tion, or both, should be tested to increase efficacy. A large-scaledouble-blind placebo-controlled study is necessary to conk-m the initial efficacy of dofetilide for conversion of paroxysmal AF or AFl. 1. Crijns HJGM, Wijk LM, Gilst WH, Kingma JH, Gelder IC, Lie KI. Acute conversion of atrial fibrillation to sinus rhythm: clinical efficacy of flecainide acetate. Eur Heart / 1988;9:634-638. 2. Suttoru MJ. Kinema JH. Jessurun ER. Lie-A-Huen L. van Hemel NM. Lie KI. The v&e if class IC antiarrhythmic dr;gs for acute conversion of paroxysmal atrial fibrillation or flutter to sinus rhythm. .I Am Co11 Cardiol 1990;16: 1777-1777 3. Allessie MA, Bonke FIM, Schopman FJG. Circus movement in rabbit atria.1 muscle as a mechanism of tachycardia. III. The “leading circle” concept: a new model of circus movement in cardiac tissue without the involvement of an anatomic obstacle. Circ Res 1977;41:9-18.
Usefulness of Transesophageal Mitral Valve Prolapse Jo& Zamorano, MD, Raimund Erbel, and Jllrgen Meyer, MD
MD.
4. Zuanetti G, Corr PB. Ant&rhythmic efficacy of a new class III agent, lJt34 mm. The TTE diagnosis of MVP was established if a marked superior systolic displacement of the mitral leaflet was visualized with the coaptation point at or superior to the annular plane, and when mild or moderate superior systolic displacement of the mitral leaflets occurred in conjunction with either chordal rupture, mitral regurgitation on Doppler ultrasound, or annular dilatation.7 A complete pulsed, continuous and color Doppler study was also obtained in BRIEF REPORTS 419
every patient from the TTE approach to evaluate the presence and severity of mitral regurgitation. Severity of mitral regurgitation was graded I to III according to the size of the regurgitant jet area in relation to left atria1 area in orthogonal views.” TABLE
I Echocardiographic
Findings
M-Mode Pt. No. Age/Gender
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18
19 20
20/F 23/F 23/F 27/M 35/F 37/M 38/F 39/F 39/M 45/M 50/F 51/M 52/F 52/F 58/F 58/F 58/M 59/F 60/F 60/F
LSPM
TTE
HH SB PCP MR SB PCP MR RCh
+ + + +
+ + + -++--+-ii++-++I-++-++---+ +-+-++I+ +++--+-+ + +++ + -++-++----
+ + + + +
+ +-+-++-+ -++ -++-++I+
+ + + +
TEE
II
+
+
II
-
II
+
+
II
+
II
+
+
II
-
II
+
+
Ill
+
II -
+ + +
+ + +
II Ill II
+ -
II I
+ +
+ +
II II
-
-
I II
+ +
+ +
II II
-
+
-
+
+
II
-
+
HH = holosystolic hammocking; LSPM = late systolic posterior motion; MR = mitral regurgitation (graded I to Ill); PCP = protrusion of the coaptation point; RCh = ruptured chordae tendinae; SB = systolic billowing; TEE = transesophageal echocardiography; TTE = tmnsthoracic echocardiography; - or + denotes absence or presence of the sign.
FlGURE l.Sdnmatic reprewhtlon of the transesophageal longiinal axis (shadow) showing both the anterior and posterior mitral valve leatkts in relatii to the surrounding cardiac structures.
420
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
69
When TTE studies were completed all patients underwent a biplane TEE study (5 MHz transducer). Patients were studied in the fasting state after receiving sedation with 5 mg of intravenous diazepam and lidoCaine spray in the oropharynx. With TEE, a 3-dimensional reconstruction of the relation between the mitral valve and the mitral annulus was attempted. With the longitudinal axis, a complete view of the posterior mitral leaflet was obtained (Figure I). From the transverse plane the anterior mitral leaflet as well as the posteromedialis commissure were analyzed (Figure 2). With a more caudal position of the transducer this plane also permitted evaluating the posterior mitral leaflet. Again, with biplane TEE, care was taken to assess the presence and severity of leaflet billowing and to accurately determine the location of the coaptation point of the mitral valve. Pulsed and color Doppler studies of the mitral valve were subsequently performed to evaluate the presence and severity of mitral regurgitation, and this information was compared with the results of the TTE studies. With TEE color Doppler, the severity of mitral regurgitation (I to III) was assessed by planimetry of the area of the regurgitant jet as previously described.t2 Continuous data are presented as mean f standard deviation. The chi-square test, with the Yate’s correction when indicated, was used to compare qualitative variables of TTE studies with those of TEE. On M-mode studies, 10 patients (50%) had thickeningof the mitral leaflets. A late systolic posterior motion of mitral leaflets was seen in 13 patients (65%) and a holosystolic hammocking of mitral valve leaflets was present in 6patients (30%). Other signs of MVP included early diastolic anterior motion of the posterior mitral
FlGURE 2. Schematic represenbtion of the transesophageal transverse axis at the mitral valve level, showing the relation between the posteromedialir commissure and the anterior mitral leattet.
FEBRUARY
1, 1992
valve leaflet (I patient), shaggy diastolic echoes (2 patients), cascading diastolic echoes (1 patient), reduplication of mitral echoes (3 patients), and abutment of the mitral valve E point against the septum (2 patients). All patients showing any of these later echocardiographic signs also had at least I of the 2 major M-mode criteria for MY?‘. M-mode echocardiography was able to make the diagnosis of MVP in 15 of the 20 patients (75%) (Table I). On TTE mitral valve annular size was 27 f 8 mm, and 13 patients (6.5%) presented with mitral valve annular dilatation. Systolic billowing of mitral valve leaflets was recognized in 8 patients (40%) from the parasternal long-axis view and in 14 (70%) from the I-chamber view. The coaptation point was beyond the mitral annulus from the parasternal long-axis view in 9 patients (45%) and from the I-chamber view in 14 (70%). According to the previously considered TTE criteria of MVP, 9 patients had the first criteria, 5 had the second and 3 had both. With TTE color Doppler 9 patients had mitral regurgitation (Table I). With biplane TEE, systolic billowing of either the anterior or posterior mitral valve leaflets into the left atrium was seen either in the longitudinal or in the transverse plane in 18 patients (90Y0) (p X0.001 compared with parasternal long-axis TTE and p = not significant compared with both TTE views) (Figure 3). In 2 of these patients billowing was not appreciated from any TTE view. Biplane TEE demonstrated systolic displacement of the coaptation point beyond the mitral valve annulus in all 20 patients (100%) (p KO.05 compared with TTE). In addition, this technique showed mitral valve chordae rupture in 3 patients (15%), which was not previously seenfrom the transthoracic approach. With color Doppler TEE, 15 patients (75%) had mitral regurgitation (Figure 4) (p = not signiftcant compared with TTE studies). No complications were seen as the result of TEE.
addition, 90%of them presentedsystolic billowing of the mitral valve leaflets. Therefore, biplane TEE was, in ou.r experience,superior to conventionalTTE in the diagnosis of MVP. Also for the diagnosis of mitral regurgitation, biplane TEE was more sensitive to TTE in the present series.This confirms our previousexperiencein a general patient population, suggestingthat TEE is a more sensitive technique for detecting the presenceof mitral regurgitation than TTE.13 Our study only analyzed a relatively small cohort of patients with classicclinical and echocardiographiccriteria of MVP. All thesepatients had biplane TEE patterm indicative of MVP. However, although it would have been of major interest to determine whether TEE could be of complementary value to TTE to prevent MVP misdiagnosis,all patients in this serieshad MVP on bi-
FIGURE 3. Left, transesophageal echocardiogram from the longitudinal axis revealing billowing of the posterior mitral lealtet into the left atrium. Right, transverse plane showing relation between the anterior and posteriar mitral leattets anti ths postsromedialis commissure morz &arty. There is marlced billowing of the posterior mitral valve leaflet into ths left atrium. AML = anterior mitral valve leafle& LA = left atrium; LV = kft ventrkbq LVOT = left ventricbr autflow tr* PML = posterior mitral valve leaftet.
The value of TTE in the diagnosis of MVP is well established.9However, the saddle-shapedmorphology of the mitral annulus may induce the false appearanceof superior displacement (into the left atrium) of the mitral leaflets, evenin normal subjects,when only 1 TTE plane is usecL3Preliminary data suggest the value of singleplane TEE in the diagnosis of MVP.“J3 However, only biplane TEE providesthe opportunity to image the mitral valve, from 2 different orthogonal planes, allowing a 3dimensional understanding of the nonplanar structure of the mitral annulus. With the transverseplane it is possible to visualize the anterior mitral leaflet and usually the posteromedialii corm&sure (Figure 1). Alternatively, the longitudinal plane evaluates,in different cuts, both the anterior and posterior mitral valve leaflets. In particular we found this view of specialvalue in the assessmentof the movement of the posterior mitral leaflet (Figure 2). The information obtained from both nlanesallowed us to FIGURE 4. Left, transesophageal echocardiogram from the completely visualize the relationship*betweenthe mitral hgitudinal plane disclosing the presence of mitral wDoppler. Right, transverse plane from the same valve leaflet and its annulus. In our study with biplane tiipatienton cokw showing billowing of both mitral valve leaflets into the TEE every patient showedan abnormally displaced mi- kft d urn. The coaptation point of the mitral valve lsaftets is tral valve coaptation point within the left atrium and, in also displaced into the left atrium (arrow)=
BRIEF REPORTS 421
plane TEE, so that the specificity of the technique could not be determined. In addition, we did not measurethe degreeof either displacementof the coaptation point into the left atrium or the severity of mitral valve billowing, and thesefactors could havediagnostic implications. Prospectivestudiesincluding larger seriesof patientswith the suspectedclinical diagnosisof MVP will be required to determine absolutecriteria for the diagnosisof MVP with biplane TEE and to define the specificity and sensitivity of this technique. Furthermore, the subsetof patients in whom biplane TEE should be performed in order to obtain a more accurate diagnosis, and the value of this technique in the decision-makingprocessinvolved in the managementof patients with MVP needsto be defined. 1. Devereux RB, Kramer-Fox R, Shear K, Kligfield P, Pini R, Savage D. Diagnosis and classification of severity of mitral valve prolapse: methodologic, biologic and prognostic considerations. Am Heart J 1987;113:1265-1280. 2. Krivokapich J, Child JS, Dadourian BJ, Perloff JK. Reassessment of echocardiographic criteria for diagnosis of mitral valve prolapse. Am J Cardiol 1988;61:131-135. 3. Levine RA, Triulzi MO, Harrigan P, Weyman AE. The relationship of mitral
422
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 69
annular shape to the diagnosis of mitral valve prolapse. Circulation 1987;75: 756-767. 4. Barlow JB, Pocock WA. Billowing, floppy, prolapsed or fail mitral valves. Am J Cardiol 1985;55:501-502. 5. DeMaria AN, King JF, Bogren HG, Lies GE. The variable spectrum of echocardiographic manifestations of the mitral valve prolapse syndrome. Circulation 1974;50:33-41. 6. Zenker G, E&l R, Kramer G, Mohr-Kahaly S, Drexler M, Harnoncourt M, Meyer J. Transesophageal two-dimensional echocardiography in young patients with cerebral ischemic events. Stroke 1988;19:345-348. 7. Perloff JK, Child JS, Edwards JE. New guidelines for the clinical diagnosis of mitral valve prolapse. Am J Cwdiol 198657:1124-l 129. 8. The committee on M-Mode Standardization of the American Society of Echocardiography. Results of a survey of echocardiographic measurements. Circulation 1978;58:1072-1083. 9. Dillon JC, Haine CL, Chang S, Feigenbaum H. Use of echocardiography in patients with prolapsed mitral valve. Circulation 1971;43:503-507. 10. Nishimura F&4, Mac Goon M, Shub C, Miller F, Ilstrup D, Tajik J. Echocardiographically documented mitral valve prolapse. Long-term follow-up of 237 patients. N Engl J Med 1985;313:1305-1309. 11. Helmcke F, Nanda NC, Hsiung M, Soto B, Adey C, Goyal R, Gatewood R. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulution 1987;75:175-183. 12. Yoshida K, Yoshikawa J, Yamamura Y, Hozumi T, Akasaka T, Fukaya T. Assessment of mitral regurgitation by biplane transeaophageal color Doppler flow mapping. Circulation 1990;82:1121-1126. 13. E&l R, Mohr-Kahaly S, Rhomann S, Schuster S, Drexler M, Wittlidh N, Pfeifer C, Schreiner G, Meyer J. Diagnostic value of the transesophageal Doppler echocardiography. Herr 1987;12:177-186.
FEBRUARY 1, 1992
Usefulness of Transesophageal Mitral Valve Prolapse Jo& Zamorano, MD, Raimund Erbel, and Jllrgen Meyer, MD
MD.
4. Zuanetti G, Corr PB. Ant&rhythmic efficacy of a new class III agent, lJt34 mm. The TTE diagnosis of MVP was established if a marked superior systolic displacement of the mitral leaflet was visualized with the coaptation point at or superior to the annular plane, and when mild or moderate superior systolic displacement of the mitral leaflets occurred in conjunction with either chordal rupture, mitral regurgitation on Doppler ultrasound, or annular dilatation.7 A complete pulsed, continuous and color Doppler study was also obtained in BRIEF REPORTS 419
every patient from the TTE approach to evaluate the presence and severity of mitral regurgitation. Severity of mitral regurgitation was graded I to III according to the size of the regurgitant jet area in relation to left atria1 area in orthogonal views.” TABLE
I Echocardiographic
Findings
M-Mode Pt. No. Age/Gender
1 2 3 4 5 6 7 8 9 10
11 12 13 14 15 16 17 18
19 20
20/F 23/F 23/F 27/M 35/F 37/M 38/F 39/F 39/M 45/M 50/F 51/M 52/F 52/F 58/F 58/F 58/M 59/F 60/F 60/F
LSPM
TTE
HH SB PCP MR SB PCP MR RCh
+ + + +
+ + + -++--+-ii++-++I-++-++---+ +-+-++I+ +++--+-+ + +++ + -++-++----
+ + + + +
+ +-+-++-+ -++ -++-++I+
+ + + +
TEE
II
+
+
II
-
II
+
+
II
+
II
+
+
II
-
II
+
+
Ill
+
II -
+ + +
+ + +
II Ill II
+ -
II I
+ +
+ +
II II
-
-
I II
+ +
+ +
II II
-
+
-
+
+
II
-
+
HH = holosystolic hammocking; LSPM = late systolic posterior motion; MR = mitral regurgitation (graded I to Ill); PCP = protrusion of the coaptation point; RCh = ruptured chordae tendinae; SB = systolic billowing; TEE = transesophageal echocardiography; TTE = tmnsthoracic echocardiography; - or + denotes absence or presence of the sign.
FlGURE l.Sdnmatic reprewhtlon of the transesophageal longiinal axis (shadow) showing both the anterior and posterior mitral valve leatkts in relatii to the surrounding cardiac structures.
420
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
69
When TTE studies were completed all patients underwent a biplane TEE study (5 MHz transducer). Patients were studied in the fasting state after receiving sedation with 5 mg of intravenous diazepam and lidoCaine spray in the oropharynx. With TEE, a 3-dimensional reconstruction of the relation between the mitral valve and the mitral annulus was attempted. With the longitudinal axis, a complete view of the posterior mitral leaflet was obtained (Figure I). From the transverse plane the anterior mitral leaflet as well as the posteromedialis commissure were analyzed (Figure 2). With a more caudal position of the transducer this plane also permitted evaluating the posterior mitral leaflet. Again, with biplane TEE, care was taken to assess the presence and severity of leaflet billowing and to accurately determine the location of the coaptation point of the mitral valve. Pulsed and color Doppler studies of the mitral valve were subsequently performed to evaluate the presence and severity of mitral regurgitation, and this information was compared with the results of the TTE studies. With TEE color Doppler, the severity of mitral regurgitation (I to III) was assessed by planimetry of the area of the regurgitant jet as previously described.t2 Continuous data are presented as mean f standard deviation. The chi-square test, with the Yate’s correction when indicated, was used to compare qualitative variables of TTE studies with those of TEE. On M-mode studies, 10 patients (50%) had thickeningof the mitral leaflets. A late systolic posterior motion of mitral leaflets was seen in 13 patients (65%) and a holosystolic hammocking of mitral valve leaflets was present in 6patients (30%). Other signs of MVP included early diastolic anterior motion of the posterior mitral
FlGURE 2. Schematic represenbtion of the transesophageal transverse axis at the mitral valve level, showing the relation between the posteromedialir commissure and the anterior mitral leattet.
FEBRUARY
1, 1992
valve leaflet (I patient), shaggy diastolic echoes (2 patients), cascading diastolic echoes (1 patient), reduplication of mitral echoes (3 patients), and abutment of the mitral valve E point against the septum (2 patients). All patients showing any of these later echocardiographic signs also had at least I of the 2 major M-mode criteria for MY?‘. M-mode echocardiography was able to make the diagnosis of MVP in 15 of the 20 patients (75%) (Table I). On TTE mitral valve annular size was 27 f 8 mm, and 13 patients (6.5%) presented with mitral valve annular dilatation. Systolic billowing of mitral valve leaflets was recognized in 8 patients (40%) from the parasternal long-axis view and in 14 (70%) from the I-chamber view. The coaptation point was beyond the mitral annulus from the parasternal long-axis view in 9 patients (45%) and from the I-chamber view in 14 (70%). According to the previously considered TTE criteria of MVP, 9 patients had the first criteria, 5 had the second and 3 had both. With TTE color Doppler 9 patients had mitral regurgitation (Table I). With biplane TEE, systolic billowing of either the anterior or posterior mitral valve leaflets into the left atrium was seen either in the longitudinal or in the transverse plane in 18 patients (90Y0) (p X0.001 compared with parasternal long-axis TTE and p = not significant compared with both TTE views) (Figure 3). In 2 of these patients billowing was not appreciated from any TTE view. Biplane TEE demonstrated systolic displacement of the coaptation point beyond the mitral valve annulus in all 20 patients (100%) (p KO.05 compared with TTE). In addition, this technique showed mitral valve chordae rupture in 3 patients (15%), which was not previously seenfrom the transthoracic approach. With color Doppler TEE, 15 patients (75%) had mitral regurgitation (Figure 4) (p = not signiftcant compared with TTE studies). No complications were seen as the result of TEE.
addition, 90%of them presentedsystolic billowing of the mitral valve leaflets. Therefore, biplane TEE was, in ou.r experience,superior to conventionalTTE in the diagnosis of MVP. Also for the diagnosis of mitral regurgitation, biplane TEE was more sensitive to TTE in the present series.This confirms our previousexperiencein a general patient population, suggestingthat TEE is a more sensitive technique for detecting the presenceof mitral regurgitation than TTE.13 Our study only analyzed a relatively small cohort of patients with classicclinical and echocardiographiccriteria of MVP. All thesepatients had biplane TEE patterm indicative of MVP. However, although it would have been of major interest to determine whether TEE could be of complementary value to TTE to prevent MVP misdiagnosis,all patients in this serieshad MVP on bi-
FIGURE 3. Left, transesophageal echocardiogram from the longitudinal axis revealing billowing of the posterior mitral lealtet into the left atrium. Right, transverse plane showing relation between the anterior and posteriar mitral leattets anti ths postsromedialis commissure morz &arty. There is marlced billowing of the posterior mitral valve leaflet into ths left atrium. AML = anterior mitral valve leafle& LA = left atrium; LV = kft ventrkbq LVOT = left ventricbr autflow tr* PML = posterior mitral valve leaftet.
The value of TTE in the diagnosis of MVP is well established.9However, the saddle-shapedmorphology of the mitral annulus may induce the false appearanceof superior displacement (into the left atrium) of the mitral leaflets, evenin normal subjects,when only 1 TTE plane is usecL3Preliminary data suggest the value of singleplane TEE in the diagnosis of MVP.“J3 However, only biplane TEE providesthe opportunity to image the mitral valve, from 2 different orthogonal planes, allowing a 3dimensional understanding of the nonplanar structure of the mitral annulus. With the transverseplane it is possible to visualize the anterior mitral leaflet and usually the posteromedialii corm&sure (Figure 1). Alternatively, the longitudinal plane evaluates,in different cuts, both the anterior and posterior mitral valve leaflets. In particular we found this view of specialvalue in the assessmentof the movement of the posterior mitral leaflet (Figure 2). The information obtained from both nlanesallowed us to FIGURE 4. Left, transesophageal echocardiogram from the completely visualize the relationship*betweenthe mitral hgitudinal plane disclosing the presence of mitral wDoppler. Right, transverse plane from the same valve leaflet and its annulus. In our study with biplane tiipatienton cokw showing billowing of both mitral valve leaflets into the TEE every patient showedan abnormally displaced mi- kft d urn. The coaptation point of the mitral valve lsaftets is tral valve coaptation point within the left atrium and, in also displaced into the left atrium (arrow)=
BRIEF REPORTS 421
plane TEE, so that the specificity of the technique could not be determined. In addition, we did not measurethe degreeof either displacementof the coaptation point into the left atrium or the severity of mitral valve billowing, and thesefactors could havediagnostic implications. Prospectivestudiesincluding larger seriesof patientswith the suspectedclinical diagnosisof MVP will be required to determine absolutecriteria for the diagnosisof MVP with biplane TEE and to define the specificity and sensitivity of this technique. Furthermore, the subsetof patients in whom biplane TEE should be performed in order to obtain a more accurate diagnosis, and the value of this technique in the decision-makingprocessinvolved in the managementof patients with MVP needsto be defined. 1. Devereux RB, Kramer-Fox R, Shear K, Kligfield P, Pini R, Savage D. Diagnosis and classification of severity of mitral valve prolapse: methodologic, biologic and prognostic considerations. Am Heart J 1987;113:1265-1280. 2. Krivokapich J, Child JS, Dadourian BJ, Perloff JK. Reassessment of echocardiographic criteria for diagnosis of mitral valve prolapse. Am J Cardiol 1988;61:131-135. 3. Levine RA, Triulzi MO, Harrigan P, Weyman AE. The relationship of mitral
422
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 69
annular shape to the diagnosis of mitral valve prolapse. Circulation 1987;75: 756-767. 4. Barlow JB, Pocock WA. Billowing, floppy, prolapsed or fail mitral valves. Am J Cardiol 1985;55:501-502. 5. DeMaria AN, King JF, Bogren HG, Lies GE. The variable spectrum of echocardiographic manifestations of the mitral valve prolapse syndrome. Circulation 1974;50:33-41. 6. Zenker G, E&l R, Kramer G, Mohr-Kahaly S, Drexler M, Harnoncourt M, Meyer J. Transesophageal two-dimensional echocardiography in young patients with cerebral ischemic events. Stroke 1988;19:345-348. 7. Perloff JK, Child JS, Edwards JE. New guidelines for the clinical diagnosis of mitral valve prolapse. Am J Cwdiol 198657:1124-l 129. 8. The committee on M-Mode Standardization of the American Society of Echocardiography. Results of a survey of echocardiographic measurements. Circulation 1978;58:1072-1083. 9. Dillon JC, Haine CL, Chang S, Feigenbaum H. Use of echocardiography in patients with prolapsed mitral valve. Circulation 1971;43:503-507. 10. Nishimura F&4, Mac Goon M, Shub C, Miller F, Ilstrup D, Tajik J. Echocardiographically documented mitral valve prolapse. Long-term follow-up of 237 patients. N Engl J Med 1985;313:1305-1309. 11. Helmcke F, Nanda NC, Hsiung M, Soto B, Adey C, Goyal R, Gatewood R. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulution 1987;75:175-183. 12. Yoshida K, Yoshikawa J, Yamamura Y, Hozumi T, Akasaka T, Fukaya T. Assessment of mitral regurgitation by biplane transeaophageal color Doppler flow mapping. Circulation 1990;82:1121-1126. 13. E&l R, Mohr-Kahaly S, Rhomann S, Schuster S, Drexler M, Wittlidh N, Pfeifer C, Schreiner G, Meyer J. Diagnostic value of the transesophageal Doppler echocardiography. Herr 1987;12:177-186.
FEBRUARY 1, 1992
