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Echocardiographic evaluation of the mitral valve

Topic Outline

GRAPHICS

INTRODUCTION

The mitral valve was the first structure to be identified by echocardiography (figure 1) [1,2]. Technical advances have enabled echocardiography to identify almost any anatomic or functional abnormality of the mitral valve. The appearance of the normal mitral valve and the more commonly encountered mitral valvular abnormalities will be reviewed here.

NORMAL MITRAL VALVE

A standard transthoracic echocardiographic (TTE) examination of the mitral valve consists of an M-mode tracing, multiple two-dimensional views, and Doppler flow evaluation. If clinically indicated (eg, technically difficult TTE or evaluation of prosthetic paravalvular leak), a transesophageal echocardiogram (TEE) may be performed. Together, these elements form an integrated examination of the mitral valve that can reliably define its function and evaluate the severity of abnormalities [3].

Anatomically, the orientation of the anterior leaflet of the mitral valve places this broad surface toward the anterior chest wall, making it an ideal sound reflecting target. Furthermore, because of its relatively large margin-to-base ratio, the anterior leaflet is highly mobile (figure 2).

The mitral valve can be recorded by ultrasound through a variety of anatomic windows in the precordium, apical, and subxiphoid regions, all of which should be used in its examination.

M-mode echocardiogram — The M-mode examination is performed from the precordium and guided from the two-dimensional long and short axis views. Normally, the anterior mitral leaflet exhibits a motion pattern that reflects the phasic nature of ventricular filling and produces a familiar M-shaped pattern (figure 3). The posterior leaflet moves in a nearly mirror image "W" pattern with a smaller excursion.

                                 

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Literature review current through: Aug 2014. | This topic last updated: Aug 28, 2014.
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References
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  1. Edler, I. Ultrasound cardiogram in mitral valve disease. Acta Chir Scand 1956; 111:230.
  2. Edler I. Ultrasoundcardiography in mitral valve stenosis. Am J Cardiol 1967; 19:18.
  3. Schiller NB, Foster E, Redberg RF. Transesophageal echocardiography in the evaluation of mitral regurgitation. The twenty-four signs of severe mitral regurgitation. Cardiol Clin 1993; 11:399.
  4. Gutman J, Wang YS, Wahr D, Schiller NB. Normal left atrial function determined by 2-dimensional echocardiography. Am J Cardiol 1983; 51:336.
  5. Flachskampf FA, Franke A, Job FP, et al. Three-dimensional reconstruction of cardiac structures from transesophageal echocardiography. Am J Card Imaging 1995; 9:141.
  6. Lang RM, Badano LP, Tsang W, et al. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. J Am Soc Echocardiogr 2012; 25:3.
  7. Altiok E, Hamada S, Brehmer K, et al. Analysis of procedural effects of percutaneous edge-to-edge mitral valve repair by 2D and 3D echocardiography. Circ Cardiovasc Imaging 2012; 5:748.
  8. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
  9. Nichol PM, Gilbert BW, Kisslo JA. Two-dimensional echocardiographic assessment of mitral stenosis. Circulation 1977; 55:120.
  10. Wann LS, Weyman AE, Feigenbaum H, et al. Determination of mitral valve area by cross-sectional echocardiography. Ann Intern Med 1978; 88:337.
  11. Hatle L, Brubakk A, Tromsdal A, Angelsen B. Noninvasive assessment of pressure drop in mitral stenosis by Doppler ultrasound. Br Heart J 1978; 40:131.
  12. Hatle L, Angelsen B, Tromsdal A. Noninvasive assessment of atrioventricular pressure half-time by Doppler ultrasound. Circulation 1979; 60:1096.
  13. Tischler MD, Niggel J. Exercise echocardiography in combined mild mitral valve stenosis and regurgitation. Echocardiography 1993; 10:453.
  14. Reis G, Motta MS, Barbosa MM, et al. Dobutamine stress echocardiography for noninvasive assessment and risk stratification of patients with rheumatic mitral stenosis. J Am Coll Cardiol 2004; 43:393.
  15. Zamorano J, Cordeiro P, Sugeng L, et al. Real-time three-dimensional echocardiography for rheumatic mitral valve stenosis evaluation: an accurate and novel approach. J Am Coll Cardiol 2004; 43:2091.
  16. Binder TM, Rosenhek R, Porenta G, et al. Improved assessment of mitral valve stenosis by volumetric real-time three-dimensional echocardiography. J Am Coll Cardiol 2000; 36:1355.
  17. Abascal VM, Wilkins GT, O'Shea JP, et al. Prediction of successful outcome in 130 patients undergoing percutaneous balloon mitral valvotomy. Circulation 1990; 82:448.
  18. Wilkins GT, Weyman AE, Abascal VM, et al. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J 1988; 60:299.
  19. Fatkin D, Roy P, Morgan JJ, Feneley MP. Percutaneous balloon mitral valvotomy with the Inoue single-balloon catheter: commissural morphology as a determinant of outcome. J Am Coll Cardiol 1993; 21:390.
  20. Himelman RB, Schiller NB. Clinical and echocardiographic comparison of patients with the carcinoid syndrome with and without carcinoid heart disease. Am J Cardiol 1989; 63:347.
  21. Himelman RB, Stulbarg MS, Lee E, et al. Noninvasive evaluation of pulmonary artery systolic pressures during dynamic exercise by saline-enhanced Doppler echocardiography. Am Heart J 1990; 119:685.
  22. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16:777.
  23. Helmcke F, Nanda NC, Hsiung MC, et al. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation 1987; 75:175.
  24. Utsunomiya T, Doshi R, Patel D, et al. Regurgitant volume estimation in patients with mitral regurgitation: initial studies using color Doppler "proximal isovelocity surface area" method. Echocardiography 1992; 9:63.
  25. Grayburn PA, Fehske W, Omran H, et al. Multiplane transesophageal echocardiographic assessment of mitral regurgitation by Doppler color flow mapping of the vena contracta. Am J Cardiol 1994; 74:912.
  26. Hall SA, Brickner ME, Willett DL, et al. Assessment of mitral regurgitation severity by Doppler color flow mapping of the vena contracta. Circulation 1997; 95:636.
  27. Thomas L, Foster E, Schiller NB. Peak mitral inflow velocity predicts mitral regurgitation severity. J Am Coll Cardiol 1998; 31:174.
  28. Simpson IA, Shiota T, Gharib M, Sahn DJ. Current status of flow convergence for clinical applications: is it a leaning tower of "PISA"? J Am Coll Cardiol 1996; 27:504.
  29. Thomas L, Foster E, Hoffman JI, Schiller NB. The Mitral Regurgitation Index: an echocardiographic guide to severity. J Am Coll Cardiol 1999; 33:2016.
  30. Avgeropoulou CC, Rahko PS, Patel AK. Reliability of M-mode, two-dimensional and Doppler echocardiography in diagnosing a flail mitral valve leaflet. J Am Soc Echocardiogr 1988; 1:433.
  31. Ogawa S, Mardelli TJ, Hubbard FE. The role of cross-sectional echocardiography in the diagnosis of flail mitral leaflet. Clin Cardiol 1978; 1:85.
  32. Cioffi G, Tarantini L, De Feo S, et al. Functional mitral regurgitation predicts 1-year mortality in elderly patients with systolic chronic heart failure. Eur J Heart Fail 2005; 7:1112.
  33. Lancellotti P, Gérard PL, Piérard LA. Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation. Eur Heart J 2005; 26:1528.
  34. Hayakawa M, Inoh T, Kawanishi H, et al. [Two-dimensional echocardiographic findings of patients with papillary muscle dysfunction]. J Cardiogr 1982; 12:137.
  35. Godley RW, Wann LS, Rogers EW, et al. Incomplete mitral leaflet closure in patients with papillary muscle dysfunction. Circulation 1981; 63:565.
  36. Kwan J, Shiota T, Agler DA, et al. Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation: real-time three-dimensional echocardiography study. Circulation 2003; 107:1135.
  37. Wann LS, Feigenbaum H, Weyman AE, Dillon JC. Cross-sectional echocardiographic detection of rheumatic mitral regurgitation. Am J Cardiol 1978; 41:1258.