Assessment of mitral valve

Dr. Abhijeet B Shitole.Dr . Rajnish Garg.Dr. Muralidhar K.

Narayana Health, Bangalore.

Anatomy of mitral valveMitral valve apparatus :- Mitral valve Annulus. Mitral leaflets with

commissures. Chordae tendinae. Papillary muscles. Supporting LV Wall. Altogether called as

mitral valve complex. Resembles the Bishops

“mitre” .

Mitral valve Annulus

Annulus :- fibroelastic ring. Encircles the valve orifice in cone like manner.

Annulus is elliptical in shape in systole & circular in diastole.

Mitral leaflets & commissures

AML :- Anterior mitral leaflet.

triangular in shape. Is in continuity of aortic

annulus. Encircles on 1/3rd of

annulus, but covers 2/3rd of valve orifice area.

PML :- posterior mitral leaflet.

Quadrangular in shape. Occupies 2/3rd of the

annulus, but covers only 1/3rd of the valve area.

Carpentiers nomenclature

Anterior leaflet is termed as “A”.

A1 scallop:- lateral third. A2 scallop:- middle third. A3 scallop:- medial third.Posterior leaflet is termed

as “P”. P1 scallop:- lateral third. P2 scallop:- middle third. P3 scallop:- medial third.

Chordae tendinaeThese are fine fibrous

strings radiating from the papillary muscles and attach to corresponding halves of the anterior and posterior mitral leaflets.

Chordae arising from the APM, attach to lateral half of A2,A1,AC,P1,lateral half of P2.

Chordae arising from PPM, attach to medial half of A2, A3, PC, P3, medial half of P2.

Papillary Muscles

Located at the junction of the apical (lower) third & middle third of the left ventricle.

2 in number.APM :- antero-lateral

wall of LV.PPM :- postero-medial

wall of LV.

APM :- has dual blood supply.

OM of CX.D1 of LAD.PPM:- has single blood

supply.Last OM/ RCA.

TEE VIEWS MID ESOPHAGEAL VIEWS :- Midesophageal 4 chamber

view. Midesophageal mitral

commissural view. Midesophageal 2 chamber

view. Midesophageal long axis

view. Midesophageal 5 chamber

view.

TRANSGASTRIC VIEWS :- Transgastric basal short axis

view. Transgastric 2 chamber view.FOR ASSESSMENT OF

TRICUSPID VALVE :- Midesophageal four

chamber view. Midesophageal RV inflow

outflow view. Hepatic venous Doppler.

Midesophageal 4 chamber view Obtained at Multiplane angle

of 0 -20 degrees and probe tip depth of 30-40 cms.

A2,P2 scallops. Leaflet morphology. Color Doppler studies. Pulmonary venous PW

Doppler. LA Size. LA clot, LA tumour. Spontaneous echo contrast. Tricuspid valve evaluation.

Midesophageal mitral commissural view

Obtained at Multiplane angle of 60-70 degrees and probe tip depth of 30-40 cms.

P1,A2,P3 scallops.Best view for leaflet

calcification, restriction & motion.

Mitral valve annulus. LAA clot. Leaflet morphology.Commissural fusion. “Seagull” wings.

Midesophageal 2 chamber view.

Obtained at Multiplane angle of 90 degrees & probe tip depth of 30-40 cm.

Evaluation of A3,P3 scallops.

Color Doppler studies.Pulmonary venous PW

DopplerMitral inflow velocities. LAA.Pulmonary venous PWD.

Midesophageal long axis view Obtained at Multiplane angle

of 120-160 degrees & Probe tip depth of 30-40 cms .

A2,P2 scallops. Measurement of annulus. Vena contracta width

measurement. AML,PML height

measurement PISA (MS/MR) MITRAL INFLOW VELOCITIES MITRAL PHT SAM.

AML & PML HEIGHT MITRAL ANNULUS

AML/PML(HEIGHT) :- <1.1 SUGGEST PROPANSITY OF

SAM

Transgastric basal short axis Obtained at Multiplane angle

of 0-20degrees and Probe tip depth of 40 -45 to 25 cms.

Ante flexion. “Fish mouth” mitral valve in

short axis. A1,A2,A3 & P1,P2,P3 scallops

of mitral leaflets. MVA by planimetry. Tricuspid valve evaluation. MR evaluation.

Transgastric 2 chamber view.

Obtained at Multiplane probe angle of 90 degrees and Probe tip depth at 40-45 cms.

Best view to assess Subvalvular apparatus

Chordal rupture.Subvalvular fusion.Papillary muscles.MVP

TEE & Leaflet orientation

ORIENTATION OF MITRAL LEAFLET SCALLOPS

Mitral StenosisETIOLOGY MECHANISM APPEARANCE

Rheumatic heart disease Leaflets and chordal tendon fibrosis & thickening, commissural fusion

Thickened chordal tendons and leaflets, restricted leaflet motion with diastolic doming. Calcium deposition on leaflets.

LA myxoma Obstruction to inflow Large mass obstructing MV inflow

Mitral annular calcification

Calcium deposits Calcium deposition from annulus to leaflets

Parachute mitral valve Restricted leaflet opening causing blood flow through the intrachordal spaces

Chordal insertion to the single papillary muscle

RHEUMATIC MITRAL STENOSIS.

HOCKEY STIC APPERENCE OF AML. RESTRICTED OPENING OF MV

RHD

THICKENED MITRAL VALVE LEAFLETS A2,P2 SCALLOPS

RUPTURED CHORDAE RESULTING IN COBRA HEAD APPERENCE OF A2 SCALLOP

SUPRAMITRAL RING LA MYXOMA

MITRAL STENOSIS SEVERITY METHOD NORMAL MILD MODERATE SEVERE

Valve area (cm2) 4-6 1.5-2.5 1.0-1.5 <1.0

Mean gradient(mmHg) no <5 6-10 >10

Pressure half time (msec)

40-70 70-150 150-200 >220

Peak velocity(m/s) <1.0 1.0-1.5 1.5-3.0 >3.0

Proximal flow convergence @ aliasing velocity 60m/s

absent absent Present usually

Always present

MITRAL VALVE AREA

PLANIMETRYPRESSURE HALF TIMEDECELERATION TIMECONTINUITY EQUATIONPISA (PROXIMAL

ISOVELOCITY SURFACE AREA.

MVA :- NORMAL -4-6cm2 MILD- 1.5-2.5 cm2 MODERATE-1-1.5 cm2 SEVERE - <1.0 cm2.

Planimetry

TG basal short axisFreeze the frame when

MV is fully open.Measured at the level

of leaflet tips.Gain setting should be

optimal.Underestimates MVA in

post valvuloplasty.

PRESSURE GRADIENT

• P1-p2=4v2.• Me 4cv• Me lax.• Mean gradient is calculated

by AUC of diastolic spectral profile curve .

• Mean gradient(mmHg)• Mild :- <5• Moderate :- 6-10• Severe :- >10

Pressure half timeIt is the time taken for the diastolic

pressure difference between LA and LV to decrease to half of the initial value.MVA = 220/Pressure half time (msec)

Normal :- 40-70. Mild MS :- 70-150Moderate MS :- 150-200. Severe MS :-

>220.

Applied only in MS. Its accuracy is questionable in :- AR. altered LA and LV compliance.High cardiac output statesAV blockPost valvuloplasty, Prosthetic mitral valve

Deceleration time

It is the time taken for the diastolic pressure difference between LA and LV to decrease to the initial value.

MVA (cm2)= 759/DT.PHT=0.29 X DT.

PISA• FLOW CONVERGENCE

r :- PISA radius.Alpha :- angle subtended by mitral leafletsV a :- aliasing velocity.V p :- peak mitral inflow velocityCan be used in presence of AR, MR.

ASSESSMENT OF MITRAL REGURGITATION

ETIOLOGY

MITRAL VALVE PROLAPSEPROLAPSE :- refers to the

excursion of the leaflet tip above the mitral annular plane.

FLAIL:- leaflet edge floats freely in LA as a result of one or more chordal rupture.

BILLOWING:- the copatation point is below annular plane but leaflets project in LA.

ISCHEMIC MR

MECHANISMS :- Alteration in mitral

leaflet configuration. Depressed LV function. Increased tethering

forces. Papillary muscle

displacement Global/regional LV

dilatation.

Decreased closing forces

Reduced LV contractility Papillary muscle

dyssychrony. LV dyssychrony. Reduced annular

contraction.

GRADING MITRAL REGURGITATIONMILD MODERATE SEVERE

SPECIFIC SIGNS OF SEVERITY

Small central jet <4cm2 or <20% of LA area.

Moderate central jet >20% but <40 % of LA area.

Large central MR jet involving >40% LA area. Wall impinging jet.

Vena contracta <0.3cm.No/Minimal flow convergence

Vena contracta >0.3 but <0.7 cm.Flow convergence.

Vena contracta > 0.7cm.Large flow convergence

SUPPORTIVE SIGNS

Systolic dominance in pulmonary venous PWD.

Systolic blunting in pulmonary venous PWD

Systolic flow reversal in pulmonary venous PWD.

A wave dominance in mitral inflow velocities

E wave dominance in mitral inflow velocity

Soft density parabolic CWD of MR Doppler signals

Dense triangular CWD of MR Doppler signals

Severity of MR

QUANTITIVE PARAMETERS MILD MODERATE SEVERE

REGURGITANT VOL (ML/BEAT) <30 30-59 >60

REGURGITANT FRACTION (%) <30 30-49 >50

EFFECTIVE REGURGITANT ORIFICE AREA (EORA) cm2

<0.2 0.2-0.39 >0.4.

Organic MR is considered severe if EROA> 40 mm2 and RV is >60ml.

In ischemic MR EROA of >20 mm2 and RV of >30 ml is considered severe MR.

MR JET AREA VENA CONTRACTA

Optimize image ,adjust color gain, reduce sector. zoom. NL:- 40-70 cm/s. Two orthogonal planes. Not additive for multiple jets.

Sector depth 12 cms.NL :- 40-60 cm/s.Obtain maximum jet width.Visualize LA .Wall Hugging jets and eccentric posteromedial jets cant be mapped in 2D.

MR CWD.

High density signals suggests severe MR.

MR envelop velocity 5m/s.

Triangular Doppler envelope with an early peak and a truncated notch suggest elevated LA pressures and severe MR.

MR PISA.

As mitral annulus is non planar, the PISA may be ellipsoidal and

hemispherical assumption can underestimate PISA

Pulmonary venous Doppler.

Evaluation of MR.S,D,A Waves.Normally S wave is

dominant.With increasing severity

of MR, S wave may show blunting.

Severe MR, there is reversal of the S wave.

Systolic blunting in pulmonary PWD

MITRAL INFLOW PATTERNPEAK E WAVE VELOCITY

In absence of MS, A PEAK E WAVE VELOCITY OF > 1.5 m/s suggest severe MR. CONVERSLY, dominant A wave rules out severe MR.

ASSESSMENT OF DEFORMATION OF MITRAL APPARATUS

Tenting height :- height of the copatation point above the annular plane.

Tenting area:- triangular area bound above by leaflets and below by annular plane.

Copatation length:- length of the copatation of AML & PML.

Annular dimensions :- Size of the annulus.

TENTING HEIGHT/ANNULAR DIMENTIONS

RECURRENCE OF MR AFTER ANNULOPLSTY :-Tenting height >1cm. Tenting area>2.5cm2.

Leaflet angle of PML >45degrees.Annular size :- >37mm.

Systolic sphericity index :->0.7

Goals of post CPB TEE Examination

• Evaluate competency of mitral valve.

• Assisting de-airing of heart.

• Detect complications of surgery.

• Presence of paravalvular leak.

• Determination of Presence and severity of SAM.

• Determination of valve stenosis.

• Determine circumflex artery injury.

• Determine aortic valve competence.

Systolic anterior motion (SAM)

• 1-9% of MV repairs.• Predictors of SAM :-• C SEPT DISTANCE :- <2.5

CM.• AML/PML HEIGHT :- <1.1.• Dynamic obstruction.• Medical :-• Improve Preload,

reduction in inotropy, reduction in HR.

SAM

RESIDUAL/PARAVALVULAR LEAKS

TRICUSPID VALVEMid esophageal RV inflow

outflow view @ 60-70 degrees.

TR.PASP.Annulus. M mode TAPSE.TG view of Hepatic vein

Doppler. Diastolic flow reversal in

hepatic venous Doppler profile suggest severe TR.

Tricuspid valve

Midesophageal four chamber view @ Multiplane angle of 0-20 degrees.

Rotate probe slightly to right.

Assess TR.LEAFLET MORPHOLOGYAnnulus.

Aortic valve

Midesophageal AV Short Axis.

At Multiplane angle 40-60 degrees

Leaflet perforation.Co optation of aortic

leaflets..Perforation of leaflet

warrants AV repair .

Fluttering AML !!!

THANK YOU !!!!!