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.