance. Independent determinants of LVOT obstruction were indexed total ML area (adjusted odds ratio, 5.651; 95% confidence interval, 1.573 to 20.304; Pϭ0.008) and inter-PM distance (adjusted odds ratio, 0.416; 95% confidence interval, 0.203 to 0.854; Pϭ0.0169). Minimal LVOT area during systole correlated well with peak LVOT pressure gradient (R 2 ϭ0.83, PϽ0.001); its independent determinants were left ventricular end-systolic volume (Pϭ0.0183), indexed total ML area (Pϭ0.0108), inter-PM distance (Pϭ0.0378), annular height (Pϭ0.0047), and LVOT hypertrophy index (Pϭ0.0098). Conclusions-Myocardium is not the only tissue affected in patients with asymmetrical septal hypertrophy, and primary changes of the mitral apparatus, including ML area increase and PM displacement, are independent determinants of LVOT obstruction and provide a comprehensive mechanism that determines leaflet slack and anteriorly directed motion. Abnormal PM-mitral valve geometry assessed by real-time 3-dimensional echocardiography can provide reasonable new targets for individualized intervention. (Circulation. 2010;122:1298-1307.)

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“…3 RT-3D-TEE also allows for spatial assessment of the extent of maximal septal thickness, the degree of LVOT obstruction and the intimate relationship between MV and LVOT (e.g., the extent of systolic mitral leaflet-to-septal contact), important information that may assist the surgeon to optimize the site and size of the septal myectomy. 4 As shown by Willert et al, 3D-TEE might be especially helpful when patients present with a combination of both obstruction of the LVOT as well as intrinsic MV pathology. 5 In addition to information provided by Willert et al, our case emphasizes the novelty of real-time assessment of the MV and the LVOT and introduces additional features obtained by using available built-in software.…”

mentioning

confidence: 95%

Mitral Valve Prolapse and Systolic Anterior Motion Illustrated by Real Time Three-Dimensional Transesophageal Echocardiography

Jungwirth¹,

Adams²,

Mathew³

et al. 2008

Anesthesia &Amp; Analgesia

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A56-yr-old man presented with increasing dyspnea with mild to moderate exercise. Transthoracic echocardiography demonstrated hypertrophic obstructive cardiomyopathy (HOCM), systolic anterior motion (SAM) of the anterior mitral valve (MV) leaflet, with a left ventricular outflow tract (LVOT) peak velocity of 4.2 m/s at rest (obtained from an apical window) and moderate to severe mitral regurgitation (MR). In agreement with current consensus guidelines, the patient was scheduled for left ventricular surgical septal myectomy. 1 The intraoperative two-dimensional transesophageal echocardiography (2D-TEE) before cardiopulmonary bypass confirmed the diagnosis of marked HOCM, SAM, and severe MR and identified a prolapse of the P2 scallop of the posterior mitral leaflet (PML) using standard midesophageal (ME) views (Video Clip 1; please see video clip available at www.anesthesia-analgesia.org). Severe MR was confirmed by both, a vena contracta of 7 mm and systolic reversal during Doppler interrogation of the pulmonary venous flow. Of note, the MR jet peaked in mid and late systole based on color flow Doppler. The MR jet originated anteriorly and was then directed centrally and slightly posteriorly, suggesting a significant role of SAM rather than PML prolapse alone in the etiology of MR (Video Clip 1). 2 The diastolic interventricular septal thickness measured 26 mm in the ME long axis view. M-mode assessment of the aortic valve in the ME aortic valve long axis view confirmed dynamic outflow tract obstruction, as leaflets opened initially, but closed in mid systole. Therefore, the patient underwent left ventricular septal myectomy aiming to alleviate LVOT obstruction and SAM and ultimately to improve the degree of MR. 2 However, 2D-TEE assessment after myectomy demonstrated unaltered MR and persistent SAM of the MV, prompting the surgeon to replace the MV with a low profile mitral prosthesis (29 mm mechanical St. Jude prosthesis). Immediate MV replacement, rather than an attempt to repair the MV, was selected to avoid the possibility of a third cardiopulmonary bypass run in case of an insufficient repair. Postoperative 2D-TEE and Doppler assessment showed the typical echocardiographic signature of a bileaflet tilting disk valve with no residual regurgitation and no residual outflow tract gradient, and the patient had an unremarkable recovery.This case of complex MV disease in the context of SAM and HOCM highlights the potential difficulties in identifying the etiology of MR. Specifically, it demonstrates the diagnostic dilemma to discern the This article has supplementary material on the Web site:www.anesthesia-analgesia.org.

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Usefulness of real-time three-dimensional echocardiography for evaluation of myectomy in patients with hypertrophic cardiomyopathy

Cited by 29 publications

References 20 publications

Direct measurement of left ventricular outflow tract by transthoracic real-time 3D-echocardiography increases accuracy in assessment of aortic valve stenosis

Direct measurement of left ventricular outflow tract by transthoracic real-time 3D-echocardiography increases accuracy in assessment of aortic valve stenosis

In Vivo Measurement of Mitral Leaflet Surface Area and Subvalvular Geometry in Patients With Asymmetrical Septal Hypertrophy

Mitral Valve Prolapse and Systolic Anterior Motion Illustrated by Real Time Three-Dimensional Transesophageal Echocardiography

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