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• W4297839618 abstract "We read with interest the paper in the July issue of the Journal of American Society of Echocardiography by Henry et al.1Henry M.P. Cotella J. Mor-Avi V. Addetia K. Miyoshi T. Schreckenberg M. et al.Three-dimensional transthoracic static and dynamic normative values of the mitral valve apparatus: results from the Multicenter World Alliance Societies of Echocardiography Study.J Am Soc Echocardiogr. 2022; 35: 738-751.e1Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar First, the authors should be congratulated for publishing this important work, which is likely to be used as the standard normal range of mitral valve (MV) morphology in future studies. As a part of the World Alliance Societies of Echocardiography study, they analyzed the three-dimensional (3D) transthoracic echocardiograms (TTEs) of 748 healthy individuals from various regions of the world using commercially available software and reported the normal range of the MV morphology. The Henry et al. study included the largest number of healthy individuals to date in a study of this type; however, some of the reported variables are out of the normal range that previous studies have reported. In particular, the tenting height of 9.7 mm is generally considered abnormal; studies report that it is 5 to 6 mm in normal subjects and 8 to 12 mm in patients with functional mitral regurgitation (MR).2Lin Q.S. Fang F. Yu C.M. Zhang Y.C. Hsiung M.C. Salgo I.S. et al.Dynamic assessment of the changing geometry of the mitral apparatus in 3D could stratify abnormalities in functional mitral regurgitation and potentially guide therapy.Int J Cardiol. 2014; 176: 878-884Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,3Mihăilă S. Muraru D. Piasentini E. Miglioranza M.H. Peluso D. Cucchini U. et al.Quantitative analysis of mitral annular geometry and function in healthy volunteers using transthoracic three-dimensional echocardiography.J Am Soc Echocardiogr. 2014; 27: 846-857Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar Tenting height >10 mm was reported as a risk factor for recurrent regurgitation after annuloplasty even in the context of functional MR.4Calafiore A.M. Gallina S. Di Mauro M. Gaeta F. Iacò A.L. D’Alessandro S. et al.Mitral valve procedure in dilated cardiomyopathy: repair or replacement?.Ann Thorac Surg. 2001; 71: 1146-1152Abstract Full Text Full Text PDF PubMed Scopus (267) Google Scholar In addition, the mitral annulus anterior-posterior diameter and area also seem larger than in previous reports. The previously reported2Lin Q.S. Fang F. Yu C.M. Zhang Y.C. Hsiung M.C. Salgo I.S. et al.Dynamic assessment of the changing geometry of the mitral apparatus in 3D could stratify abnormalities in functional mitral regurgitation and potentially guide therapy.Int J Cardiol. 2014; 176: 878-884Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar normal mitral annulus area was 6 to 8 cm2, while Henry et al.1Henry M.P. Cotella J. Mor-Avi V. Addetia K. Miyoshi T. Schreckenberg M. et al.Three-dimensional transthoracic static and dynamic normative values of the mitral valve apparatus: results from the Multicenter World Alliance Societies of Echocardiography Study.J Am Soc Echocardiogr. 2022; 35: 738-751.e1Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar reported 10.3 cm2 as the normal value. A couple of concerns are raised by the methodology. The authors used the semiautomated software for TTE, which tracks the MV throughout systole. Considering the reproducibility, they chose early systole (the frame after MV closure) for the MV measurements, as the frame was automatically selected by the program. However, the left ventricular pressure becomes highest in mid systole, which puts the greatest stress on the MV. As a result, the tenting parameters become the smallest in mid systole, and so does the mitral annular size. Thus, most previous reports assessed MV morphology in mid systole, and the tenting height in mid systole is correlated with the presence and severity of functional MR.5Zoghbi W.A. Adams D. Bonow R.O. Enriquez-Sarano M. Foster E. Grayburn P.A. et al.Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance.J Am Soc Echocardiogr. 2017; 30: 303-371Abstract Full Text Full Text PDF PubMed Scopus (1868) Google Scholar The guidelines by the American Society of Echocardiography also support measuring the tenting in mid systole.5Zoghbi W.A. Adams D. Bonow R.O. Enriquez-Sarano M. Foster E. Grayburn P.A. et al.Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance.J Am Soc Echocardiogr. 2017; 30: 303-371Abstract Full Text Full Text PDF PubMed Scopus (1868) Google Scholar Thus, the timing of measurements should be the major reason for these discrepancies. Yet, even considering the difference in the timing of assessment, the reported values are still greater than in a few reports that measured the MV in early systole.2Lin Q.S. Fang F. Yu C.M. Zhang Y.C. Hsiung M.C. Salgo I.S. et al.Dynamic assessment of the changing geometry of the mitral apparatus in 3D could stratify abnormalities in functional mitral regurgitation and potentially guide therapy.Int J Cardiol. 2014; 176: 878-884Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Another possible minor concern may be image quality. Although TTE was a reasonable choice for this study enrolling healthy individuals, 3D TTE has less spatial resolution than transesophageal echocardiography. As seen in Figure 1 in Henry et al., inferior spatial resolution sometimes makes it very difficult to determine the mitral annular position by an automated tracking system, resulting in the inclusion of the aortomitral fibrous continuity as the MV. In summary, despite the large and heterogenous population, the MV parameters measured by 3D TTE in this study are out of the normal ranges reported in previous studies. The different timing of measurements is likely the major reason for these discrepancies. These methodological details should be considered when applying these results in clinical practice. Response to “Dynamic Nature of the Mitral Valve Morphology: Consideration of the Normal Ranges”Journal of the American Society of EchocardiographyVol. 36Issue 1PreviewWe appreciate the comments of Dr. Kagiyama and coworkers regarding the results of our study on the three-dimensional (3D) transthoracic echocardiography (TTE) normative values of the mitral valve (MV) apparatus.1 They correctly point out that some of the measurements reported in our study present relevant discrepancies with previous studies2-4 and guidelines recommendations.5 Full-Text PDF" @default.
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• W4297839618 title "Dynamic Nature of the Mitral Valve Morphology: Consideration of the Normal Ranges" @default.
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• W4297839618 doi "https://doi.org/10.1016/j.echo.2022.09.005" @default.
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