PRe-oPeRATIve TRAnSThoRAcIc LIve ThRee-DImenSIonAL echocARDIoGRAPhY In The ASSeSSmenT oF mITRAL STenoSIS: cLInIcAL exPeRIence

We investigated three-dimensional (3D) live transthoracic echocardiography (TTE) in the assessment of mitral stenosis. Bidimensional (2D) TTE and 3D TEE was performed in 42 patients with mitral stenosis concomitent with cardiac catheterisation, prior to valve surgery. Using a surgical scoring protocol for recognition of the valvular segments, 2D and 3D methods were compared. Adequate echocardiographic visualization of the mitral segments was more frequently obtained by 3D TTE than by 2D TTE. Total 3D TTE score were significantly better than 2D TTE score. Using surgical classification as gold standard, the sensibility and specificity were 93% and 87 % for 3D TEE, and 86% and 79% for 2D TTE. The opening area determined by 3D TEE showed better linear association with the area determined intraoperative or invasively by Gorlin formula compared with 2D TTE. In conclusions, 3D TTE was superior to 2D TTE for the analysis of mitral stenosis and could be used for the accurate identification of the severity. KEywordS mitral valve stenosis, mitral valve area, three-dimensional live transthoracic echocardiography, bidimensional transthoracic echocardiography, Gorlin formula. IntroductIon Rheumatic mitral valve stenosis still remains an important public health concern, and the assessment of the severity of mitral valve stenosis requires accurate measurements of the mitral valve orifice area. Direct measurement of the MVA can be performed by planimetry using two-dimensional (2D) echocardiography (Nichol PM et al., 1977). However, planimetry by 2-D echo requires significant experience and operator skill to define the correct image plane that displays the true mitral valve orifice (Binder et al., 2000). As repair techniques have advanced, so has the need to obtain accurate information prior to surgery. Some studies suggest that adding three-dimensional (3D) imaging to standard 2D echocardiography could be helpful in the quantification of valvular diseases (García-Fernández et al., 2010; Wei et al., 2010; Hoole et al., 2008). Three-dimensional echocardiography is a new emerging technique that allows recording of volumetric echographic data (Pandian et al., 1994). This technique can provide views of the entire valve, allowing a complete assessment of the valve leaflets and commissures (Solis et al., 2009; Uno et al., 2009). 3D echocardiography has a good accuracy (Tamborini et al., 2010), so that several authors recommended already to integrate this new technique in the standard preoperative examination and become an important tool in the decision to process valvular repair/replacement. The aim of this prospective study was to evaluate two aspects of 3D live transthoracic echocardiography (3D TTE): the accuracy of the method (vs. surgical inspection) in patients undergoing surgery for mitral stenosis; (ii) to compare the accuracy of 3D TEE with 2D TTE; (iii) to compare the valvular area measured 3D TTE and 2D TTE with the area determined by Gorlin method and intraoperative area in patients with mitral stenosis. MAtErIAL And MEthod Forty-two consecutive patients with mitral stenosis referred to surgery were evaluated by 2D TTE and 3D TTE. Exclusion criteria were represented by inadequate echocardiografic images, movement artifacts caused by coughing or hiccough, difficulty with ECG registering, and equipment failure. A complet TTE study was obtained prior to or following the invasive study, in a time gap <48 h; surgery was done in the next 7 days. Three-dimensional and 2D data were compared with invasive and, than with surgical data. The local ethics committee approved the study. Informed consent was obtained from all patients. The TTE study was performed in all patients using Vivid 9 GE echocardiographic system. Two-dimensional TTE views of the mitral valve was obtained from the parasternal window; the planimetry was also performed. Three cardiac cycles for patients in sinus rhythm and five for patients in atrial fibrillation were recorded, and their results averaged for every patient. The 3D examination was done after a routine diagnostic. The Carpentier nomenclature was applied to the mitral leaflets (Carpentier, 1983). All valvular segments were classified as normal, prolapsing, flail, tenting, perforation, erosion, fibrosis or calcification. The fusion Corepondence author: Cristian Mornos, MD, PhD, Victor Babes University of Medicine and Pharmacy, Timişoara Institute of Cardiovascular Disease, 13 A Gh. Adam st., tel: +4