Tee

Transesophageal ECHO and the Mitral Valve

Anesth Analg 1999;88:1205–12.

Am Heart J. 2000;139: 378-87.

Fibrous Skeleton Of The HeartFibrous Skeleton Of The Heart

Ann Thorac Surg 1998: 65:1025-1031.J Heart Valve Dis 1995; 4:70-75.Cardiol Clin. 2000; 18: 731-50.

Anatomic Classification Schema:Mitral Valve Segments Duran Classification

JASE. 2003; 16: 61 – 66.

•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 ValveAssessment of the Mitral Valve

JASE. 2003; 16: 61 – 66.

Anesth Analg 1999;88:1205–12.

Mid-esophageal Views(Transducer @ 0°)

Cardiol Clin. 2000; 18: 731-50.

Four Chamber Views: Four Chamber Views: Isolating Mitral Valve Leaflet SegmentsIsolating Mitral Valve Leaflet Segments

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

Four Chamber ViewFour Chamber View

Anesth Analg 1999;88:1205–12.

Mid-esophageal Views(Transducer @ ~60°)

Cardiol Clin. 2000; 18: 731-50.

Two Chamber Views: Two Chamber Views: Isolating Mitral Valve Leaflet SegmentsIsolating Mitral Valve Leaflet Segments

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

Two Chamber: Posterior ViewTwo Chamber: Posterior View

Apical Long Axis ViewApical Long Axis View

Cardiol Clin. 2000; 18: 731-50.

Commissural ViewCommissural View

JASE. 2003; 16: 61 – 66.

Flail lateral scallop

Commissural ViewCommissural View

Flail medial scallop

JASE. 2003; 16: 61 – 66.

Anesth Analg 1999;88:1205–12.

Transgastric Views(Transducer @ 0°)

Cardiol Clin. 2000; 18: 731-50.

Transgastric Long-axis View:Transgastric Long-axis View:Visualization of the Papillary MusclesVisualization of the Papillary Muscles

Posteromedial Papillary Muscle

Anterolateral Papillary Muscle

JASE.1998;11:966-71.

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

Affected Leaflet n TEE diagnosis Accuracy (%)

Anterior 6 6 100

Posterior 45 45 100

Bileaflet 3 1 33

TotalTotal 5454 5252 96

JASE.1998;11:966-71.

Accuracy of Transesophageal Echocardiographic Diagnosis of Affected Scallop Among Patients

With Posterior Flail Mitral Leaflet

Affected Scallop Affected Scallop IdentifiedIdentified nn

Sensitivity Sensitivity (%)(%)

Specificity Specificity (%)(%)

Overall Overall accuracy (%)accuracy (%)

Middle (P2) 34 82 82 82

Lateral (P1) 7 100 89 90

Medial (P3) 10 50* 100 90

TotalTotal 5151 7878 9292 8888

JASE. 2003; 16: 61 – 66.

Diagnostic Accuracy of Identification of Diagnostic Accuracy of Identification of Mitral Regurgitant Defects by Correlation withMitral Regurgitant Defects by Correlation with

Surgical FindingsSurgical Findings

Defect LocationDefect Location Sensitivity (%)Sensitivity (%) Specificity (%)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

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

JASE.1998;11:966-71.

LocationLocation nn Repaired (n)Repaired (n) Repaired (%)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

TotalTotal 5454 3232 5959

Pathologic Anatomic Changes to Assess During Transesophageal Echocardiographic

Examination of the Mitral Valve

• Calcification

• Dilatation

• Perivalvular Leak

(Prosthetic Valves)

Mitral Annulus

Cardiol Clin. 2000; 18: 731-50.

Midesophageal View of the Mitral Valve Midesophageal View of the Mitral Valve Mitral Annular Calcification Mitral Annular Calcification

Circulation. 2000;101:695.

Mitral LeafletsMitral 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)



Apical Displacement of Mitral Coaptation(aka “Tenting”)

Cardiol Clin. 2000; 18: 731-50.

Mitral Valve ProlapseMitral Valve Prolapse

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

Non-Classic MVP•Displacement > 2 mm

Diagnostic Criteria

Atrial Views of Prolapse of the Atrial Views of Prolapse of the Anterior Mitral Valve Leaflet Anterior Mitral Valve Leaflet

ChordaeChordae

• Chordal systolic anterior motion

• Thickening

• Fusion

• Calcification

• Elongation

• Rupture

Cardiol Clin. 2000; 18: 731-50.

Posterior Mitral Leaflet Prolapse Posterior Mitral Leaflet Prolapse (Flail Posterior Leaflet)(Flail Posterior Leaflet)

Ruptured Chord Ruptured Chord

Papillary MusclesPapillary Muscles

• Ruptured papillary muscle

• LV-papillary muscle dysfunction

Cardiol Clin. 2000; 18: 731-50.

Subtotal Ruptured Papillary Muscle Subtotal Ruptured Papillary Muscle

MiscellaneousMiscellaneous

Miscellaneous FindingsMiscellaneous Findings

• Left atrial enlargement

• Atrial appendage thrombus,

• LV dilation/aneurysm,

• TV annulus dilation,

• tricuspid regurgitation,

• right ventricular enlargement

Systolic anterior motion Systolic anterior motion

• Mitral valve repair• Narrow LVOT

• Small LV diameter

• Increased anterior and posterior leaflet area

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

Post-Operative Assessment:Post-Operative Assessment:Residual Mitral RegurgitationResidual Mitral Regurgitation

BeforeBefore

And After

Cardiol Clin. 1998; 16: 477-89.

Post-Operative Assessment:Post-Operative Assessment:Residual Mitral RegurgitationResidual Mitral Regurgitation

BeforeBefore

And After

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

Post-Operative Assessment:Post-Operative Assessment:Exclude Systolic Anterior Motion of the Mitral ValveExclude Systolic Anterior Motion of the Mitral Valve

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

Post-Operative Assessment:Post-Operative Assessment:Exclude Mitral StenosisExclude Mitral Stenosis

Anesth Analg 1999;88:1205–12.

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