The Echocardiographers View

The mitral valve is examined by using 4 mid-esophageal views and 3 transgastric views2. It is important in all planes to maximize left ventricular cavity size in order to transect the mitral orifice at its centre. In the mid esophageal views this often requires some retroflexion of the probe tip. Depending on the position of the heart in relation to the esophagus the angles to visualize certain parts of the mitral valve may vary somewhat in individual patients.

First the anatomical structures of the mitral valve are visualized and thereafter the entire sequence of views is repeated in the Color Doppler flow imaging mode.

Mid esophageal views (transducer depth 30-40 cm from the incisors). See figure I.

The 'four chamber view' (both atria and both ventricles) is obtained at a multiplane angle of 0° - 20° and displays the middle section of the anterior mitral leaflet (A2) at the left of the image display and the middle scallop of the posterior mitral leaflet (P2) to the right.

Sometimes the anterolateral scallop of the posterior mitral leaflet (P1) instead of P2 is displayed in this view.

The 'mitral-commissural view' is obtained at 60° - 70°. This view displays the anterior mitral leaflet in the middle of the image, the anterolateral commissure and anterolateral scallop of the posterior leaflet (P1) to the right and the posteromedial commissure and posteromedial scallop of the posterior mitral leaflet (P3) to the left of the image.

1. The 'two-chamber view' (left atrium and left ventricle) is obtained at 90°. This view displays the posteromedial scallop of the posterior mitral valve leaflet (P3) to the left and the anterolateral part of the anterior mitral leaflet (A1) to the right.

2. The 'long-axis view' (left atrium, left ventricle and aorta) is obtained at 120° - 160°. This view displays the middle scallop of the posterior mitral valve leaflet (P2) to the left and the middle part of the anterior mitral leaflet (A2) at the right.

Transgastric views (transducer depth 40-50 cm from the incisors).

3. The transgastric 'mid short-axis view' is visualized at 0° - 20°. In this view the posteromedial papillary muscle is displayed to the upper left and the anterolateral papillary muscle to the lower right. The papillary muscles are situated below the commissures of the mitral valve. In this view, wall motion abnormalities in left ventricular segments adjacent to the papillary muscles are detected.

4. The transgastric 'basal short-axis view' is also visualized at 0° - 20° by advancing the probe a little deeper in the stomach and anteflexing it with the big wheel. In this view the posteromedial commissure is displayed in the upper left of the image and the anterolateral commissure to the lower right, the anterior leaflet is to the left and the posterior leaflet to the right. This view gives the best impression of which part of the anterior and / or posterior leaflet is affected.

5. The transgastric basal 'two-chamber view' is obtained at the same level at 80° - 100°; in this view chordae to the posteromedial papillary muscle are seen at the top of the image and chordae to the anterolateral papillary muscle to the bottom.

Figure I. Mitral valve seen from the apex and midesophageal TEE imaging views

Transverse view or 0 0 ; bi-commisural view or 60 longitudinal 'two chamber' view or 90

longaxis view or ¡35

A1 = anterolateral part of the anterior mitral valve leaflet (AMVL); A2 = middle part of the AMVL; A3 = posteromedial part of the AMVL.

P I = anterolateral scallop of the posterior mitral valve leaflet (PMVL); P2 = middle scallop of the PMVL; P3 = posteromedial scallop of the PMVL.

Reprinted with permission from the Society of Thoracic Surgeons. (The Annals of Thoracic Surgery 1998; 65: 1025-31 Foster GP et al.)

Figure I. Mitral valve seen from the apex and midesophageal TEE imaging views

Transverse view or 0 0 ; bi-commisural view or 60 longitudinal 'two chamber' view or 90

longaxis view or ¡35

A1 = anterolateral part of the anterior mitral valve leaflet (AMVL); A2 = middle part of the AMVL; A3 = posteromedial part of the AMVL.

P I = anterolateral scallop of the posterior mitral valve leaflet (PMVL); P2 = middle scallop of the PMVL; P3 = posteromedial scallop of the PMVL.

Reprinted with permission from the Society of Thoracic Surgeons. (The Annals of Thoracic Surgery 1998; 65: 1025-31 Foster GP et al.)

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