Transesophageal ECHO and the Mitral Valve
Anesth Analg 1999;88:1205–12.
Am Heart J. 2000;139: 378-87.
Fibrous Skeleton Of The Heart
Anatomic Classification Schema: Mitral Valve Segments
Duran Classification
Ann Thorac Surg 1998: 65:10251031. J Heart Valve Dis 1995; 4:70-75. Cardiol Clin. 2000; 18: 731-50.
JASE. 2003; 16: 61 – 66.
Assessment of the Mitral Valve
•Mid-esophageal 4C View
•A3 and A1
•Commisural View
•P3-A2-P1
•Two Chamber View
•P3-A1
•Long Axis View
•A2
•Transgastric Views (Short)
•Posteromedial commissure
•Anterolateral commissure
•Transgastric Views (Long)
•Chordae Tendinae •Papillary Muscle
JASE. 2003; 16: 61 – 66.
Mid-esophageal Views
(Transducer @ 0°)
Anesth Analg 1999;88:1205–12.
Four Chamber Views: Isolating Mitral Valve Leaflet Segments
Cardiol Clin. 2000; 18: 73150.
Four Chamber View
Crit Care Clin. 1996; 12: 321-81.
Mid-esophageal Views
(Transducer @ ~60°)
Anesth Analg 1999;88:1205–12.
Two Chamber Views: Isolating Mitral Valve Leaflet Segments
Cardiol Clin. 2000; 18: 73150.
Two Chamber: Posterior View
Crit Care Clin. 1996; 12: 321-81.
Apical Long Axis View
Cardiol Clin. 2000; 18: 73150.
Commissural View
Flail lateral scallop
JASE. 2003; 16: 61 – 66.
Commissural View
Flail medial scallop
JASE. 2003; 16: 61 – 66.
Transgastric Views
(Transducer @ 0°)
Anesth Analg 1999;88:1205–12.
Transgastric Long-axis View: Visualization of the Papillary Muscles
Posteromedial Papillary Muscle
Anterolateral Papillary Muscle
Cardiol Clin. 2000; 18: 73150.
Accuracy of Transesophageal Echocardiographic (TEE) Diagnosis in Determination of Affected Flail Leaflet
Affected Leaflet
Anterior
n
6
45
TEE diagnosis
6
45
Accuracy (%)
100
Posterior Bileaflet
100 33
3
1
52 Total 54
96
JASE.1998;11:966-71.
Accuracy of Transesophageal Echocardiographic Diagnosis of Affected Scallop Among Patients With Posterior Flail Mitral Leaflet
Affected Scallop Identified
Middle (P2) Lateral (P1) Medial (P3)
n
34 7 10
Sensitivity Specificity (%) (%)
82 100 50* 82 89 100
Overall accuracy (%)
82 90 90
Total
51
78
92
88
JASE.1998;11:966-71.
Diagnostic Accuracy of Identification of Mitral Regurgitant Defects by Correlation with Surgical Findings
Defect Location A1 A2 A3 P1 P2 P3 Sensitivity (%) 97.1 96.3 98.5 98.7 99.6 94.7 Specificity (%) 98.3 97.7 97.9 97.8 92.4 96.9
JASE. 2003; 16: 61 – 66.
Frequency of Valve Repair According to Location of Flail Leaflet and Scallop
Location
Posterior Middle Medial Lateral Multiple Not specified Anterior
n
45 28 5 5 4 3 6
Repaired (n)
30 20 5 3 1 1 0
Repaired (%)
67 71 100 60 25 33 0
Bileaflet
3
54
2
32
67
59
JASE.1998;11:966-71.
Total
Pathologic Anatomic Changes to Assess During Transesophageal Echocardiographic Examination of the Mitral Valve
Mitral Annulus
• Calcification • Dilatation • Perivalvular Leak (Prosthetic Valves)
Midesophageal View of the Mitral Valve Mitral Annular Calcification
Cardiol Clin. 2000; 18: 731-50.
Circulation. 2000;101:695.
Mitral Leaflets
Billowing leaflet • Coaptation level of anterior and posterior leaflet relative to annulus • Systolic anterior motion of anterior leaflet • Leaflet thickening • Leaflet fusion (rheumatic); doming of fused leaflets in diastole (mitral stenosis) • Calcification of leaflets • Prolapse • Deformation of leaflet free margin • Thickening, retraction of free margin into ventricle (curling under) • Endocarditis • Vegetation, leaflet aneurysm, perforation, associated regurgitant jet of aortic insufficiency hugging ventricular side of anterior leaflet (possible source of infectious seeding)
Circulation. 2000;102:1400.
Apical Displacement of Mitral Coaptation (aka “Tenting”)
Circulation. 2000;102:1400.
Mitral Valve Prolapse
Diagnostic Criteria
Classic MVP
•Displacement > 2 mm •Thickness ≥ 5 mm
Non-Classic MVP
•Displacement > 2 mm
Cardiol Clin. 2000; 18: 73150.
Atrial Views of Prolapse of the Anterior Mitral Valve Leaflet
Chordae
• Chordal systolic anterior motion • Thickening • Fusion • Calcification • Elongation • Rupture
Posterior Mitral Leaflet Prolapse (Flail Posterior Leaflet) Ruptured Chord
Cardiol Clin. 2000; 18: 73150.
Papillary Muscles
• Ruptured papillary muscle • LV-papillary muscle dysfunction
Subtotal Ruptured Papillary Muscle
Cardiol Clin. 2000; 18: 73150.
Miscellaneous
Systolic anterior motion Miscellaneous Findings
• • • •
Mitral valve repair Narrow LVOT Small LV diameter Increased anterior and posterior leaflet area
• Left atrial enlargement • Atrial appendage thrombus, • LV dilation/aneurysm, • TV annulus dilation, • tricuspid regurgitation, • right ventricular enlargement
Post-Operative Assessment: Residual Mitral Regurgitation
And After
Before
Am Heart J. 1996; 131: 162-76.
Post-Operative Assessment: Residual Mitral Regurgitation
And After
Before
Cardiol Clin. 1998; 16: 477-89.
Post-Operative Assessment: Exclude Systolic Anterior Motion of the Mitral Valve
Crit Care Clin. 1996; 12: 321-81.
Post-Operative Assessment: Exclude Mitral Stenosis
Crit Care Clin. 1996; 12: 321-81.
Anesth Analg 1999;88:1205–12.