Routine methods of analyzing mitral annulus
The European Society of Cardiology (ESC) recommendations suggest A-P diameter of the mitral annulus to be the gold standard measurement for guiding surgical interventions and do not take into account the annulus area and circumference (11). However, one of the first indications for 3D echocardiography was MV assessment (12,13) and the development of probes and software helped in understanding the exact complex anatomy of the annulus and the leaflets, label the scallops and commissures, localize the pathology and provide corresponding “surgical” 3D en face views of the MV (13,14). This advanced quantitative assessment of the annular geometry helped the surgeons to improve the reparative surgery results (15). Still, all these measurements were provided from TOE examinations and, through several previous clinical studies, it has been confirmed that these data correlate well with the ones measured with cardiac computed tomography (3, 4, 16), cardiac magnetic resonance (17,18) and even the direct valve measurements during the operations (19). Nevertheless, it is practically difficult to follow up every patient with TOE, as this is a semi-invasive method that mostly requires sedation which may alter the hemodynamics of the patient resulting in inaccurate assessment during mitral regurgitation evaluation. TTE is the gold standard method for routine evaluation of patients, as TTE probes achieve high quality 2D and color Doppler images that make the assessment relatively easy (11). Recent developments in TTE probes increased the spatial and temporal resolution and provided more detailed evaluation of the MV. Thus, 3D TTE became more reproducible and accurate. Our study demonstrated a strong correlation between TTE and TOE in mitral annular assessment, however further investigation needs to be done to establish TTE for routine MV assessment.