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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: 65:1025-1031. J Heart Valve Dis 1995; 4:70-75.

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Transesophageal ECHO and the Mitral Valve


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slide5

Anatomic Classification Schema:

MitralValve Segments

Duran Classification

Ann Thorac Surg1998: 65:1025-1031.

J Heart Valve Dis 1995; 4:70-75.

Cardiol Clin. 2000; 18: 731-50.

slide10

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

Assessment of the Mitral Valve

JASE. 2003; 16: 61 – 66.

slide11

Mid-esophageal Views

(Transducer @ 0°)

Anesth Analg 1999;88:1205–12.

slide12

Four Chamber Views:

Isolating Mitral Valve Leaflet Segments

Cardiol Clin. 2000; 18: 731-50.

slide13

P2/P3

A2/A3

Four Chamber View

Crit Care Clin. 1996; 12: 321-81.

slide14

Mid-esophageal Views

(Transducer @ ~60°)

Anesth Analg 1999;88:1205–12.

slide15

Two Chamber Views:

Isolating Mitral Valve Leaflet Segments

Cardiol Clin. 2000; 18: 731-50.

slide16

P3

P2

P1

Two Chamber: Posterior View

Crit Care Clin. 1996; 12: 321-81.

slide17

P2

A2

Apical Long Axis View

Cardiol Clin. 2000; 18: 731-50.

slide18

Flail lateral scallop

Commissural View

JASE. 2003; 16: 61 – 66.

slide19

Flail medial scallop

Commissural View

JASE. 2003; 16: 61 – 66.

slide20

Transgastric Views

(Transducer @ 0°)

Anesth Analg 1999;88:1205–12.

slide21

Transgastric Long-axis View:

Visualization of the Papillary Muscles

Posteromedial

Papillary Muscle

Anterolateral

Papillary Muscle

Cardiol Clin. 2000; 18: 731-50.

slide22

Affected Leaflet

n

TEE diagnosis

Accuracy (%)

Anterior

6

6

100

Posterior

45

45

100

Bileaflet

3

1

33

Total

54

52

96

Accuracy of Transesophageal Echocardiographic (TEE)

Diagnosis in Determination of Affected Flail Leaflet

JASE.1998;11:966-71.

slide23

Affected Scallop Identified

n

Sensitivity (%)

Specificity (%)

Overall accuracy (%)

Middle (P2)

34

82

82

82

Lateral (P1)

7

100

89

90

Medial (P3)

10

50*

100

90

Total

51

78

92

88

Accuracy of Transesophageal Echocardiographic

Diagnosis of Affected Scallop Among Patients

With Posterior Flail Mitral Leaflet

JASE.1998;11:966-71.

slide24
Diagnostic Accuracy of Identification of Mitral Regurgitant Defects by Correlation withSurgical Findings

Defect Location Sensitivity (%) Specificity (%)

A1 97.1 98.3

A2 96.3 97.7

A3 98.5 97.9

P1 98.7 97.8

P2 99.6 92.4

P3 94.7 96.9

JASE. 2003; 16: 61 – 66.

slide25

Frequency of Valve Repair According to Location of Flail Leaflet and Scallop

Location

n

Repaired (n)

Repaired (%)

Posterior

45

30

67

   Middle

28

20

71

   Medial

5

5

100

   Lateral

5

3

60

   Multiple

4

1

25

   Not specified

3

1

33

Anterior

6

0

0

Bileaflet

3

2

67

Total

54

32

59

JASE.1998;11:966-71.

slide26
Pathologic Anatomic Changes to Assess During Transesophageal Echocardiographic Examination of the Mitral Valve
  • Calcification
  • Dilatation
  • Perivalvular Leak

(Prosthetic Valves)

Mitral Annulus

slide27

Midesophageal View of the Mitral Valve

Mitral Annular Calcification

Cardiol Clin. 2000; 18: 731-50.

mitral leaflets
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)
slide31

Apical Displacement of

Mitral Coaptation

(aka “Tenting”)

Circulation. 2000;102:1400.

slide32

Mitral Valve Prolapse

Diagnostic Criteria

  • Classic MVP
    • Displacement > 2 mm
    • Thickness ≥ 5 mm
  • Non-Classic MVP
    • Displacement > 2 mm

Cardiol Clin. 2000; 18: 731-50.

chordae
Chordae
  • Chordal systolic anterior motion
  • Thickening
  • Fusion
  • Calcification
  • Elongation
  • Rupture
slide35

Posterior Mitral Leaflet Prolapse

(Flail Posterior Leaflet)

Ruptured Chord

Cardiol Clin. 2000; 18: 731-50.

papillary muscles
Papillary Muscles
  • Ruptured papillary muscle
  • LV-papillary muscle dysfunction
slide37

Subtotal Ruptured Papillary Muscle

Cardiol Clin. 2000; 18: 731-50.

miscellaneous
Miscellaneous Findings

Left atrial enlargement

Atrial appendage thrombus,

LV dilation/aneurysm,

TV annulus dilation,

tricuspid regurgitation,

right ventricular enlargement

Systolic anterior motion

Mitral valve repair

Narrow LVOT

Small LV diameter

Increased anterior and posterior leaflet area

Miscellaneous
slide39

And After

Before

Post-Operative Assessment:

Residual Mitral Regurgitation

Am Heart J. 1996; 131: 162-76.

slide40

And After

Before

Post-Operative Assessment:

Residual Mitral Regurgitation

Cardiol Clin. 1998; 16: 477-89.

slide41

Post-Operative Assessment:

Exclude Systolic Anterior Motion of the Mitral Valve

Crit Care Clin. 1996; 12: 321-81.

slide42

Post-Operative Assessment:

Exclude Mitral Stenosis

Crit Care Clin. 1996; 12: 321-81.