The echocardiographic characteristics and risk stratification of patients with above grade 3<sup>+</sup> mitral regurgitation: Based on the preliminary findings of echo core-lab_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

KE Yutong ¹ , LU Zhinan ² , WU Wenhui ² , LIU Xinmin ² , YAO Jing ² ,  HE Yihua ¹ ,  SONG Guangyuan ²

1. Department of Echocardiography, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, P. R. China;
2. Department of Heart Valve Intervention, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, P. R. China;

Corresponding author：

HE Yihua, Email: yihuaheecho@163.com; SONG Guangyuan, Email: songgy_anzhen@VIP.163.com

Keywords：

Three-dimensional echo; transesophageal echocardiography; valve regurgitation; pathogenesis; mitral valve

DOI：

10.7507/1007-4848.202209021

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Objective To analyze the echocardiographic characteristics of above grade 3⁺ mitral regurgitation (MR) patients by 3D transesophageal echocardiography (3D-TEE) in transcatheter edge-to-edge repair (TEER) and compare the intervention rate of TEER treatment in patients with different risk stratification. Methods We retrospectively analyzed the clinical data of 91 patients with above grade 3⁺ MR in Anzhen Hospital between June 2021 and April 2022. There were 45 males and 46 females aged 66.5±15.9 years. According to pathogenesis, the patients were divided into different anatomical groups and risk stratification groups. There were 34 patients in a simple degenerative group (simple DMR group), 28 patietns in a complex disease group (Complex group), 14 patients in a simple ventricular functional reflux group (simple VFMR group), 9 patients in a simple atrial functional reflux group (simple AFMR group), and 6 patients in a mixed functional reflux group (mixed FMR group). All patients were examined with a unified standard of transthoracic echocardiography (TTE) and 3D-TEE to compare the characteristic three-dimensional structural changes of the mitral valve in each group. According to the three partition strategy of preoperative anatomical evaluation of TEER, the risk stratification was conducted for the enrolled patients, which was divided into three regions from light to heavy: green area, yellow area, and red area. TEER treatment intervention rate of patients with different risk stratification was calculated. Results Ant leaf angle and post leaf angle were negative in the simple DMR and Complex groups, and non-planar angle, prolapse height and prolapse volume were higher than those of the other groups (P=0.000). Ant leaf angle and post leaf angle were positive in the VFMR group and the mixed FMR group. Anterior and posterior (AP) diameter of valve ring (P=0.036), tenting height and tenting volume were higher than those of other groups (P=0.000). AP diameter, tenting height and tenting volume were changed mildly in patients with simple AFMR. MR patients in red and yellow zone achieved a 28.1% TEER intervention rate.Conclusion Standardized TTE and TEE examinations are crucial for the qualitative and quantitative diagnosis of MR in the echo core-lab. 3D-TEE mitral valve parameter can help determine the exact pathogenesis of MR and to improve the interventional rate of challenging MR patients.

Citation： KE Yutong, LU Zhinan, WU Wenhui, LIU Xinmin, YAO Jing, HE Yihua, SONG Guangyuan. The echocardiographic characteristics and risk stratification of patients with above grade 3⁺ mitral regurgitation: Based on the preliminary findings of echo core-lab. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(2): 205-213. doi: 10.7507/1007-4848.202209021 Copy

1.	Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: A population-based study. Lancet, 2006, 368(9540): 1005-1011.
2.	Bonow RO, O’Gara PT, Adams DH, et al. 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation. J Am Coll Cardiol, 2020, 75: 2236-2270.
3.	Hahn RT, Saric M, Faletra FF, et al. Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography (2021). J Am Soc Echocardiogr, 2022, 35(1): 1-76.
4.	Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr, 2015, 28: 1-39.e14.
5.	Lancellotti P, Tribouilloy C, Hagendorff A, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: An executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging, 2013, 14(7): 611-644.
6.	Lang RM, Adams DH. 3D echocardiographic quantification in functional mitral regurgitation. JACC Cardiovasc Imaging, 2012, 5: 346-347.
7.	Quinones MA, Otto CM, Stoddard M, et al. Recommendations for quantification of doppler echocardiography: A report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr, 2002, 15: 167-184.
8.	Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography. J Am Soc Echocardiogr, 2003, 16: 777-802.
9.	Lang RM, Badano LP, Tsang W, et al. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr, 2012, 25: 3-46.
10.	Chandra S, Salgo IS, Sugeng L, et al. Characterization of degenerative mitral valve disease using morphologic analysis of real-time three-dimensional echocardiographic images: Objective insight into complexity and planning of mitral valve repair. Circ Cardiovasc Imaging, 2011, 4: 24-32.
11.	Lim DS, Herrmann HC, Grayburn P, et al. Consensus document on non-suitability for transcatheter mitral valve repair by edge-to-edge therapy. Structural Heart, 2021, 5(3): 227-233.
12.	蒲朝霞, 余蕾, 游向东, 等. 经食管超声心动图在经导管二尖瓣缘对缘修复治疗二尖瓣反流中的初步应用. 中华超声影像学杂志, 2014, 10(9): 842-846.
13.	陈昕, 杨军, 石璨, 等. 实时三维经食管超声在二尖瓣反流Carpentier's分型中的应用. 中国医学影像技术, 2017, 33(3): 360-364.
14.	Tribouilloy C, Rusinaru D, Grigioni F, et al. Longterm mortality associated with left ventricular dysfunction in mitral regurgitation due to flail leaflets: A multicenter analysis. Circ Cardiovasc Imaging, 2014, 7(3): 363-370.
15.	Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation, 1994, 90: 830-837.
16.	Ling LH, Enriquez-Sarano M, Seward JB, et al. Clinical outcome of mitral regurgitation due to flail leaflet. N Engl J Med, 1996, 335: 1417-1423.
17.	Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: Best practice revolution. Eur Heart J, 2010, 31: 1958-1966.
18.	Mesi O, Gad MM, Alejandro D. Severe atrial functional mitral regurgitation: Clinical and echocardiographic characteristics, management and outcomes. JACC: Cardiovasc Imaging, 2021, 14(4): 797-808.
19.	Ho SY. Anatomy of the mitral valve. Heart, 2002, 88(Suppl): Ⅳ5-Ⅳ10.
20.	Muresian H. The clinical anatomy of the mitral valve. Clin Anat, 2009, 22: 85-98.

1. Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: A population-based study. Lancet, 2006, 368(9540): 1005-1011.
2. Bonow RO, O’Gara PT, Adams DH, et al. 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation. J Am Coll Cardiol, 2020, 75: 2236-2270.
3. Hahn RT, Saric M, Faletra FF, et al. Recommended standards for the performance of transesophageal echocardiographic screening for structural heart intervention: From the American Society of Echocardiography (2021). J Am Soc Echocardiogr, 2022, 35(1): 1-76.
4. Lang RM, Badano LP, Mor-Avi V, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: An update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr, 2015, 28: 1-39.e14.
5. Lancellotti P, Tribouilloy C, Hagendorff A, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: An executive summary from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging, 2013, 14(7): 611-644.
6. Lang RM, Adams DH. 3D echocardiographic quantification in functional mitral regurgitation. JACC Cardiovasc Imaging, 2012, 5: 346-347.
7. Quinones MA, Otto CM, Stoddard M, et al. Recommendations for quantification of doppler echocardiography: A report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr, 2002, 15: 167-184.
8. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography. J Am Soc Echocardiogr, 2003, 16: 777-802.
9. Lang RM, Badano LP, Tsang W, et al. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr, 2012, 25: 3-46.
10. Chandra S, Salgo IS, Sugeng L, et al. Characterization of degenerative mitral valve disease using morphologic analysis of real-time three-dimensional echocardiographic images: Objective insight into complexity and planning of mitral valve repair. Circ Cardiovasc Imaging, 2011, 4: 24-32.
11. Lim DS, Herrmann HC, Grayburn P, et al. Consensus document on non-suitability for transcatheter mitral valve repair by edge-to-edge therapy. Structural Heart, 2021, 5(3): 227-233.
12. 蒲朝霞, 余蕾, 游向东, 等. 经食管超声心动图在经导管二尖瓣缘对缘修复治疗二尖瓣反流中的初步应用. 中华超声影像学杂志, 2014, 10(9): 842-846.
13. 陈昕, 杨军, 石璨, 等. 实时三维经食管超声在二尖瓣反流Carpentier's分型中的应用. 中国医学影像技术, 2017, 33(3): 360-364.
14. Tribouilloy C, Rusinaru D, Grigioni F, et al. Longterm mortality associated with left ventricular dysfunction in mitral regurgitation due to flail leaflets: A multicenter analysis. Circ Cardiovasc Imaging, 2014, 7(3): 363-370.
15. Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation, 1994, 90: 830-837.
16. Ling LH, Enriquez-Sarano M, Seward JB, et al. Clinical outcome of mitral regurgitation due to flail leaflet. N Engl J Med, 1996, 335: 1417-1423.
17. Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: Best practice revolution. Eur Heart J, 2010, 31: 1958-1966.
18. Mesi O, Gad MM, Alejandro D. Severe atrial functional mitral regurgitation: Clinical and echocardiographic characteristics, management and outcomes. JACC: Cardiovasc Imaging, 2021, 14(4): 797-808.
19. Ho SY. Anatomy of the mitral valve. Heart, 2002, 88(Suppl): Ⅳ5-Ⅳ10.
20. Muresian H. The clinical anatomy of the mitral valve. Clin Anat, 2009, 22: 85-98.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

The echocardiographic characteristics and risk stratification of patients with above grade 3⁺ mitral regurgitation: Based on the preliminary findings of echo core-lab

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The echocardiographic characteristics and risk stratification of patients with above grade 3+ mitral regurgitation: Based on the preliminary findings of echo core-lab

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The echocardiographic characteristics and risk stratification of patients with above grade 3⁺ mitral regurgitation: Based on the preliminary findings of echo core-lab