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Echocardiographic anatomy of the mitral valve: a critical appraisal of 2-dimensional imaging protocols with a 3-dimensional perspective.

OBJECTIVE
To highlight the limitations of traditional 2-dimensional (2D) echocardiographic mitral valve (MV) examination methodologies, which do not account for patient-specific transesophageal echocardiographic (TEE) probe adjustments made during an actual clinical perioperative TEE examination.


DESIGN
Institutional quality-improvement project.


SETTING
Tertiary care hospital.


PARTICIPANTS
Attending anesthesiologists certified by the National Board of Echocardiography.


INTERVENTION
Using the technique of multiplanar reformatting with 3-dimensional (3D) data, ambiguous 2D images of the MV were generated, which resembled standard midesophageal 2D views. Based on the 3D image, the MV scallops visualized in each 2D image were recognized exactly by the position of the scan plane. Twenty-three such 2D MV images were created in a presentation from the 3D datasets. Anesthesia staff members (n = 13) were invited to view the presentation based on the 2D images only and asked to identify the MV scallops. Their responses were scored as correct or incorrect based on the 3D image.


METHODS AND MAIN RESULTS
The overall accuracy was 30.4% in identifying the MV scallops. The transcommissural view was identified correctly >90% of the time. The accuracy of the identification of A1, A3, P1, and P3 scallops was <50%. The accuracy of the identification of A2P2 scallops was ≥50%.


CONCLUSION
In the absence of information on TEE probe adjustments performed to acquire a specific MV image, it is possible to misidentify the scallops.