Mitral Valve Flashcards by Tim Montrief

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

Intervalvular Fibrosa

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Name the papillary muscles of the mitral valve.

1. Anterolateral

2. Posteromedial

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Which papillary muscle is likely to rupture and why?

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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What are the other synonymous names for mitral valve Commissures?

Anterior Commissure = Anterior - Lateral Commissure

Posterior Commissure = Posterior - Medial Commissure

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

ME LAX Normal End Systolic Annulus <36 mm

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

*Hint: 3 reasons*

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

2. Best place to measure vena contracta

A2 and P2 scallops seen (Most common prolapse to repair easily is P2)
Measure the end systolic annulus

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

ME Commissural View

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

<46 mm

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

ME 4 chamber

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

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

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

P1 = Right

A2 = Center

P3 = Left

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

Mid Esophageal 2 chamber

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

Mid Esophageal Long Axis

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What view is seen here?

Basal Short Axis View

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What view is seen here?

Transgastric 2 chamber view

Mitral Valve Subvalvular Apparatus

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What walls of the heart are shown here?

INFERIOR = CLOSE TO THE PROBE

ANTERIOR = AWAY FROM THE PROBE

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What papillary muscle is seen here?

Posteromedial Papillary Muscle

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

Loading conditions change (Afterload and Preload drop)

Severity of MR Underestimated

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

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

Rheumatic Disease

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

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

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Label the Papillary muscles in the Mid Commissural View

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

ME LAX (high point of the annulus)

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

ME LAX

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

(Most common prolapse to repair easily is P2) Best seen in ME LAx (A2-P2)

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

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

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

P3 and A1 scallops

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

P2 and A2

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

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

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

Left side = Anterior RIght side = Posterior 3 on top of image 1 omn bottom of image

What papillary muscle is seen in TG 2 chamber view?

Posteriomedial Papillary muscle **always seen**

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

1. Severity 2. Mechanism 3. Location of Lesion 4. Repairable

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

**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

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

**Rheumatic**

How can ischemia cause mitral insufficiency?

**Posteriomedial** papillary muscle *_dysfunction*_ vs. _*rupture_* Blood supply: **Single** from RCA --\> PDA (70% of patients)

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

SLE RA Marfans

What are the 3 different types of MV leaflet motion?

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

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

Prolapse Billowing Flail

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

**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

A_jet / A_atria Mitral Regurgitation What is **Mild**?

\<20 %

A_jet / A_atria Mitral Regurgitation What is **Moderate**?

20 - 40%

A_jet / A_atria Mitral Regurgitation What is **Severe**?

\>40%

Vena Contracta Mitral Regurgitation What is **Mild**?

\<3 mm

Vena Contracta Mitral Regurgitation What is **Moderate**?

3 - 7 mmHg

Vena Contracta Mitral Regurgitation What is **Severe**?

**\> 7 mm**

MR Jet Area Mitral Regurgitation What is **Mild**?

\< 4 cm²

MR Jet Area Mitral Regurgitation What is **Moderate**?

4 - 10 cm²

MR Jet Area Mitral Regurgitation What is **Severe**?

\> 10 cm²

**Pulmonary Vein Flow** to grade Mitral Regurgitation What is **Mild**?

Blunted S

**Pulmonary Vein Flow** to grade Mitral Regurgitation What is **Moderate**?

S \< D

**Pulmonary Vein Flow** to grade Mitral Regurgitation What is **Severe**?

S reversal

**Mitral Regurgitant Fraction** to grade Mitral Regurgitation What is **Mild**?

\< 30%

**Mitral Regurgitant Fraction** to grade Mitral Regurgitation What is **Moderate**?

30 - 49%

**Mitral Regurgitant Fraction** to grade Mitral Regurgitation What is **Severe**?

\>50%

**Mitral Regurgitant Volume** to grade Mitral Regurgitation What is **Mild**?

\<30 cm³ (mL)

**Mitral Regurgitant Volume** to grade Mitral Regurgitation What is **Moderate**?

30 - 59 cm³ (mL)

**Mitral Regurgitant Volume** to grade Mitral Regurgitation What is **Severe**?

\>60 cm³ (mL)

**Mitral Valve Orifice Area** (cm²) to grade Mitral Regurgitation What is **Mild**?

\< 0.2 cm²

**Mitral Valve Orifice Area** (cm²) to grade Mitral Regurgitation What is **Moderate**?

0.2 - 0.39 cm²

**Mitral Valve Orifice Area** (cm²) to grade Mitral Regurgitation What is **Severe**?

\>/= 0.4 cm²

**PISA radius** (mm) to grade Mitral Regurgitation What is **Mild**?

**\< 4 mm**

**PISA radius** (mm) to grade Mitral Regurgitation What is **Moderate**?

4 - 10 mm

**PISA radius** (mm) to grade Mitral Regurgitation What is **Severe**?

\>10 mm

PISA radius assumes what: 1. Alias velocity?

20-40 cm/sec

PISA radius assumes what: 1. Velocity_{MR Peak} ?

Velocity_{MR Peak} = 500 cm/sec

**CWD signal strength** to grade MR. What is **mild**?

Faint

**CWD signal strength** to grade MR. What is **moderate**?

Moderately Dense

**CWD signal strength** to grade MR. What is **Severe**?

Very Dense

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?

**Coanda** Effect

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

1. HOCM 2. SAM

**What are the 6 risk factors for SAM after MV repair** Size of LV?

Small non-dilated LV

**What are the 6 risk factors for SAM after MV repair** Annuloplasty size?

Small annuloplasty ring

**What are the 6 risk factors for SAM after MV repair** Posterior Leaflet?

XS Post Leaflet Tissue caausing ant displacement of the coapt line

**What are the 6 risk factors for SAM after MV repair** C-Sept?

C-Sept \<2.5 cm

**What are the 6 risk factors for SAM after MV repair** AL/PL Ratio?

AL / PL ratio of **\<1**

**What are the 6 risk factors for SAM after MV repair** Anterior Leftlet size

XS Anterior leaflet **distal to coaptation point**

SAM after MV repair What C-sept distance is decreased risk?

\>3 cm = Decreased risk \<2.5 cm = Increased risk

SAM after MV repair What AL/PL is decreased risk?

AL / PL **\>3** = Decreased risk AL / PL **\<1** = Increased risk

What is the most common cause of Mitral Stenosis?

Rheumatic Heart Disease

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

LA myxomaaa Severe mitral annular calcification Thrombus formation Parachute MV Congenital Subvalvular Mitral Ring Cortriatiatum Sinister

What is seen here?

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.

How do you calculate the Mitral Valve area using planimetry?

Trace of TG Basal SAX

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

220 / PHT

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

MVA = 759 / DT

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

Mitral Valve Area = [**A_LVOT x TVI_LVOT**] / **TVI_MV**

How do you calculate the mitral valve area using PISA?

Q_PISA / V_PEAK

What is the mean gradient of **mild** *_mitral stenosis_*?

\< 5 mmHg

What is the mean gradient of **moderate** *_mitral stenosis_*?

5 - 10 mmHg

What is the mean gradient of **severe** *_mitral stenosis_*?

\>10 mmHg

What is a normal PHT of the mitral valve?

30 - 89

What is a PHT of **mild** *_mitral stenosis_*?

90 - 150

What is a PHT of **moderate** *_mitral stenosis_*?

151 - 219

What is a PHT of **severe** *_mitral stenosis_*?

\>220

What is a normal Mitral Valve Area?

\>2.5 cm²

What is a Mitral Valve Area with *_mild_* **Mitral Stenosis**?

1.6 - 2.5 cm²

What is a Mitral Valve Area with **moderate** *_Mitral Stenosis_*?

1.0 - 1.5 cm²

What is a Mitral Valve Area with **severe** *_Mitral Stenosis_*?

\< 1.0 cm²

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

**1. Decreased LV compliance** **2. Severe AI** Rapid rise in LVEDP causing decreased PHT Overestimates MVA (PHT too low) Underestimates degree of Mitral Stenosis

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

1. **Severe MR** (Increased LAP) 2. **Higher HR** (Increased mean gradient) 3. **Increased SV** (SV_{MV diastolic inflow})

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

1. **Angle of Incidence** 2. **LV Active relaxation** (Impaired relaxation)

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

Decreased LV Compliance

What does PISA stand for?

**P**roximal **I**sovelocity **S**urface **A**rea (**PISA**)

What is the PISA equation?

MV area (Hole) = **Area_PISA x Velocity_ALIAS** / *_Velocity_Peak_* **Area_PISA** = 2πr² \* [Alpha / 180] 2πr² = Area of hemisphere Alpha / 180 = Not a perfect hemisphere r = Leaflet to the first aliasing velocity **Velocity_ALIAS** = Velocity that aliasing begins to occur *_Velocity_Peak_* = Peak through Mitral Valve

What are the steps to obtaining a PISA?

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 6. Measure Alpha Angle

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

Regurgitant Volume = ***_SV_{MV Inflow}_*** - **SVLVOT** ***_SV_{MV Inflow}_*** = A_MV x TVI_MV **SVLVOT =** [CSA_LVOT x TVI_LVOT] A_MVfrom PHT equation TVI_MVfrom spectral doppler SV_LVOT from PWD from LVOT measurement

What is the regurgitant fraction?

Backwards Flow / Total Flow

What is the equation for Regurgitant Fraction?

Regurgitant Volume / SV_{MV 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. SV_{MV Inflow}** = A_MV x TVI_MV

What is the equation for the regurgitant orifice area?

ROA = Regurgitant Volume / TVI_MR

What is the equation for PISA for MR?

Q_MRpisa = A_PISA x Velocity_ALIAS

What is the equation for EROA _{MR PISA}?

EROA _{MR PISA} = Q_MRpisa / V_MRpeak

What is equation for regurgitant volume?

EROA_MRpisa \* TVI_MR

What mitral valve leaflet is shown?

Anterior Mitral Leaflet

What mitral leaflet is shown?

Anterior Leaflet

What mitral leaflet is shown?

P2 scallop

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

PISA

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

ME Long Axis

Best view to visualze the mitral valve subvalvular apparatus?

TG 2 chamber

What is the most repairable Mitral valve lesion?

**P2 prolapse** = Most common cause of MR in the west

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

A2 P2

What valve is most commonly affected by rheumatic valvular disease?

Mitral Valve

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?

ME Long Axis View

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

MV regurgitant volume