Transesophageal echocardiography in the evaluation of mitral valve disease
- Elyse Foster, MD
Elyse Foster, MD
- Professor of Clinical Medicine
- University of California, San Francisco
- 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
While transthoracic echocardiography (TTE) is the primary diagnostic modality for evaluation of mitral disease, transesophageal echocardiography (TEE) is an important adjunct in selected patients when more detailed visualization of the mitral valve morphology and of the left atrium (eg, to identify atrial thrombus) is needed.
This topic will discuss the use of TEE in evaluating the mitral valve. TTE of the mitral valve is discussed separately. (See "Echocardiographic evaluation of the mitral valve".)
Mitral regurgitation (MR) is one of the most common derangements of native valves and increases in frequency with age. MR is broadly classified as primary, related to structural abnormalities of the valve itself, or secondary, due to impaired leaflet coaptation associated with underlying left ventricular disease or left atrial disease. Defining the morphology of the valve (figure 1) and the precise mechanism of regurgitation has gained importance in the modern era of surgical and percutaneous mitral valve repair.
The important role transesophageal echocardiography (TEE) plays in the evaluation of mitral regurgitation is due to the proximity of the TEE transducer to the left atrium. In situations that impede transthoracic echocardiography (TTE) (eg, acoustic shadowing from annular calcium or a mitral prosthesis), TEE provides an unobstructed view. TEE provides enhanced views of the mitral valve, which now include three-dimensional (3D) reconstruction to provide detailed information as to the nature of the underlying pathology. The TEE also provides information that is adjunctive to the TTE in determining the severity.
Primary mitral regurgitation — As noted in the American Heart Association/American College of Cardiology (AHA/ACC) guidelines, TEE is indicated in evaluation of patients with chronic primary MR (stages B to D) (table 1) in whom noninvasive imaging provides nondiagnostic information about severity of MR, mechanism of MR, and/or status of left ventricular function . TEE may provide significant additional information in the following conditions that lead to chronic mitral regurgitation.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline 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. J Am Coll Cardiol 2014; 63:e57.
- La Canna G, Arendar I, Maisano F, et al. Real-time three-dimensional transesophageal echocardiography for assessment of mitral valve functional anatomy in patients with prolapse-related regurgitation. Am J Cardiol 2011; 107:1365.
- Ben Zekry S, Nagueh SF, Little SH, et al. Comparative accuracy of two- and three-dimensional transthoracic and transesophageal echocardiography in identifying mitral valve pathology in patients undergoing mitral valve repair: initial observations. J Am Soc Echocardiogr 2011; 24:1079.
- Roldan CA, Shively BK, Lau CC, et al. Systemic lupus erythematosus valve disease by transesophageal echocardiography and the role of antiphospholipid antibodies. J Am Coll Cardiol 1992; 20:1127.
- Habib G, Guidon C, Tricoire E, et al. Papillary muscle rupture caused by bacterial endocarditis: role of transesophageal echocardiography. J Am Soc Echocardiogr 1994; 7:79.
- Bai AD, Steinberg M, Showler A, et al. Diagnostic Accuracy of Transthoracic Echocardiography for Infective Endocarditis Findings Using Transesophageal Echocardiography as the Reference Standard: A Meta-Analysis. J Am Soc Echocardiogr 2017.
- López-Pardo F, González-Calle A, López-Haldón J, et al. Real time three-dimensional transesophageal echocardiography in the anatomical assessment of complex mitral valve regurgitation secondary to endocarditis. Rev Esp Cardiol (Engl Ed) 2012; 65:188.
- Roldan CA, Tolstrup K, Macias L, et al. Libman-Sacks Endocarditis: Detection, Characterization, and Clinical Correlates by Three-Dimensional Transesophageal Echocardiography. J Am Soc Echocardiogr 2015; 28:770.
- Jafar MZ, Morgan MC, Gorcsan J 3rd. Transesophageal echocardiographic detection of multiple mitral valve masses in primary antiphospholipid syndrome with stroke. Am Heart J 1994; 127:445.
- Kranidis A, Koulouris S, Filippatos G, et al. Mitral regurgitation from papillary muscle rupture: role of transesophageal echocardiography. J Heart Valve Dis 1993; 2:529.
- Kaul S, Spotnitz WD, Glasheen WP, Touchstone DA. Mechanism of ischemic mitral regurgitation. An experimental evaluation. Circulation 1991; 84:2167.
- Zhu WX, Oh JK, Kopecky SL, et al. Mitral regurgitation due to ruptured chordae tendineae in patients with hypertrophic obstructive cardiomyopathy. J Am Coll Cardiol 1992; 20:242.
- Yu EH, Omran AS, Wigle ED, et al. Mitral regurgitation in hypertrophic obstructive cardiomyopathy: relationship to obstruction and relief with myectomy. J Am Coll Cardiol 2000; 36:2219.
- 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.
- Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation: A Report from the American Society of Echocardiography Developed in Collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr 2017; 30:303.
- Grayburn PA, She L, Roberts BJ, et al. Comparison of Transesophageal and Transthoracic Echocardiographic Measurements of Mechanism and Severity of Mitral Regurgitation in Ischemic Cardiomyopathy (from the Surgical Treatment of Ischemic Heart Failure Trial). Am J Cardiol 2015; 116:913.
- 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.
- Rivera JM, Vandervoort PM, Thoreau DH, et al. Quantification of mitral regurgitation with the proximal flow convergence method: a clinical study. Am Heart J 1992; 124:1289.
- Schwammenthal E, Chen C, Benning F, et al. Dynamics of mitral regurgitant flow and orifice area. Physiologic application of the proximal flow convergence method: clinical data and experimental testing. Circulation 1994; 90:307.
- Mele D, Vandervoort P, Palacios I, et al. Proximal jet size by Doppler color flow mapping predicts severity of mitral regurgitation. Clinical studies. Circulation 1995; 91:746.
- Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005; 352:875.
- 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.
- Tribouilloy C, Shen WF, Quéré JP, et al. Assessment of severity of mitral regurgitation by measuring regurgitant jet width at its origin with transesophageal Doppler color flow imaging. Circulation 1992; 85:1248.
- Hwang JJ, Shyu KG, Hsu KL, et al. Significant mitral regurgitation is protective against left atrial spontaneous echo contrast formation, but not against systemic embolism. Chest 1994; 106:8.
- Movsowitz C, Movsowitz HD, Jacobs LE, et al. Significant mitral regurgitation is protective against left atrial spontaneous echo contrast and thrombus as assessed by transesophageal echocardiography. J Am Soc Echocardiogr 1993; 6:107.
- Chen CG, Thomas JD, Anconina J, et al. Impact of impinging wall jet on color Doppler quantification of mitral regurgitation. Circulation 1991; 84:712.
- Klein AL, Bailey AS, Cohen GI, et al. Importance of sampling both pulmonary veins in grading mitral regurgitation by transesophageal echocardiography. J Am Soc Echocardiogr 1993; 6:115.
- Klein AL, Obarski TP, Stewart WJ, et al. Transesophageal Doppler echocardiography of pulmonary venous flow: a new marker of mitral regurgitation severity. J Am Coll Cardiol 1991; 18:518.
- Klein AL, Stewart WJ, Bartlett J, et al. Effects of mitral regurgitation on pulmonary venous flow and left atrial pressure: an intraoperative transesophageal echocardiographic study. J Am Coll Cardiol 1992; 20:1345.
- Roach JM, Stajduhar KC, Torrington KG. Right upper lobe pulmonary edema caused by acute mitral regurgitation. Diagnosis by transesophageal echocardiography. Chest 1993; 103:1286.
- Zeng X, Levine RA, Hua L, et al. Diagnostic value of vena contracta area in the quantification of mitral regurgitation severity by color Doppler 3D echocardiography. Circ Cardiovasc Imaging 2011; 4:506.
- Freeman WK, Schaff HV, Khandheria BK, et al. Intraoperative evaluation of mitral valve regurgitation and repair by transesophageal echocardiography: incidence and significance of systolic anterior motion. J Am Coll Cardiol 1992; 20:599.
- Maurer G, Siegel RJ, Czer LS. The use of color flow mapping for intraoperative assessment of valve repair. Circulation 1991; 84:I250.
- Saiki Y, Kasegawa H, Kawase M, et al. Intraoperative TEE during mitral valve repair: does it predict early and late postoperative mitral valve dysfunction? Ann Thorac Surg 1998; 66:1277.
- Tamborini G, Muratori M, Maltagliati A, et al. Pre-operative transthoracic real-time three-dimensional echocardiography in patients undergoing mitral valve repair: accuracy in cases with simple vs. complex prolapse lesions. Eur J Echocardiogr 2010; 11:778.
- Vegas A, Meineri M. Core review: three-dimensional transesophageal echocardiography is a major advance for intraoperative clinical management of patients undergoing cardiac surgery: a core review. Anesth Analg 2010; 110:1548.
- Maffessanti F, Marsan NA, Tamborini G, et al. Quantitative analysis of mitral valve apparatus in mitral valve prolapse before and after annuloplasty: a three-dimensional intraoperative transesophageal study. J Am Soc Echocardiogr 2011; 24:405.
- Vergnat M, Jassar AS, Jackson BM, et al. Ischemic mitral regurgitation: a quantitative three-dimensional echocardiographic analysis. Ann Thorac Surg 2011; 91:157.
- Hatle L. Doppler echocardiographic evaluation of mitral stenosis. Cardiol Clin 1990; 8:233.
- Kronzon I, Tunick PA, Glassman E, et al. Transesophageal echocardiography to detect atrial clots in candidates for percutaneous transseptal mitral balloon valvuloplasty. J Am Coll Cardiol 1990; 16:1320.
- Goldstein SA, Campbell AN. Mitral stenosis. Evaluation and guidance of valvuloplasty by transesophageal echocardiography. Cardiol Clin 1993; 11:409.
- Manning WJ, Reis GJ, Douglas PS. Use of transoesophageal echocardiography to detect left atrial thrombi before percutaneous balloon dilatation of the mitral valve: a prospective study. Br Heart J 1992; 67:170.
- Levin TN, Feldman T, Bednarz J, et al. Transesophageal echocardiographic evaluation of mitral valve morphology to predict outcome after balloon mitral valvotomy. Am J Cardiol 1994; 73:707.
- Palacios IF, Block PC, Wilkins GT, Weyman AE. Follow-up of patients undergoing percutaneous mitral balloon valvotomy. Analysis of factors determining restenosis. Circulation 1989; 79:573.
- Marwick TH, Torelli J, Obarski T, et al. Assessment of the mitral valve splitability score by transthoracic and transesophageal echocardiography. Am J Cardiol 1991; 68:1106.
- Dreyfus J, Brochet E, Lepage L, et al. Real-time 3D transoesophageal measurement of the mitral valve area in patients with mitral stenosis. Eur J Echocardiogr 2011; 12:750.
- Schlosshan D, Aggarwal G, Mathur G, et al. Real-time 3D transesophageal echocardiography for the evaluation of rheumatic mitral stenosis. JACC Cardiovasc Imaging 2011; 4:580.
- Dobarro D, Gomez-Rubin MC, Lopez-Fernandez T, et al. Real time three-dimensional transesophageal echocardiography for guiding percutaneous mitral valvuloplasty. Echocardiography 2009; 26:746.
- Fatkin D, Loupas T, Low J, Feneley M. Inhibition of red cell aggregation prevents spontaneous echocardiographic contrast formation in human blood. Circulation 1997; 96:889.
- Peverill RE, Gelman J, Harper RW, Smolich JJ. Stability of left atrial spontaneous echo contrast at repeat transesophageal echocardiography in patients with mitral stenosis. Am J Cardiol 1997; 79:516.
- Fatkin D, Herbert E, Feneley MP. Hematologic correlates of spontaneous echo contrast in patients with atrial fibrillation and implications for thromboembolic risk. Am J Cardiol 1994; 73:672.
- Castello R, Pearson AC, Labovitz AJ. Prevalence and clinical implications of atrial spontaneous contrast in patients undergoing transesophageal echocardiography. Am J Cardiol 1990; 65:1149.
- Black IW, Hopkins AP, Lee LC, Walsh WF. Left atrial spontaneous echo contrast: a clinical and echocardiographic analysis. J Am Coll Cardiol 1991; 18:398.
- Daniel WG, Nellessen U, Schröder E, et al. Left atrial spontaneous echo contrast in mitral valve disease: an indicator for an increased thromboembolic risk. J Am Coll Cardiol 1988; 11:1204.
- Bernstein NE, Demopoulos LA, Tunick PA, et al. Correlates of spontaneous echo contrast in patients with mitral stenosis and normal sinus rhythm. Am Heart J 1994; 128:287.
- Michalis LK, Thomas MR, Smyth DW, et al. Left atrial spontaneous echo contrast assessed by TEE in patients with either native mitral valve disease or mitral valve replacement. J Am Soc Echocardiogr 1993; 6:299.
- Tsai LM, Chen JH, Fang CJ, et al. Clinical implications of left atrial spontaneous echo contrast in nonrheumatic atrial fibrillation. Am J Cardiol 1992; 70:327.
- Hwang JJ, Kuan P, Chen JJ, et al. Significance of left atrial spontaneous echo contrast in rheumatic mitral valve disease as a predictor of systemic arterial embolization: a transesophageal echocardiographic study. Am Heart J 1994; 127:880.
- Mügge A, Kühn H, Nikutta P, et al. Assessment of left atrial appendage function by biplane transesophageal echocardiography in patients with nonrheumatic atrial fibrillation: identification of a subgroup of patients at increased embolic risk. J Am Coll Cardiol 1994; 23:599.
- Sharma R, Mann J, Drummond L, et al. The evaluation of real-time 3-dimensional transthoracic echocardiography for the preoperative functional assessment of patients with mitral valve prolapse: a comparison with 2-dimensional transesophageal echocardiography. J Am Soc Echocardiogr 2007; 20:934.
- MITRAL REGURGITATION
- Primary mitral regurgitation
- - Degenerative mitral valve disease
- - Rheumatic disease
- - Congenital abnormalities
- - Infective endocarditis
- - Degenerative calcific disease
- Secondary mitral regurgitation
- - Ischemic mitral regurgitation
- - Dilated cardiomyopathy
- - Hypertrophic cardiomyopathy
- Severity of mitral regurgitation
- - Color flow Doppler
- - Pulsed-wave Doppler
- - Continuous wave Doppler
- - Evaluation of pulmonary veins
- - Two-dimensional echocardiogram
- - Three-dimensional echocardiogram
- Role of intraoperative transesophageal echocardiography
- Role in transcatheter mitral valve repair
- MITRAL STENOSIS
- Use for percutaneous balloon valvotomy
- Spontaneous echo contrast
- - Left atrial appendage
- Role of intraoperative transesophageal echocardiography