Transesophageal Echocardiography of Mitral Valve

M. Arif Nugroho, MD

Introduction The mitral valve has triple function :

• Regulating blood to LV at low pressure, while preventing systolic backflow to LA

• Contributes LVOT formation on systolic phase

• Maintain normal size, geometry and function of Left Ventricle

Components of Mitral Valve Five Components : -Annulus -Leaflets -Commisures -Chordae tendinea -Papillary muscles

Mitral Valve Complex

Normal function of MV depends on complex interaction of MV components defined as “MV complex”

Mitral Valve Morphology

Mitral Annulus

- The mitral annulus constitutes the anatomical junction between the LV and LA, it serves as insertion site for the leaflet tissue

- Oval and saddle shaped

- it’s a fibrotic ring that consists of an anterior part and posterior part

- The annulus is deficient anteriorly at he level of the aorto - mitral curtain

Continued • The anterior portion of

mitral annulus is attached to the fibrous trigones and generally more developed than posterior ann.

• The aortic – mitral curtain is a fibrous structure that connects the anterior mitral annulus intimately with the aortic valve annulus (at the level of the left and NCC)

MITRAL LEAFLETS

Minor Axis

• An appropriate measurement of the minor axis (antero – posterior diameter) of the mitral annulus is performed at end systole during TTE in the apical long axis view ( 3 chamber view) or

• Its transesophageal equivalent, found at mid esophageal, with the probe tilted at 120-135o

The Major Axis (inter commisural diameter)

• The major axis is found at a bicommisural two chamber TEE view

• It is when the P1 – A2 – P3 mitral leaflet scallops is visualized

• Or in a midesophageal bicommisural view at 45’-60’

View of Minor and Major axises of MV

Anatomic Classification Scheme: Mitral Valve Segments & Duran Classification

Duran Classification

•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

TEE Assessment of the Mitral Valve

Cardiol Clin. 2000; 18: 731-50.

Four Chamber Views vs Two Chamber Views : Isolating Mitral Valve Leaflet Segments

Two Chamber Views: ↓

↑ Four Chamber Views:

Mid-esophageal Views (Transducer @ 0°)

Four Chamber View

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

Two Chamber: Posterior View

Apical Long Axis View

Cardiol Clin. 2000; 18: 731-50.

Cardiol Clin. 2000; 18: 731-50.

Transgastric Long-axis View: Visualization of the Papillary Muscles

Posteromedial Papillary Muscle

Anterolateral Papillary Muscle