Transthoracic Echocardiography
Transthoracic echocardiography (TTE) examination was performed using the ”Philips Epiq 7 echocardiography device X5-1 transthoracic probe” (Philips Epiq7; Philips Healthcare, Inc., Andover, MA, USA). The standard evaluation included M-mode, 2-dimensional, and Doppler studies according to the recommendations of the American Society of Echocardiography. The anatomy of mitral valve apparatus was systematically evaluated to identify prolapsing scallops and/or presence of a flail leaflet; trans esophageal echocardiography was performed when appropriate. Systolic movement of one or both leaflets ≥ 2mm above the mitral annular plane was accepted as MVP. Although the patients were not divided according to the aetiology of MVP, most patients were having myxomatous MVP rather than fibroelastic deficiency (6). The location of the mitral annulus is identified in the long axis view by zooming on the mitral valve at the maximum achievable frame rate. Subsequently, the images were scrutinized on a frame-by-frame basis to accurately view the mitral annulus and to quantify the width of the MAD trench in addition to the extent of the prolapsus depth. Along with these aspects, upper and lower limits of MAD were defined according the expert consensus statement on arrhythmic MVP and MAD (1). The LV end-diastolic and end-systolic diameters and volumes were measured and indexed to BSA, and EF was calculated using biplane Simpson’s method. To assess LV geometry, end-diastolic relative wall thickness, LV mass/BSA (g/m2), and sphericity index were obtained. Indexed LA area and biplane volumes also were calculated. Myocardial function was assessed with two dimensional speckle tracking echocardiography with layer specific myocardial deformation quantitative analysis function. End diastole was defined with R wave peak in ECG and end systole was defined as aortic valve closing time. Endocardial borders were observed from end systolic 2-dimensional images. Wide myocardial width was calibrated and epicardial borders were evaluated. Mid zone speckles between epicardial and endocardial borders, mid myocardial border were defined automatically. Manual adjustments were carried out in order to obtain correct tracking and 2D speckle tracking width to cover all LV wall thickness if required. Peak systolic strain measurements were performed automatically in each segment via software analysis program (QLAB-CMQ software program of Philips Epiq 7C). Non-traceable segments were excluded after manual adjustment by the operator.