Echocardiographic evaluation of the mitral valve
- Nelson B Schiller, MD, FACC, FRCP, FASE
Nelson B Schiller, MD, FACC, FRCP, FASE
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Anesthesia
- University of California, San Francisco
- Xiushui Ren, MD
Xiushui Ren, MD
- Associate Research Director, Cardiology Fellowship
- California Pacific Medical Center
- Section Editors
- Warren J Manning, MD
Warren J Manning, MD
- Section Editor — Noninvasive Cardiac Imaging and Stress Testing
- Professor of Medicine and Radiology
- Harvard Medical School
- William H Gaasch, MD
William H Gaasch, MD
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Massachusetts Medical School
- Tufts University School of Medicine
- Senior Consultant in Cardiology
- Lahey Clinic
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 .
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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- NORMAL MITRAL VALVE
- M-mode echocardiogram
- Two-dimensional echocardiogram
- Doppler echocardiogram
- Three-dimensional echocardiogram
- MITRAL VALVE LESIONS CAUSING INFLOW OBSTRUCTION
- Mitral stenosis
- - M-mode echocardiography
- - Two-dimensional TTE
- - Doppler echocardiography
- - Stress echocardiography
- - Three-dimensional echocardiography
- - Echocardiography in balloon valvuloplasty
- Mitral annular calcification
- - Cor triatriatum
- - Left atrial myxoma
- - Other cardiac tumors
- - Carcinoid heart disease
- ABNORMALITIES ASSOCIATED WITH MITRAL REGURGITATION
- Determination of severity
- - Structural parameters
- - Color flow Doppler
- - Pulsed and continuous wave Doppler of mitral inflow
- - Quantitative parameters of mitral regurgitation
- - Doppler of pulmonary veins
- - Index of severity
- MITRAL VALVE LESIONS CAUSING MITRAL REGURGITATION
- Mitral valve prolapse
- Flail mitral valve
- Endocarditis of the mitral valve
- Functional mitral regurgitation
- Ischemic heart disease
- Rheumatic mitral regurgitation
- SUMMARY AND RECOMMENDATIONS