case_images: PMC3927007_01
case_images: Preoperative two-dimensional (2D) transthoracic echocardiography. Two-chamber views with 2D and color Doppler showing severe mitral regurgitation due to a coaptation defect between the anterior and posterior mitral leaflets. The regurgitant flow arising from the tip of the AML in these views (arrow) suggests a defect in the free margin of the AML tip. LA: left atrium, LV: left ventricle, AML: anterior mitral leaflet (Video images are available on-line, video link 1 and 2).
case_images: kjae-66-75-g001.jpg
case_images: PMC3927007_01_kjae-66-75-g001.jpg
case_images: F1
case_images: MR; two-chambered views using color Doppler showed a severe central MR jet projecting into an enlarged left atrium (Fig. 1, Video 1 and 2). MVR to install a bioprosthetic valve was planned preoperatively considering the technical difficulties and worse outcome of a patch repair of a large defect on the free margin of the AML.
case_images: Intraoperative two-dimensional transesophageal echocardiography. Midesophageal (ME) long-axis (LAX) and commissural views with color Doppler showing severe regurgitation between the mid-part of anterior and posterior mitral leaflets (A2 and P2 scallops). The free margin of the AML tip appears intact in the ME LAX view. Central regurgitant flow arising from the mid scallop gap, A2 or P2, is noted in the ME commissural view. However, it was difficult to make a definite diagnosis regarding which part was responsible for the concurrent coaptation defect of the mitral valve producing mitral regurgitation using these views. LA: left atrium, LV: left ventricle, Ao: aorta, AML: anterior mitral leaflet, PML: posterior mitral leaflet. P1: anteriolateral scallop of PML, P2: middle scallop of PML, P3: posteromedial scallop of PML, and A2: middle part of AML (Video images are available on-line, video link 3 and 4).
case_images: kjae-66-75-g002.jpg
case_images: PMC3927007_01_kjae-66-75-g002.jpg
case_images: F2
case_images: MR; two-chambered views using color Doppler showed a severe central MR jet projecting into an enlarged left atrium (Fig. 1, Video 1 and 2). MVR to install a bioprosthetic valve was planned preoperatively considering the technical difficulties and worse outcome of a patch repair of a large defect on the free margin of the AML. Healthcare, Andover, MA, USA) and intraoperative 2D and 3D TEE examinations were performed. The 2D TEE images in the midesophageal commissural and long axis views also supported the preoperative diagnosis regarding a severe MR and systolic coaptation defect between the AML and posterior mitral leaflet (PML) (Fig. 2, Video 3 and 4). However, intraoperative real time 3D TEE provided more detailed spatial information on the MR pathology, which was entirely different from that suggested by the preoperative TTE; the "en face view" in the left atrial perspective showed a cleft in the middle of the PML, a ruptured chordae attached to the P3 scallop moving toward the left atrium during systole, and fusion of both ends of the MV commissures producing mild MS (Fig. 3, Video 5).
case_images: Intraoperative pre-procedural real-time three-dimensional transesophageal echocardiography. Pre-procedural "en face view" of the mitral valve in the left atrial perspective, depicting the "surgeon's view," showing a large defect in the mid-part of the posterior mitral leaflet (P2 scallop), fusion of both anterolateral and posteromedial commissures, and a ruptured chorda of the P3 scallop. AML: anterior mitral leaflet, ALC: anterolateral commissure, PMC: posteromedial commissure. P1: anterolateral scallop of posterior mitral leaflet, P3: posteriomedial scallop of posterior mitral leaflet (Video images are available on-line, video link 5).
case_images: kjae-66-75-g003.jpg
case_images: PMC3927007_01_kjae-66-75-g003.jpg
case_images: F3
case_images: Healthcare, Andover, MA, USA) and intraoperative 2D and 3D TEE examinations were performed. The 2D TEE images in the midesophageal commissural and long axis views also supported the preoperative diagnosis regarding a severe MR and systolic coaptation defect between the AML and posterior mitral leaflet (PML) (Fig. 2, Video 3 and 4). However, intraoperative real time 3D TEE provided more detailed spatial information on the MR pathology, which was entirely different from that suggested by the preoperative TTE; the "en face view" in the left atrial perspective showed a cleft in the middle of the PML, a ruptured chordae attached to the P3 scallop moving toward the left atrium during systole, and fusion of both ends of the MV commissures producing mild MS (Fig. 3, Video 5).
case_images: Intraoperative post-procedural real-time three-dimensional transesophageal echocardiography. The "en face" view of the mitral valve in the left atrial perspective immediately after the mitral valve repair procedure (MVRep) showing the successfully repaired posterior mitral leaflet and enlarged mitral valve opening. AML: anterior mitral leaflet, PML: posterior mitral leaflet, ALC: anterolateral commissure, PMC: posteromedial commissure (Video images are available on-line, video link 6).
case_images: kjae-66-75-g004.jpg
case_images: PMC3927007_01_kjae-66-75-g004.jpg
case_images: F4
case_images: Healthcare, Andover, MA, USA) and intraoperative 2D and 3D TEE examinations were performed. The 2D TEE images in the midesophageal commissural and long axis views also supported the preoperative diagnosis regarding a severe MR and systolic coaptation defect between the AML and posterior mitral leaflet (PML) (Fig. 2, Video 3 and 4). However, intraoperative real time 3D TEE provided more detailed spatial information on the MR pathology, which was entirely different from that suggested by the preoperative TTE; the "en face view" in the left atrial perspective showed a cleft in the middle of the PML, a ruptured chordae attached to the P3 scallop moving toward the left atrium during systole, and fusion of both ends of the MV commissures producing mild MS (Fig. 3, Video 5).