Turk Kardiyol Dern Ars. 2025; 53(2): 107-112 | DOI: 10.5543/tkda.2024.50328

The Role of Clefts and Cleft-Like Indentations in Mitral Regurgitation Etiology Detected by Three-Dimensional Echocardiography in Patients with Hypertrophic Cardiomyopathy

Ceren Yıldırım Karakan¹, Arda Güler², İbrahim Halil Tanboğa³, Ali Birant², Begum Uygur², Hicaz Zencirkiran Agus², Seda Tükenmez Karakurt², Aysel Türkvatan Cansever⁴, Mehmet Ertürk², Gamze Babur Güler^2
1Department of Cardiology, Ağrı Training and Research Hospital, Ağrı, Türkiye
²Department of Cardiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Türkiye
³Department of Biostatistics and Cardiology, Nisantasi University Medical School, Istanbul, Türkiye
⁴Department of Radiology, University of Health Sciences, Istanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Türkiye

OBJECTIVE
Mitral regurgitation (MR) is a critical determinant in patients with hypertrophic cardiomyopathy (HCM). Three-dimensional (3D) echocardiography has transformed the imaging of the mitral valve by enabling real-time, direct visualization. This study aims to determine the frequency of clefts and cleft-like indentations (CLIs) and assess their contribution to MR in HCM patients.

METHOD
A total of 50 patients with HCM and moderate or severe MR who underwent 3D transesophageal echocardiography (TEE) were enrolled. For the control group, 200 patients with moderate or severe MR but without HCM were selected. The two groups were compared in terms of demographic characteristics, echocardiographic findings, and cardiac magnetic resonance imaging results.

RESULTS
Patients with HCM were younger and had higher regurgitant volumes and effective regurgitant orifice areas compared to the control group. Clefts or CLIs were present in 14 patients (28%) in the HCM group compared to 31 patients (15.6%) in the control group (P = 0.041). Evaluation of MR jet direction in relation to the presence of clefts or CLIs revealed a significant association between anteriorly directed jets and the presence of clefts (P = 0.003).

CONCLUSION
In this study, the frequency of clefts or CLIs was higher in patients with HCM compared to the control group. Clefts influence the direction of MR jets (anteriorly), whereas CLIs do not. 3D-TEE can aid in the differential diagnosis of HCM in patients with anteriorly directed MR jets. However, using 3D-TEE to identify CLIs alone has no significant impact on the management of MR.

Keywords: Cleft-like indentation, cleft, hypertrophic cardiomyopathy, mitral regurgitation, three-dimensional transesophageal echocardiography

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