1. Quantitative Real-Time Three-Dimensional Echocardiography Provides New Insight into the Mechanisms of Mitral Valve Regurgitation Post-Repair of Atrioventricular Septal Defect 
Ken Takahashi, MD, Andrew S. Mackie, MD, SM, Richard Thompson, PhD, Ghassan Al-Naami, MD, Akio Inage, MD, Ivan M. Rebeyka, MD, David B. Ross, MD, Nee S. Khoo, MBChB, Timothy Colen, MBBS, Jeffrey F. Smallhorn, MBBS 
Journal of the American Society of Echocardiography 
Volume 25, Issue 11, Pages (November 2012)
DOI: /j.echo
Copyright © 2012 American Society of Echocardiography Terms and Conditions

2. Figure 1
Schematic diagram of the comparison between a normal mitral valve (top) and the left-sided inflow valve after repair of an AVSD. Note the smaller ML in the diagram of the AVSD, as well as the different position of the papillary muscles. AO, Aorta.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions

3. Figure 2
(A,B) Annular coordinates as indicated by the black dots in four-chamber and two-chamber views. The white dot represents the tip of the anterior papillary muscle. The red dots are the coordinates of the leaflet seen in one individual plane. (D) Three-dimensional reconstruction of the same case. (C) En face view of the reconstructed annulus as indicated by the green outer line, with the inner line indicating the line of leaflet coaptation. The green dots represent some of the 15 planes at 24° to one another. The red dots represent the coordinates from the leaflets in one of these 15 planes. APM, Anterolateral papillary muscle; LA, left atrium; LV, left ventricle; PPM, posteromedial papillary muscle.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions

4. Figure 3
(A) Posteromedial papillary muscle (PPM) (red) and anterolateral papillary muscle (APM) (green) measurements. The {x, y, z} coordinates of the chords, papillary muscles, and their attachment to the leaflets were identified within the RT3D data sets (Figure 2). The subvalvar apparatus variables derived are illustrated in the diagram. (B) Reconstructed coordinates obtained in (a) in a 3D model seen in different views: above, from the side, and in a 3D model. (C) Two volume-rendered images showing examples of papillary muscle position. (Left) A patient in whom the APM angle with the annulus was normal (72°) without lateral displacement. (Right) A patient in whom the APM had a more acute angle with the mitral valve annulus (64°) and was displaced laterally. BC, Base to center of left ventricular distance; CL, chordal length; LV, left ventricular length in diastole; PMH, papillary muscle height; PML, papillary muscle length; TC, tip of papillary muscle to center of left ventricular distance.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions

5. Figure 4
Image demonstrating the saddle shape of the left atrioventricular annulus and the calculation of the bending angle by a best fit (nonnegative least squares) plane that was fit to the annular points in each of the two sections. LA, Left atrium; LV, left ventricle.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions

6. Figure 5
(Top left) A patient from group 1 with mild regurgitation and (top middle) a patient from group 2 with prolapse in the region of the superior leaflet and ML. (Top right) Tethering in the inferior leaflet and ML region from a patient in group 2. The tethering in this example is most likely related to the fact that the IBL is often attached by short chordae as it bridges the interventricular septum. The red area represents the area above the least fit annular plane (closest to the left atrium) and the blue below, closest to the apex of the left ventricle. The black arrow represents the septal region of the left atrioventricular valve. ANT, Anterior; POST, posterior.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions

7. Figure 6
RT3D cropped images (from QLAB) of an AVSD (right) and a mitral valve (left) seen from a left atrial view to demonstrate the shape of the annulus and the division of the leaflets used to assess regional prolapse and tethering. The top two images were taken during late diastole and thus do not demonstrate all of the leaflets but best demonstrate the commissure regions shape of the annulus and the residual cleft (indicated by the black arrow in the top right panel). The bottom two images were taken in systole and show the leaflets. The black dots indicate where the papillary muscles are located in the left ventricle. The circumference of the mitral valve was divided into four quadrants, and regional prolapse or tethering was evaluated in each of the four quadrants. AL, Anterior leaflet; AO, aorta; PL, posterior leaflet; RAVV, right atrioventricular valve; TV, tricuspid valve.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions

8. Figure 7
These images demonstrate how the residual cleft measurements were made. (A) The red plane running parallel along the right side of the interventricular septum (IVS). The surface of the right side of the IVS is seen in (B). (C) En face view of the left atrioventricular valve seen in the blue plane and shows the green plane running through the IVS at the level of the sutured and unsutured component of the cleft. The two yellow lines represent how the measurements were made of the sutured (D1) and unsutured (D2) cleft. (D) RT3D cropped image in the same orientation as (C). Note the small residual cleft between the SBL and IBL. AO, Aorta; D1, distance between IVS and apex of cleft; D2, distance from apex of cleft to free edge; LA, left atrium; LAVV, left atrioventricular valve; LV, left ventricle; MV, mitral valve; RAVV, right atrioventricular valve; RV, right ventricle; TV, tricuspid valve.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions

9. Figure 8
(Top left, top right) Bland-Altman plot of prolapsed volume: difference versus mean and percentage difference versus mean. (Bottom left, bottom right) Bland-Altman plot of tethered volume: difference versus mean and percentage difference versus mean.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions

10. Figure 9
Bland-Altman plot of papillary muscle angle, percentage difference versus mean.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions

11. Figure 10
Interobserver analysis of the mitral valve after AVSD repair in subject 10. Observer 1 analysis shown in the top three images demonstrates the mathematical best-fit plane for mitral annular plane, leaflet surface, and prolapsed and tethered volumes respectively. Observer 2 analysis is shown in the lower images. Annular orientation is seen in the labeling. The red areas represent the mitral valve above the annular plane, while the blue areas are below the annular plane. Note the similarity in the two sets of images with regard to annular shape and regions of prolapse and tethering.
Journal of the American Society of Echocardiography  , DOI: ( /j.echo )
Copyright © 2012 American Society of Echocardiography Terms and Conditions