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 1/3rd 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.

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.

12. 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.

13. 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.

15. 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.

16. 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.

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

18. 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.

19. 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

21. TEE & Leaflet orientation

22. ORIENTATION OF MITRAL LEAFLET
SCALLOPS

23. 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

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

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

26. SUPRAMITRAL RING LA MYXOMA

27. 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

28. 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.

29. 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.

30. 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

31. 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

32. 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.

33. 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.

34. ASSESSMENT OF MITRAL
REGURGITATION

35. ETIOLOGY

36. 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.

37. 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.

38. 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

39. 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.

40. 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.

41. 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.

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

43. 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.

44. Systolic blunting in pulmonary PWD

45. 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.

46. 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.

47. 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

48. 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.

49. 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.

50. SAM

51. RESIDUAL/PARAVALVULAR LEAKS

52. 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.

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

54. 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 .

55. Fluttering AML !!!

56. THANK YOU !!!!!