Messika-Zeitoun David, Brochet Eric, Holmin Caroline, Rosenbaum David, Cormier Bertrand, Serfaty Jean-Michel, Iung Bernard, Vahanian Alec
Cardiovascular Department, AP-HP, Bichat Hospital, 46 rue Henri Huchard, 75018 Paris, France.
Eur Heart J. 2007 Jan;28(1):72-9. doi: 10.1093/eurheartj/ehl206. Epub 2006 Aug 25.
Management of patients with mitral stenosis (MS) relies on accurate evaluation of the mitral valve area (MVA). Planimetry (MVA(2D)) is considered as the reference method but must be performed at the tips of the leaflets with the correct plane orientation and therefore requires experienced operators. Real-time three-dimensional echocardiography (RT3DE) may overcome this limitation but its usefulness for experienced when compared with less experienced operators has not been evaluated. In addition, superiority of RT3DE for the evaluation of commissural splitting after percutaneous mitral commissurotomy (PMC) is unknown.
60 patients were prospectively evaluated by 2D and RT3DE before and after PMC by experienced operators. Before PMC, MVA(3D) was slightly higher than MVA(2D) (1.15 +/- 0.25 vs. 1.06 +/- 0.22 cm2, P = 0.0001) but correlation between methods was excellent (r = 0.73, P < 0.0001), mean difference was small (0.09 +/- 0.18 cm2) and clinically meaningless (three patients misclassified, two of whom had borderline MS severity). After PMC, MVA(3D) did not differ from and correlated well with MVA(2D) (1.87 +/- 0.37 vs. 1.85 +/- 0.32 cm2, P = 0.36; r = 0.76, P < 0.0001; mean difference 0.03 +/- 0.24 cm2). Twenty-five additional patients were also evaluated both by an experienced and a less experienced operators. Bland-Altman analysis showed the better agreement between MVA(3D) measured by the less experienced operator and MVA(2D) measured by the experienced operator than between MVA(2D) measured by the less experienced and the experienced operators (mean difference 0.03 +/- 0.34 vs. - 0.13 +/- 0.46 cm2, P = 0.03). When compared with RT3DE, 2DE underestimated the degree of commissural opening in 33% of patients and agreement between methods was weak (kappa = 0.41).
RT3DE provides accurate MVA measurements similar to 2D planimetry performed by experienced operators. Thus, it does not provide a real advantage for experienced operators, whereas it seems particularly helpful for less experienced operators. In addition, RT3DE improves the description of valvular anatomy.
二尖瓣狭窄（MS）患者的管理依赖于对二尖瓣面积（MVA）的准确评估。平面测量法（MVA(2D)）被视为参考方法，但必须在瓣叶尖端以正确的平面方向进行，因此需要经验丰富的操作人员。实时三维超声心动图（RT3DE）可能克服这一局限性，但与经验较少的操作人员相比，其对经验丰富的操作人员的有用性尚未得到评估。此外，RT3DE在经皮二尖瓣交界切开术（PMC）后评估交界裂开方面的优越性尚不清楚。
60例患者在PMC前后由经验丰富的操作人员进行二维和RT3DE前瞻性评估。在PMC前，MVA(3D)略高于MVA(2D)（1.15±0.25 vs. 1.06±0.22 cm²，P = 0.0001），但两种方法之间的相关性极佳（r = 0.73，P < 0.0001），平均差异较小（0.09±0.18 cm²）且临床意义不大（3例患者分类错误，其中2例MS严重程度处于临界值）。PMC后，MVA(3D)与MVA(2D)无差异且相关性良好（1.87±0.37 vs. 1.85±0.32 cm²，P = 0.36；r = 0.76，P < 0.0001；平均差异0.03±0.24 cm²）。另外25例患者也由一位经验丰富的操作人员和一位经验较少的操作人员进行了评估。Bland-Altman分析显示，经验较少的操作人员测量的MVA(3D)与经验丰富的操作人员测量的MVA(2D)之间的一致性优于经验较少的操作人员与经验丰富的操作人员测量的MVA(2D)之间的一致性（平均差异0.03±0.34 vs. -0.13±0.46 cm²，P = 0.03）。与RT3DE相比，二维超声心动图（2DE）在33%的患者中低估了交界开口程度，两种方法之间的一致性较弱（kappa = 0.41）。
RT3DE提供的MVA测量结果与经验丰富的操作人员进行的二维平面测量法相似。因此，它对经验丰富的操作人员没有真正的优势，而对经验较少的操作人员似乎特别有帮助。此外，RT3DE改善了瓣膜解剖结构的描述。
