Assessment of mitral valve by TEE

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

1. Assessment of mitral valve Dr. Abhijeet B Shitole . Dr . Rajnish Garg . Dr. Muralidhar K. Narayana Health, Bangalore.

2. Anatomy of mitral valve Mitral 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” .

3. Mitral valve Annulus Annulus :- fibroelastic ring. Encircles the valve orifice in cone like manner. Annulus is elliptical in shape in systole & circular in diastole.

4. Mitral leaflets & commissures AML :- Anterior mitral leaflet. triangular in shape. Is in continuity of aortic annulus. Encircles on 1/3 rd of annulus, but covers 2/3 rd of valve orifice area. PML :- posterior mitral leaflet. Quadrangular in shape. Occupies 2/3 rd of the annulus, but covers only 1/3 rd of the valve area.

5. 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.

6. Chordae tendinae These 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.

7. 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.

8. 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.

9. 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.

10. 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.

11. 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 Doppler Mitral inflow velocities. LAA. Pulmonary venous PWD.

12. 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.

13. AML & PML HEIGHT MITRAL ANNULUS AML/PML(HEIGHT) :- < 1.1 SUGGEST PROPANSITY OF SAM

14. 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.

15. 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

16. TEE & Leaflet orientation

17. ORIENTATION OF MITRAL LEAFLET SCALLOPS

18. Mitral Stenosis ETIOLOGY 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

19. RHEUMATIC MITRAL STENOSIS. HOCKEY STIC APPERENCE OF AML. RESTRICTED OPENING OF MV

20. RHD THICKENED MITRAL VALVE LEAFLETS A2,P2 SCALLOPS RUPTURED CHORDAE RESULTING IN COBRA HEAD APPERENCE OF A2 SCALLOP

21. SUPRAMITRAL RING LA MYXOMA

22. 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

23. MITRAL VALVE AREA PLANIMETRY PRESSURE HALF TIME DECELERATION TIME CONTINUITY EQUATION PISA (PROXIMAL ISOVELOCITY SURFACE AREA. MVA :- NORMAL -4-6cm2 MILD- 1.5-2.5 cm2 MODERATE-1-1.5 cm2 SEVERE - <1.0 cm2.

24. Planimetry TG basal short axis Freeze the frame when MV is fully open. Measured at the level of leaflet tips. Gain setting should be optimal. Underestimates MVA in post valvuloplasty.

25. 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

26. Pressure half time It 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 :- 70-150 Moderate MS :- 150-200. Severe MS :->220. Applied only in MS. Its accuracy is questionable in :- AR. altered LA and LV compliance. High cardiac output states AV block Post valvuloplasty, Prosthetic mitral valve

27. 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.

28. PISA FLOW CONVERGENCE r :- PISA radius. Alpha :- angle subtended by mitral leaflets V a :- aliasing velocity. V p :- peak mitral inflow velocity Can be used in presence of AR, MR.

29. ASSESSMENT OF MITRAL REGURGITATION

30. ETIOLOGY

31. MITRAL VALVE PROLAPSE PROLAPSE :- 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.

32. 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.

33. GRADING MITRAL REGURGITATION MILD 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

34. 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.

35. 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.

36. 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.

37. MR PISA. As mitral annulus is non planar, the PISA may be ellipsoidal and hemispherical assumption can underestimate PISA

38. 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.

39. Systolic blunting in pulmonary PWD

40. MITRAL INFLOW PATTERN PEAK 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.

41. 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.

42. 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

43. 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.

44. 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.

45. SAM

46. RESIDUAL/PARAVALVULAR LEAKS

47. TRICUSPID VALVE Mid 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.

48. Tricuspid valve Midesophageal four chamber view @ Multiplane angle of 0-20 degrees. Rotate probe slightly to right. Assess TR. LEAFLET MORPHOLOGY Annulus.

49. 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 .

50. Fluttering AML !!!

51. THANK YOU !!!!!