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Advance Publication by-J-STAGE
Circulation Journal
Official Journal of the Japanese Circulation Society
http://www. j-circ.or.jp
IMAGES IN CARDIOVASCULAR MEDICINE
New Echo Window to Quantify Eccentric Mitral
Regurgitation Using a Transgastric Approach
on Transesophageal Echocardiography
Tomoko Tamada, MD; Hiroyuki Okura, MD; Kiyoshi Yoshida, MD
Figure. Transesophageal echocardiography (TEE). (A) Standard
TEE 2-chamber view; (B) color
Doppler 2-chamber view; (C)
transgastric TEE view showing P3
prolapse; (D) color Doppler transgastric view; (E) proximal isovelocity surface area method; (F)
continuous wave Doppler signal of
the mitral regurgitant jet. LA, left
atrium; LV, left ventricle.
Received October 8, 2014; accepted October 22, 2014; released online November 20, 2014 Time for primary review: 13 days
Division of Cardiology, Kawasaki Medical School, Kurashiki (T.T., H.O.); Division of Cardiology, Sakakibara Heart Institute of Okayama,
Okayama (K.Y.), Japan
Mailing address: Hiroyuki Okura, MD, Division of Cardiology, Kawasaki Medical School, 577 Matsushima, Kurashiki 701-0192,
Japan. E-mail: hokura@fides.dti.ne.jp
ISSN-1346-9843 doi: 10.1253/circj.CJ-14-1103
All rights are reserved to the Japanese Circulation Society. For permissions, please e-mail: cj@j-circ.or.jp
Advance Publication by-J-STAGE
P
roximal isovelocity surface area (PISA) has been used
to quantify mitral regurgitation (MR) volume as well
as effective regurgitant orifice area (ERO) in patients
with MR.1–3 One of the limitations of the PISA method is its
Doppler angle dependence.2 The PISA method requires both
color Doppler-derived proximal flow convergence signal measurement and the mitral regurgitant jet signal by continuous
wave (CW) Doppler. Because the CW signal needs to be well
aligned with the mitral regurgitant jet, it is difficult to maintain
adequate CW signal in patients with eccentric regurgitant jet.
Transesophageal echocardiography (TEE) provides better
visualization of the mitral valve complex and thus is widely
used for the assessment of MR.4,5 Recently, we introduced a
transgastric approach for TEE as a new echocardiographic
window to visualize and to assess submitral apparatus including papillary muscles and chordae tendinea.6,7
A 78-year-old man was admitted to hospital because of progressive exertional dyspnea. He had a past history of chronic
obstructive pulmonary disease. On physical examination, grade
3/6 pan-systolic murmur was audible at apex. Transthoracic
echocardiography showed eccentric MR due to prolapse of the
postero-medial leaflet (P3). Because quantitative assessment
of the MR was difficult, he underwent TEE. TEE clearly visualized eccentric mitral regurgitant jet from P3 prolapse using
standard approaches (Figures A,B). We further inserted the
transducer deep into the stomach and tilted up the transducer
to obtain a transgastric view (Figures C,D). Using this approach,
prolapse of the P3 and the regurgitant jet through the leaflet
could be better visualized. In addition, good alignment of the
CW Doppler signal with the regurgitant jet was obtained, and
thus PISA could be used to quantify MR volume and ERO
(Figures E,F). MR volume was 77 ml and ERO was calculated
as 0.35 cm2 and he was diagnosed with severe MR. During the
examination, the patient partially awoke and the blood pressure
temporarily rose up to 190/90 mmHg, which subsequently returned to normal after additional sedation.
Surgical indication of MR8 should be individually determined
based on the severity of the MR and the symptoms.9 Because
ERO correlates well with MR prognosis,10 quantification of
the MR rather than semiquantitative assessment11,12 is strongly recommended. Transgastric view may be a useful alternative echo window in some MR patients with eccentric regurgitant jet and thus should be used for such patients.
TAMADA T et al.
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