Pre-Op Assessment of Mitral Valve Regurgitation
Pre-Op Assessment of Mitral Valve Regurgitation
Mitral regurgitation may develop when the leaflets or any other portion of the apparatus becomes abnormal. As the repair techniques for mitral valve disease evolved, so has the need for detailed and accurate imaging of the mitral valve prior to surgery in order to better define the mechanism of valve dysfunction and the severity of regurgitation. In patients with significant mitral valve disease who require surgical intervention, multiplane transesophageal echocardiogram (TEE) is invaluable for surgical planning. However, a comprehensive TEE in a patient with complex mitral valve disease requires great experience and skill. There is evidence to suggest that 3D echocardiography can overcome some of the limitations of 2D multiplane TEE and thus is crucial in evaluation of patients undergoing mitral valve surgery. In the following sections, we review some of the crucial 2D and 3D echo images necessary for evaluation of MR based on the Carpentier classification.
The mitral valve apparatus is a complex structure made of the annulus, the leaflets, the chordae, the papillary muscles, and the left ventricular wall. Mitral regurgitation may develop when the leaflets or any other portion of the apparatus becomes abnormal. The mitral valve apparatus may also become dysfunctional when the left ventricle dilates and the papillary muscles are displaced. As the repair techniques for mitral valve disease evolved, so has the need for detailed and accurate imaging of the mitral valve prior to surgery in order to better define the mechanism of valve dysfunction and the severity of regurgitation.
In patients with significant mitral valve disease who require surgical intervention, multiplane transesophageal echocardiogram (TEE) is invaluable for surgical planning. TEE can identify the mechanism of valve pathology and the specific area on the valve causing the malfunction. However, a comprehensive TEE in a patient with complex mitral valve disease requires great experience and skill, (Figure 1). Even in experienced hands, using multiplane 2D TEE alone can sometimes lead to misinterpretation of scallops. There is evidence to suggest that 3D echocardiography can overcome some of the limitations of 2D multiplane TEE and thus is crucial in evaluation of patients undergoing mitral valve surgery. In addition, 3D TEE unifies the language used by the echocardiographer to communicate mitral valve pathology to the surgeon by providing an en face (surgeon's view) of the mitral valve.
(Enlarge Image)
Figure 1.
Multiplane 2D TEE with color Doppler is utilized to identify the mitral valve scallops. Panel A demonstrates a TEE at midesophageal 0 degrees view. In this view one can visualize the A2 and P2 scallops of the mitral valve at the tips of the leaflets. However the scallops visualized depend on the level of depth. At 0 degrees midesophageal view, when the aortic valve is visualized, the A1/P1 scallops are noted at the leaflet tips. When the TEE probe is advanced further into the esophagus past the midesophageal level, the A3/P3 scallops are identified at the leaflet tips [16]. Of note, the A2 scallop of the mitral valve is flail with a posteriorly directed mitral regurgitation jet. Panel B demonstrates a commissural view at 60 degrees. In this view, the lateral most scallop (close to the appendage) is P1. One can also visualize the central, flail A2 scallop. The P3 scallop is also well visualized in this view. The mitral regurgitation originated around the A2 scallops as was seen in the 0 degree view. Panel C is the long axis view between demonstrating the A2 and P2 scallops.
Mitral valve leaflet anatomy has been described by Carpentier as being divided into six scallops: three that form the anterior leaflet and three that form the posterior leaflet (Figure 2). In addition, Carpentier classified the etiology of mitral valve regurgitation into Type 1-normal leaflet motion, Type II: leaflet prolapse, Type III-restricted leaflet motion. The echocardiographic must be familiar with this nomenclature as part of the preoperative assessment of mitral valve.
(Enlarge Image)
Figure 2.
The mitral valve has two leaflets: the anterior and posterior leaflet. Each leaflet is further subdivided into three different scallops with the A1 and P1 scallops closest to the left atrial appendage. This view of the mitral valve is referred to as the surgeons view with the aortic valve oriented at the top of the image. LAA: left atrial appendage; AoV: aortic valve.
The following sections highlight some crucial steps that must be undertaken by the echocardiographer to accurately image the mitral valve. This includes both 2D and 3D assessment of the valve. Of note, the iE33 xMATRIX Echocardiography System (Phillips Healthcare, MA) was utilized for image acquisitions in this paper. Multiple other ultrasound companies also manufacture 3D echo systems. Image acquisition in other systems may vary slightly but the anatomic concepts are similar.
Abstract and Introduction
Abstract
Mitral regurgitation may develop when the leaflets or any other portion of the apparatus becomes abnormal. As the repair techniques for mitral valve disease evolved, so has the need for detailed and accurate imaging of the mitral valve prior to surgery in order to better define the mechanism of valve dysfunction and the severity of regurgitation. In patients with significant mitral valve disease who require surgical intervention, multiplane transesophageal echocardiogram (TEE) is invaluable for surgical planning. However, a comprehensive TEE in a patient with complex mitral valve disease requires great experience and skill. There is evidence to suggest that 3D echocardiography can overcome some of the limitations of 2D multiplane TEE and thus is crucial in evaluation of patients undergoing mitral valve surgery. In the following sections, we review some of the crucial 2D and 3D echo images necessary for evaluation of MR based on the Carpentier classification.
Introduction
The mitral valve apparatus is a complex structure made of the annulus, the leaflets, the chordae, the papillary muscles, and the left ventricular wall. Mitral regurgitation may develop when the leaflets or any other portion of the apparatus becomes abnormal. The mitral valve apparatus may also become dysfunctional when the left ventricle dilates and the papillary muscles are displaced. As the repair techniques for mitral valve disease evolved, so has the need for detailed and accurate imaging of the mitral valve prior to surgery in order to better define the mechanism of valve dysfunction and the severity of regurgitation.
In patients with significant mitral valve disease who require surgical intervention, multiplane transesophageal echocardiogram (TEE) is invaluable for surgical planning. TEE can identify the mechanism of valve pathology and the specific area on the valve causing the malfunction. However, a comprehensive TEE in a patient with complex mitral valve disease requires great experience and skill, (Figure 1). Even in experienced hands, using multiplane 2D TEE alone can sometimes lead to misinterpretation of scallops. There is evidence to suggest that 3D echocardiography can overcome some of the limitations of 2D multiplane TEE and thus is crucial in evaluation of patients undergoing mitral valve surgery. In addition, 3D TEE unifies the language used by the echocardiographer to communicate mitral valve pathology to the surgeon by providing an en face (surgeon's view) of the mitral valve.
(Enlarge Image)
Figure 1.
Multiplane 2D TEE with color Doppler is utilized to identify the mitral valve scallops. Panel A demonstrates a TEE at midesophageal 0 degrees view. In this view one can visualize the A2 and P2 scallops of the mitral valve at the tips of the leaflets. However the scallops visualized depend on the level of depth. At 0 degrees midesophageal view, when the aortic valve is visualized, the A1/P1 scallops are noted at the leaflet tips. When the TEE probe is advanced further into the esophagus past the midesophageal level, the A3/P3 scallops are identified at the leaflet tips [16]. Of note, the A2 scallop of the mitral valve is flail with a posteriorly directed mitral regurgitation jet. Panel B demonstrates a commissural view at 60 degrees. In this view, the lateral most scallop (close to the appendage) is P1. One can also visualize the central, flail A2 scallop. The P3 scallop is also well visualized in this view. The mitral regurgitation originated around the A2 scallops as was seen in the 0 degree view. Panel C is the long axis view between demonstrating the A2 and P2 scallops.
Mitral valve leaflet anatomy has been described by Carpentier as being divided into six scallops: three that form the anterior leaflet and three that form the posterior leaflet (Figure 2). In addition, Carpentier classified the etiology of mitral valve regurgitation into Type 1-normal leaflet motion, Type II: leaflet prolapse, Type III-restricted leaflet motion. The echocardiographic must be familiar with this nomenclature as part of the preoperative assessment of mitral valve.
(Enlarge Image)
Figure 2.
The mitral valve has two leaflets: the anterior and posterior leaflet. Each leaflet is further subdivided into three different scallops with the A1 and P1 scallops closest to the left atrial appendage. This view of the mitral valve is referred to as the surgeons view with the aortic valve oriented at the top of the image. LAA: left atrial appendage; AoV: aortic valve.
The following sections highlight some crucial steps that must be undertaken by the echocardiographer to accurately image the mitral valve. This includes both 2D and 3D assessment of the valve. Of note, the iE33 xMATRIX Echocardiography System (Phillips Healthcare, MA) was utilized for image acquisitions in this paper. Multiple other ultrasound companies also manufacture 3D echo systems. Image acquisition in other systems may vary slightly but the anatomic concepts are similar.
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