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Crossed Swords Sign: A 3-Dimensional Echocardiographic Appearance

Gao, Zhifeng MD*,†; Bortman, Jeffrey M. BS; Mahmood, Feroze MD; Matyal, Robina MD; Khabbaz, Kamal R. MD

doi: 10.1213/XAA.0000000000000937
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Intraoperative evaluation of mitral regurgitation is a complex undertaking. Bileaflet prolapse/flail can result in divergent mitral regurgitation jets with a characteristic “crossed swords sign” appearance. We present a case of divergent mitral regurgitation jets that were detected intraoperatively and evaluated using 3-dimensional imaging. The accurate assessment of eccentric mitral regurgitation jets, especially bilateral eccentric mitral regurgitation jets, is challenging before surgical repair. Intraoperative 3-dimensional transesophageal echocardiography with and without color-flow Doppler can significantly improve the localization of the anatomical lesion.

From the *Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China

Department of Anesthesia, Critical Care and Pain Medicine

Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.

Accepted for publication November 1, 2018.

Funding: None.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the HTML and PDF versions of this article on the journal’s website.

Address correspondence to Feroze Mahmood, MD, Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215. Address e-mail to fmahmood@bidmc.harvard.edu.

Intraoperative evaluation of mitral regurgitation is a complex undertaking. Besides structural evaluation using 2- and 3-dimensional imaging, a combination of Doppler-derived variables is used for accurate quantification of mitral regurgitation.1 In addition to severity, the origin and direction of the mitral regurgitation jet are also important considerations in identification of the underlying anatomical abnormality. A central mitral regurgitation jet signifies bileaflet abnormality,2 and an eccentric jet implies a single leaflet excessive motion or restriction.1 In this context, echocardiographic assessment of left atrial wall hugging eccentric mitral regurgitation jets is challenging because they are likely to be underestimated due to reduction in jet area and lack of circumferential entrainment.3

Bileaflet prolapse/flail of the mitral valve can give rise to multiple mitral regurgitation jets that are often complex in shape and vary in duration and direction, requiring a more methodical approach toward quantification.4 Ben Zekry et al5 demonstrated that, when compared with 2-dimensional imaging, enhanced spatial orientation with 3-dimensional imaging improves understanding and evaluation of these complex mitral regurgitation jets. More specifically, Ben Zekry et al5 established that 2- and 3-dimensional transesophageal echocardiography (TEE) demonstrated similar abilities to distinguish between functional and organic mitral regurgitation. Furthermore, they found that 2-dimensional TEE had a higher sensitivity but a lower specificity for identifying specific scallop prolapse when compared with 3-dimensional TEE.5 In another study, Izumo et al6 demonstrated that 3-dimensional TEE more accurately measured mitral valve prolapse gap when compared with 2-dimensional TEE, which could help better inform surgical planning when considering a mitral clip. Bileaflet prolapse/flail of nonadjacent scallops can sometimes result in divergent mitral regurgitation jets with a characteristic “crossed swords sign” appearance.4,7 We present a similar case of divergent mitral regurgitation jets that were detected intraoperatively and evaluated using 3-dimensional imaging, and it led to a change in surgical plan.

Written consent was obtained from the patient to publish this case report.

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CASE DESCRIPTION

An otherwise healthy and physically active 85-year-old woman presented with a short history of intermittent chest pain and worsening dyspnea. The shortness of breath was attributed to severe eccentric mitral regurgitation due to flail of the myxomatous, posterior leaflet that was discovered on a transthoracic echocardiography. The rest of the transthoracic echocardiography examination was normal. Based on history, physical examination, and the transthoracic echocardiography results, the patient was scheduled for an elective mitral valve repair procedure.

After an uneventful induction of general anesthesia, a comprehensive TEE examination was performed with an EPIQ ultrasound system using an X7-2t 3-dimensional TEE probe (Philips Medical Systems, Andover, MA). Two-dimensional images demonstrated a bileaflet myxomatous degeneration of the mitral valve with likely posterior leaflet 2 (P2) and anterior leaflet 2 (A2) flail, and 2 eccentric and divergent mitral regurgitation jets with a characteristic “crossed swords” sign (Figures 1 and 2; Supplemental Digital Content, Video 1, http://links.lww.com/AACR/A236, and Video 2, http://links.lww.com/AACR/A237). Each of these mitral regurgitation jets was judged to be moderate in intensity by visual assessment (Figures 1 and 2; Supplemental Digital Content, Video 1, http://links.lww.com/AACR/A236, and Video 2, http://links.lww.com/AACR/A237). Although the P2 flail scallop and anteriorly associated directed mitral regurgitation jet were readily apparent with 2-dimensional imaging, the origin of the posteriorly directed mitral regurgitation jet was uncertain. A full-volume R-wave gated data set was then acquired over 6 consecutive heartbeats with and without color-flow Doppler. The reconstructed 3-dimensional en face view (surgical view) of the mitral valve demonstrated a flail posterior leaflet middle scallop (P2) and the medial segment of the anterior leaflet (A3).8 With incorporation of color-flow Doppler information, the eccentric mitral regurgitation jets could be appreciated originating from these underlying anatomical lesions. Besides their divergent nature, the flattening of the mitral regurgitation jets on the left atrial wall could also be clearly seen in a 3-dimensional en face view (Figure 3; Supplemental Digital Content, Video 3, http://links.lww.com/AACR/A238).

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Figure 3.

Figure 3.

Figure 4.

Figure 4.

The surgical team was informed of the complex nature of the anatomical lesions and the severity of mitral regurgitation. Based on the initial transthoracic echocardiography findings, the surgical plan consisted of a quadrangular resection of the posterior leaflet with annuloplasty. However, incorporation of the additive information obtained from 3-dimensional TEE necessitated a revision to a more complex surgical repair procedure. The latter consisted of insertion of multiple neochords to the anterior and posterior leaflets in the flail scallops with minimal resection of the P2 scallop, followed by implantation of a Physio-II annuloplasty ring (Edwards Lifesciences Corps, Irvine, CA). There was trace residual regurgitation after separation from cardiopulmonary bypass, with a mean postsurgical gradient of 2 mm Hg (Figure 4; Supplemental Digital Content, Video 4, http://links.lww.com/AACR/A239). The rest of the hospital course was uneventful.

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DISCUSSION

Our case highlights the challenges encountered in the assessment of eccentric mitral regurgitation jets, in general, and bileaflet eccentric mitral regurgitation jets, in particular. The presence of 2 eccentric mitral regurgitation jets from separate locations implies 2 regurgitant orifice areas with additive effect on the severity assessment. It can be difficult to appreciate the shape and extent of complex mitral regurgitation jets by 2-dimensional transthoracic echocardiography and TEE. Multiple jets can arise from different locations along the zone of coaptation and differ in timing and direction. In this situation, when possible, R-wave gated 3-dimensional image acquisition can significantly improve appreciation of the jet timing, size, and direction. Also, because of the excellent spatial resolution and unique anatomic views, we were able to isolate the anatomical abnormality with a degree of precision and assist the surgical team in procedure planning.5

Prolapse is one of the most common cardiac valve abnormalities and the leading surgical indication for mitral regurgitation and affects almost 3% of the population.9 Posterior leaflet prolapse caused by posterior chordal rupture or elongation is the most common form and the cause of mitral regurgitation in 40%–60% of patients.10 Although anterior leaflet prolapse and bileaflet prolapse are less common, ≤30% of patients with significant mitral regurgitation have bileaflet pathology.11

The repair procedure for posterior leaflet prolapse has become standardized with very low morbidity, and early surgery has become the gold standard.12 Traditionally, anterior leaflet and bileaflet prolapse resulted in increased surgical complexity and decreased durability of the repair; however, recent reports have placed the repair of anterior leaflet prolapse and bileaflet prolapse in the same level of difficulty as posterior leaflet prolapse.13 This change is a result of the surgical approach shifting from the classical Carpentier techniques (chordal transfer or shortening) to the predominance of polytetrafluoroethylene neochord (NeoChord Inc, Minneapolis, MN) implantation, which proved to be a simple, versatile, and durable technique.14

In summary, “crossed swords sign” of mitral regurgitation with color-flow Doppler is an important sign of bileaflet involvement. The presence of multiple jets makes localization of the anatomical lesion a very challenging undertaking. Intraoperative 3-dimensional TEE can significantly improve the localization of the anatomical lesion.

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DISCLOSURES

Name: Zhifeng Gao, MD.

Contribution: This author helped draft and revise the manuscript.

Name: Jeffrey M. Bortman, BS.

Contribution: This author helped draft and revise the manuscript.

Name: Feroze Mahmood, MD.

Contribution: This author helped conceive the case report, acquire the ultrasound images, and review the manuscript.

Name: Robina Matyal, MD.

Contribution: This author helped conceive the case report, acquire the ultrasound images, and review the manuscript.

Name: Kamal R. Khabbaz, MD.

Contribution: This author helped conceive the case report, acquire the ultrasound images, and review the manuscript.

This manuscript was handled by: Nikolaos J. Skubas, MD, DSc, FACC, FASE.

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REFERENCES

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