Quantitative Assessment of Mitral Valve Coaptation Using Three-Dimensional Transesophageal Echocardiography Frederick C. Cobey, MD, MPH, Madhav Swaminathan,

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Quantitative Assessment of Mitral Valve Coaptation Using Three-Dimensional Transesophageal Echocardiography Frederick C. Cobey, MD, MPH, Madhav Swaminathan, MD, Barbara Phillips-Bute, PhD, Martin Hyca, MD, Donald D. Glower, MD, Pamela S. Douglas, MD, Andrew D. Shaw, MD, Joseph P. Mathew, MD, G. Burkhard Mackensen, MD, PhD The Annals of Thoracic Surgery Volume 97, Issue 6, Pages 1998-2004 (June 2014) DOI: 10.1016/j.athoracsur.2014.01.015 Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 (A) For each valve, the three-dimensional mitral valve coaptation zone was determined by defining a large series of coaptation lengths within rotational cross-sections, centered on the aortomitral junction. (B) These pairs of points in space were used to create individual subareas. The sequential subareas were added to achieve the total mitral valve coaptation zone. (LM = landmark.) The Annals of Thoracic Surgery 2014 97, 1998-2004DOI: (10.1016/j.athoracsur.2014.01.015) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Screen shots show the three-dimensional (3D) model of the mitral valve coaptation zone from the (A) surgical view and (B) from a posterior and (C) a posterior-medial commissural position. The green lines represent the annulus and the coaptation line. The yellow and orange dots depict the multitude of x, y, and z coordinates used to define the individual subareas and the larger coaptation zone. The Annals of Thoracic Surgery 2014 97, 1998-2004DOI: (10.1016/j.athoracsur.2014.01.015) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Three-dimensional model of a mitral valve demonstrates the calculation of the total valve area used to produce the dimensionless coaptation zone index. (A) The exposed leaflet area of the anterior mitral valve leaflet and (B) the exposed leaflet area of the posterior mitral valve leaflet, both at end systole, are illustrated. (A = anterior; AL = anterolateral commissure; Ao = aortic valve; P = posterior; PM = posteromedial commissure.) The Annals of Thoracic Surgery 2014 97, 1998-2004DOI: (10.1016/j.athoracsur.2014.01.015) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Association between the three-dimensional (3D) coaptation zone index and the severity grade of functional mitral regurgitation as assessed with analysis of variance (r2 = 0.75, p < 0.0001). The horizontal line in the middle of each box indicates the median; the top and bottom borders of the box mark the 75th and 25th percentiles, respectively; and the whiskers mark the 90th and 10th percentiles. (B) Association between the two-dimensional vena contracta width and the 3D coaptation zone index using a scatter plot and a best fit line as assessed with Pearson correlation (r = –0.74, p < 0.0003). The Annals of Thoracic Surgery 2014 97, 1998-2004DOI: (10.1016/j.athoracsur.2014.01.015) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions