Visualization and measurement of mitral valve chordae tendineae using three-dimensional transesophageal echocardiography from the transgastric approach

Abstract

Background: The evaluation of the submitral apparatus is challenging from the conventional transesophageal approach. The aim of this study was to test the feasibility of using three-dimensional (3D) transesophageal echocardiographic (TEE) imaging from the transgastric approach to visualize the submitral apparatus and quantify the lengths of the chordae tendineae by using multiplanar reconstruction analysis.

Methods: Twenty-two patients who had transgastric full-volume 3D TEE data sets before mitral valve surgery underwent surgical measurement of chordal length. A short-axis plane at the chordal level was extracted from the 3D data set to identify leaflet segments and the corresponding primary chords. Then, for each chord, the optimal plane was selected to visualize and measure the entire chordal length from its origin at the leaflet margin to the papillary muscle tips. Measurements were performed at the phase of the cardiac cycle when chordal length reached its maximum. Measured values were compared with surgical measurements using linear regression and Bland-Altman analyses.

Result: One hundred forty-six primary chords were measured intraoperatively. Three-dimensional TEE imaging was able to measure the lengths of all these chords. The surgical and 3D TEE measurements (mean, 1.96 ± 0.56 vs 1.93 ± 0.50 cm, respectively) correlated highly (r = 0.93, P < .0001), with a minimal bias of 0.03 cm and narrow limits of agreement from -0.39 to 0.45 cm.

Conclusion: Transgastric 3D TEE imaging of the submitral apparatus allows visualization and accurate measurement of chordae tendineae lengths, which may be useful for planning mitral valve repair, including percutaneous transcatheter procedures.

Keywords: 3D transesophageal echocardiography; Mitral valve chordae tendineae; Multiplanar reconstruction; Submitral apparatus; Transgastric view.