Transesophageal ECHO and the Mitral Valve

Anesth Analg 1999;88:120512.

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. 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;88:120512.

Four Chamber Views: Isolating Mitral Valve Leaflet Segments

Cardiol Clin. 2000; 18: 731-50.

Four Chamber View

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

Mid-esophageal Views
(Transducer @ ~60)

Anesth Analg 1999;88:120512.

Two Chamber Views: Isolating Mitral Valve Leaflet Segments

Cardiol Clin. 2000; 18: 731-50.

Two Chamber: Posterior View

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

Apical Long Axis View

Cardiol Clin. 2000; 18: 731-50.

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;88:120512.

Transgastric Long-axis View: Visualization of the Papillary Muscles

Posteromedial Papillary Muscle

Anterolateral Papillary Muscle

Cardiol Clin. 2000; 18: 731-50.

Accuracy of Transesophageal Echocardiographic (TEE) Diagnosis in Determination of Affected Flail Leaflet

Affected Leaflet
Anterior Posterior Bileaflet

n
6
45

TEE diagnosis
6
45

Accuracy (%)
100 100 33

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*

Overall accuracy (%)

82
90 90

82
89 100

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 Sensitivity (%) Specificity (%)

A1 A2 A3 P1 P2 P3

97.1 96.3 98.5 98.7 99.6 94.7

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 Bileaflet

n
45 28 5 5 4 3 6 3 54

Repaired (n)
30 20 5 3 1 1 0 2 32

Repaired (%)
67 71 100 60 25 33 0 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: 731-50.

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: 731-50.

Papillary Muscles
Ruptured papillary muscle LV-papillary muscle dysfunction

Subtotal Ruptured Papillary Muscle

Cardiol Clin. 2000; 18: 731-50.

Miscellaneous
Systolic anterior motion Mitral valve repair Narrow LVOT Small LV diameter Increased anterior and posterior leaflet area Miscellaneous Findings 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;88:120512.