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PTE Masters + A Practical Approach to Transesophageal Echocardiography > Mitral Valve > Flashcards

Mitral Valve Flashcards

1
Q

What is the structure in between the aortic valve and mitral valve?

A

Intervalvular Fibrosa

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2
Q

Name the papillary muscles of the mitral valve.

A

1. Anterolateral

2. Posteromedial

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3
Q

Which papillary muscle is likely to rupture and why?

A

Posteromedial muscle blood supply: Solo blood supply = right coronary artery - posterior interventricular artery (RCA) More likely to rupture (70%) of patients

Anterolateral muscle blood supply: left anterior descending artery - diagonal branch (LAD) and left circumflex artery - obtuse marginal branch (LCX)

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4
Q

What are the other synonymous names for mitral valve Commissures?

A

Anterior Commissure = Anterior - Lateral Commissure

Posterior Commissure = Posterior - Medial Commissure

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5
Q

What is the normal “Short Axis” measurements of the mitral valve in the Mid Esophageal Long Axis view during end-systole?

A

ME LAX Normal End Systolic Annulus <36 mm

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6
Q

Why is the mid esophageal long axis the best view for mitral valve high axis measurements?

*Hint: 3 reasons*

A
  1. Best place to look for MV Prolapse or excessive leaflet motion (high point of the annulus)

2. Best place to measure vena contracta

  1. A2 and P2 scallops seen (Most common prolapse to repair easily is P2)
  2. Measure the end systolic annulus
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7
Q

What is the best view to measure the long axis of the mitral valve?

A

ME Commissural View

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8
Q

What is the normal “Long Axis” measurement of the mitral valve annulus during end-systole?

A

<46 mm

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9
Q

What view of the Mitral Valve is seen in the mid esophageal at approximately 0 - 30 degrees?

A

ME 4 chamber

Segments of the anterior (A2) and posterior (P2) mitral valve leaflets are typically imaged in this view

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10
Q

What view of the Mitral Valve is seen in the mid esophageal at approximately 60 degrees?

A

ME Commissural View

The mid-esophageal commissural view can be found anywhere between 30-90 degrees on the omniplane angle depending on the rotation of the heart. The ASA / SCA standard ME commissural view runs along the low, long axis of the mitral valve and brings both the anterior and posterior commissures and papillary muscles into view. In this view, you will find from left to right on your screen the P3 / A2 / P1 segments.

If you rotate your probe clockwise towards the right you bring more of the anterior mitral segments into view. Here you will see the A3 / A2 / A1 segments.

If you rotate your probe counterclockwise towards the left, you bring more of the posterior segments into view. Here you will see the P3 / P2 / P1 segments.

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11
Q

What scallops are seen in the commissural view of the mitral valve?

A

P1 = Right

A2 = Center

P3 = Left

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12
Q

What view of the Mitral Valve is seen in the mid esophageal at approximately 90 Degrees?

A

Mid Esophageal 2 chamber

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13
Q

What view of the Mitral Valve is seen in the mid esophageal at approximately 120 degrees?

A

Mid Esophageal Long Axis

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14
Q

What view is seen here?

A

Basal Short Axis View

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15
Q

What view is seen here?

A

Transgastric 2 chamber view

Mitral Valve Subvalvular Apparatus

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16
Q

What walls of the heart are shown here?

A

INFERIOR = CLOSE TO THE PROBE

ANTERIOR = AWAY FROM THE PROBE

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17
Q

What papillary muscle is seen here?

A

Posteromedial Papillary Muscle

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18
Q

What does induction of general anesthesia do to the severity of MR?

A

Loading conditions change (Afterload and Preload drop)

Severity of MR Underestimated

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19
Q

What is the most common cause of MR in the west?

A

Myxomatous Degeneration

Myxomatous degeneration is a process that occurs when the valve becomes thickened with formation of small nodules on the edges of the leaflets. This prevents complete closing of the valves and as a result blood can flow backward into the left atrium. The resultant backflow is called mitral regurgitation.

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20
Q

What is the most common cause of MR in developing nations?

A

Rheumatic Disease

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21
Q

Besides myxomatous degeneration and rheumatic disease, what are some causes of MR?

A

Ischemia (Pap Muscle Dysfunction and/or rupture)

Cardiomyopathy (Dilated vs. idiopathic hypertrophic subaortic stenosis)

Endocarditis

Congenital (cleft anterior leaflet with AV Canal defect)

Connective Tissue Diseases (SLE, RA, Marfan’s)

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22
Q

Label the Papillary muscles in the TG SAX Mid-Papillary TEE view

A
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23
Q

Label the Papillary muscles in the Mid Commissural View

A
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24
Q

What is the Best place to look for MV Prolapse or excessive leaflet motion?

A

ME LAX (high point of the annulus)

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25
Q

What is the best place to measure vena contracta of mitral valve?

A

ME LAX

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26
Q

What is the most common prolapse scallop of the mitral valve?

A

(Most common prolapse to repair easily is P2)

Best seen in ME LAx (A2-P2)

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27
Q

What scallops of the mitral valve are seen in Mid Commissural view of the mitral valve?

A

P1 (Far Right) - A2 - P3 (Far Left)

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28
Q

What scallops of the mitral valve are seen in 2 chamber view of the mitral valve?

A

P3 and A1 scallops

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29
Q

What scallops of the mitral valve are seen in Long Axis view of the mitral valve?

A

P2 and A2

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30
Q

What do you measure in the ME LAX in terms of the mitral valve?

A
  1. Anterior leaflet length (Estimates ring for mitral valve repair)
  2. Vena Contracta
  3. Assess MVP (High access of the valve)
  4. End systolic annulus length <36 mm
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31
Q

Draw the posterior and anterior leaftlet scallops of the TG Basal SAX.

A

Left side = Anterior

RIght side = Posterior

3 on top of image

1 omn bottom of image

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32
Q

What papillary muscle is seen in TG 2 chamber view?

A

Posteriomedial Papillary muscle always seen

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33
Q

What are the 4 questions you must answer when determining MR TEE evaluation?

A
  1. Severity
  2. Mechanism
  3. Location of Lesion
  4. Repairable
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34
Q

What is the most common cause of MR in the west?

A

Myxomatous Degeneration = non-inflammatory progressive disarray of the valve structure caused by a defect in the mechanical integrity of the leaflet due to the altered synthesis and/or remodeling by type VI collagen

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35
Q

What is the most common cause of MR in developing nations?

A

Rheumatic

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36
Q

How can ischemia cause mitral insufficiency?

A

Posteriomedial papillary muscle dysfunction* vs. *rupture

Blood supply: Single from RCA –> PDA (70% of patients)

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37
Q

What are the 3 connective tissue diseases that can cause MR?

A

SLE

RA
Marfans

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38
Q

What are the 3 different types of MV leaflet motion?

A
  1. Normal (Type 1)
    - Leaftlet is dilated
  2. Excessive (Type 2)
    - Goes away from diseased leaflet
  3. Restrictive (Type 3)
    - Jet goes toward the defective leaflet
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39
Q

What are the three Type 2 types (Excessive) of mitral valve excessive leaflet motion?

A

Prolapse

Billowing

Flail

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40
Q

What are the 4 types of MV leaflet motion (Carpentier classification?

A

type I: normal leaflet motion

type II: excessive leaflet motion

type IIIa: restricted leaflet motionIIIa: leaflet motion restricted in both systole and diastole

IIIb: leaflet motion restricted in diastole

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41
Q

Ajet / Aatria Mitral Regurgitation

What is Mild?

A

<20 %

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42
Q

Ajet / Aatria Mitral Regurgitation

What is Moderate?

A

20 - 40%

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43
Q

Ajet / Aatria Mitral Regurgitation

What is Severe?

A

>40%

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44
Q

Vena Contracta Mitral Regurgitation

What is Mild?

A

<3 mm

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45
Q

Vena Contracta Mitral Regurgitation

What is Moderate?

A

3 - 7 mmHg

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46
Q

Vena Contracta Mitral Regurgitation

What is Severe?

A

> 7 mm

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47
Q

MR Jet Area Mitral Regurgitation

What is Mild?

A

< 4 cm2

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48
Q

MR Jet Area Mitral Regurgitation

What is Moderate?

A

4 - 10 cm2

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49
Q

MR Jet Area Mitral Regurgitation

What is Severe?

A

> 10 cm2

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50
Q

Pulmonary Vein Flow to grade Mitral Regurgitation

What is Mild?

A

Blunted S

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51
Q

Pulmonary Vein Flow to grade Mitral Regurgitation

What is Moderate?

A

S < D

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52
Q

Pulmonary Vein Flow to grade Mitral Regurgitation

What is Severe?

A

S reversal

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53
Q

Mitral Regurgitant Fraction to grade Mitral Regurgitation

What is Mild?

A

< 30%

54
Q

Mitral Regurgitant Fraction to grade Mitral Regurgitation

What is Moderate?

A

30 - 49%

55
Q

Mitral Regurgitant Fraction to grade Mitral Regurgitation

What is Severe?

A

>50%

56
Q

Mitral Regurgitant Volume to grade Mitral Regurgitation

What is Mild?

A

<30 cm3 (mL)

57
Q

Mitral Regurgitant Volume to grade Mitral Regurgitation

What is Moderate?

A

30 - 59 cm3 (mL)

58
Q

Mitral Regurgitant Volume to grade Mitral Regurgitation

What is Severe?

A

>60 cm3 (mL)

59
Q

Mitral Valve Orifice Area (cm2) to grade Mitral Regurgitation

What is Mild?

A

< 0.2 cm2

60
Q

Mitral Valve Orifice Area (cm2) to grade Mitral Regurgitation

What is Moderate?

A

0.2 - 0.39 cm2

61
Q

Mitral Valve Orifice Area (cm2) to grade Mitral Regurgitation

What is Severe?

A

>/= 0.4 cm2

62
Q

PISA radius (mm) to grade Mitral Regurgitation

What is Mild?

A

< 4 mm

63
Q

PISA radius (mm) to grade Mitral Regurgitation

What is Moderate?

A

4 - 10 mm

64
Q

PISA radius (mm) to grade Mitral Regurgitation

What is Severe?

A

>10 mm

65
Q

PISA radius assumes what:

  1. Alias velocity?
A

20-40 cm/sec

66
Q

PISA radius assumes what:

  1. VelocityMR Peak ?
A

VelocityMR Peak = 500 cm/sec

67
Q

CWD signal strength to grade MR.

What is mild?

A

Faint

68
Q

CWD signal strength to grade MR.

What is moderate?

A

Moderately Dense

69
Q

CWD signal strength to grade MR.

What is Severe?

A

Very Dense

70
Q

What if you have an eccentric MR jet that “hugs” the walls of the LA.

  1. What is this called?
  2. What effect is this?
A

Coanda Effect

71
Q

When are the two times you can have posterior jet of MR?

A
  1. HOCM
  2. SAM
72
Q

What are the 6 risk factors for SAM after MV repair

Size of LV?

A

Small non-dilated LV

73
Q

What are the 6 risk factors for SAM after MV repair

Annuloplasty size?

A

Small annuloplasty ring

74
Q

What are the 6 risk factors for SAM after MV repair

Posterior Leaflet?

A

XS Post Leaflet Tissue caausing ant displacement of the coapt line

75
Q

What are the 6 risk factors for SAM after MV repair

C-Sept?

A

C-Sept <2.5 cm

76
Q

What are the 6 risk factors for SAM after MV repair

AL/PL Ratio?

A

AL / PL ratio of <1

77
Q

What are the 6 risk factors for SAM after MV repair

Anterior Leftlet size

A

XS Anterior leaflet distal to coaptation point

78
Q

SAM after MV repair

What C-sept distance is decreased risk?

A

>3 cm = Decreased risk

<2.5 cm = Increased risk

79
Q

SAM after MV repair

What AL/PL is decreased risk?

A

AL / PL >3 = Decreased risk

AL / PL <1 = Increased risk

80
Q

What is the most common cause of Mitral Stenosis?

A

Rheumatic Heart Disease

81
Q

Other than rheumatic disease, what is the cause of mitral stenosis?

A

LA myxomaaa

Severe mitral annular calcification

Thrombus formation

Parachute MV

Congenital

Subvalvular Mitral Ring

Cortriatiatum Sinister

82
Q

What is seen here?

A

As in rheumatic Mitral Stenosis, the anterior mitral leaflet (AMVL) shows diastolic doming or hockey-stick shape. And the posterior mitral leaflet (PMVL) has restricted motion or is totally immobile.

This doming is due to the reduced mobility of the valve tips compared to the base of the leaflets.

83
Q

How do you calculate the Mitral Valve area using planimetry?

A

Trace of TG Basal SAX

84
Q

How do you calculate the Mitral Valve area using pressure half time?

A

220 / PHT

85
Q

How do you calculate the Mitral Valve area using deceleration time?

A

MVA = 759 / DT

86
Q

How do you calculate the Mitral Valve area using continuity equation?

A

Mitral Valve Area = [ALVOT x TVILVOT] / TVIMV

87
Q

How do you calculate the mitral valve area using PISA?

A

QPISA / VPEAK

88
Q

What is the mean gradient of mild mitral stenosis?

A

< 5 mmHg

89
Q

What is the mean gradient of moderate mitral stenosis?

A

5 - 10 mmHg

90
Q

What is the mean gradient of severe mitral stenosis?

A

>10 mmHg

91
Q

What is a normal PHT of the mitral valve?

A

30 - 89

92
Q

What is a PHT of mild mitral stenosis?

A

90 - 150

93
Q

What is a PHT of moderate mitral stenosis?

A

151 - 219

94
Q

What is a PHT of severe mitral stenosis?

A

>220

95
Q

What is a normal Mitral Valve Area?

A

>2.5 cm2

96
Q

What is a Mitral Valve Area with mild Mitral Stenosis?

A

1.6 - 2.5 cm2

97
Q

What is a Mitral Valve Area with moderate Mitral Stenosis?

A

1.0 - 1.5 cm2

98
Q

What is a Mitral Valve Area with severe Mitral Stenosis?

A

< 1.0 cm2

99
Q

What are two problems with using PHT for Mitral Valve area?

A

1. Decreased LV compliance

2. Severe AI

Rapid rise in LVEDP causing decreased PHT

Overestimates MVA (PHT too low)

Underestimates degree of Mitral Stenosis

100
Q

What 3 things will give you a higher mean gradient when evaluating Mitral stenosis?

A
  1. Severe MR (Increased LAP)
  2. Higher HR (Increased mean gradient)
  3. Increased SV (SVMV diastolic inflow)
101
Q

What 2 things will give you a understimated mean gradients when evaluating Mitral stenosis?

A
  1. Angle of Incidence
  2. LV Active relaxation (Impaired relaxation)
102
Q

What will give you an overestimated mean gradient when evaluating Mitral stenosis?

A

Decreased LV Compliance

103
Q

What does PISA stand for?

A

Proximal Isovelocity Surface Area (PISA)

104
Q

What is the PISA equation?

A

MV area (Hole) = AreaPISA x VelocityALIAS / VelocityPeak

AreaPISA = 2πr2 * [Alpha / 180]

2πr2 = Area of hemisphere

Alpha / 180 = Not a perfect hemisphere

r = Leaflet to the first aliasing velocity

VelocityALIAS = Velocity that aliasing begins to occur

VelocityPeak = Peak through Mitral Valve

105
Q

What are the steps to obtaining a PISA?

A
  1. Color box on the mitral valve
  2. Adjust the Nyquist Limit to obtain Isovelocity Shells
  3. Determine your aliasing velocity

4. Measure Radius of isovelocity shell

5. CWD to measure peak velocity of regurgitation

  1. Measure Alpha Angle
106
Q

What is the equation for Regurgitant Volume of the Mitral Valve?

A

Regurgitant Volume = SVMV Inflow - SVLVOT

SVMV Inflow = AMV x TVIMV

SVLVOT = [CSALVOT x TVILVOT]

AMV from PHT equation

TVIMV from spectral doppler

SVLVOT from PWD from LVOT measurement

107
Q

What is the regurgitant fraction?

A

Backwards Flow / Total Flow

108
Q

What is the equation for Regurgitant Fraction?

A

Regurgitant Volume / SVMV Inflow

1. Regurgitant Volume = SVMV Inflow - SVLVOT

SVMV Inflow = AMV x TVIMV

SVLVOT = [CSALVOT x TVILVOT]

AMV from PHT equation

TVIMV from spectral doppler

SVLVOT from PWD from LVOT measurement

2. SVMV Inflow = AMV x TVIMV

109
Q

What is the equation for the regurgitant orifice area?

A

ROA = Regurgitant Volume / TVIMR

110
Q

What is the equation for PISA for MR?

A

QMRpisa = APISA x VelocityALIAS

111
Q

What is the equation for EROA MR PISA?

A

EROA MR PISA = QMRpisa / VMRpeak

112
Q

What is equation for regurgitant volume?

A

EROAMRpisa * TVIMR

113
Q

What mitral valve leaflet is shown?

A

Anterior Mitral Leaflet

114
Q

What mitral leaflet is shown?

A

Anterior Leaflet

115
Q

What mitral leaflet is shown?

A

P2 scallop

116
Q

What method of measuring MVA is not influenced by AI and MR?

A

PISA

117
Q

If you measure the vena contracta of a mitral regurgitant jet to determine MR, what view should best evaluate this?

A

ME Long Axis

118
Q

Best view to visualze the mitral valve subvalvular apparatus?

A

TG 2 chamber

119
Q

What is the most repairable Mitral valve lesion?

A

P2 prolapse = Most common cause of MR in the west

120
Q

What MV scallops are seen in the ME Long axis view?

A

A2 P2

121
Q

What valve is most commonly affected by rheumatic valvular disease?

A

Mitral Valve

122
Q

What view passes through the “high” (Anterior-Posterior) axis of the mtiral valve annulsu and is therefore appropriate view in which to assess leaflet prolapse?

A

ME Long Axis View

123
Q

The intensity of the transmitral regurgitant jet relative to the intensity of the transmitral diastolic inflow by CWD reflects what?

A

MV regurgitant volume

124
Q

see question on image

A

A = 0.64 cm2

125
Q

See attached question

A

SV = AreaMitral Valve * TVIMV Inflow = 0.64cm2 * 50 cm = 32 mL

126
Q

See attached question

A

7 mL

127
Q
A

8.2 mm2

128
Q
A

B 22%

129
Q

See table to answer question

A

Mild MR

R Vol.= 7mL

Rfx = 22%

EOA = 8.2 mm2

130
Q

Answer the question

A

Severe MS

(0.6 valve area)

131
Q
A
132
Q

What is Cor triatriatum sinister?

A

Left atrium is divided into two compartments by a membrane.

The membrane can vary in size and shape and may have one or more openings.

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