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THIS IS A BRIEF GUIDELINE TO ASSESS THE MITRAL VALVE BY TEE. HOPE IT WILL HELP YOU.
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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 !!!!!