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Transesophageal ECHO and the Mitral Valve

Transesophageal ECHO and the Mitral Valve. Anesth Analg 1999;88:1205–12. Am Heart J. 2000;139: 378-87. Fibrous Skeleton Of The Heart. Anatomic Classification Schema: Mitral Valve Segments . Duran Classification. Ann Thorac Surg 1998: 65:1025-1031. J Heart Valve Dis 1995; 4:70-75.

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Transesophageal ECHO and the Mitral Valve

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  1. Transesophageal ECHO and the Mitral Valve

  2. Anesth Analg 1999;88:1205–12.

  3. Am Heart J. 2000;139: 378-87.

  4. Fibrous Skeleton Of The Heart

  5. Anatomic Classification Schema: MitralValve Segments Duran Classification Ann Thorac Surg1998: 65:1025-1031. J Heart Valve Dis 1995; 4:70-75. Cardiol Clin. 2000; 18: 731-50.

  6. JASE. 2003; 16: 61 – 66.

  7. Mid-esophageal 4C View • A3 and A1 • Commisural View • P3-A2-P1 • Two Chamber View • P3-A1 • Long Axis View • A2 • Transgastric Views (Short) • Posteromedial commissure • Anterolateral commissure • Transgastric Views (Long) • Chordae Tendinae • Papillary Muscle Assessment of the Mitral Valve JASE. 2003; 16: 61 – 66.

  8. Mid-esophageal Views (Transducer @ 0°) Anesth Analg 1999;88:1205–12.

  9. Four Chamber Views: Isolating Mitral Valve Leaflet Segments Cardiol Clin. 2000; 18: 731-50.

  10. P2/P3 A2/A3 Four Chamber View Crit Care Clin. 1996; 12: 321-81.

  11. Mid-esophageal Views (Transducer @ ~60°) Anesth Analg 1999;88:1205–12.

  12. Two Chamber Views: Isolating Mitral Valve Leaflet Segments Cardiol Clin. 2000; 18: 731-50.

  13. P3 P2 P1 Two Chamber: Posterior View Crit Care Clin. 1996; 12: 321-81.

  14. P2 A2 Apical Long Axis View Cardiol Clin. 2000; 18: 731-50.

  15. Flail lateral scallop Commissural View JASE. 2003; 16: 61 – 66.

  16. Flail medial scallop Commissural View JASE. 2003; 16: 61 – 66.

  17. Transgastric Views (Transducer @ 0°) Anesth Analg 1999;88:1205–12.

  18. Transgastric Long-axis View: Visualization of the Papillary Muscles Posteromedial Papillary Muscle Anterolateral Papillary Muscle Cardiol Clin. 2000; 18: 731-50.

  19. Affected Leaflet n TEE diagnosis Accuracy (%) Anterior 6 6 100 Posterior 45 45 100 Bileaflet 3 1 33 Total 54 52 96 Accuracy of Transesophageal Echocardiographic (TEE) Diagnosis in Determination of Affected Flail Leaflet JASE.1998;11:966-71.

  20. Affected Scallop Identified n Sensitivity (%) Specificity (%) Overall accuracy (%) Middle (P2) 34 82 82 82 Lateral (P1) 7 100 89 90 Medial (P3) 10 50* 100 90 Total 51 78 92 88 Accuracy of Transesophageal Echocardiographic Diagnosis of Affected Scallop Among Patients With Posterior Flail Mitral Leaflet JASE.1998;11:966-71.

  21. Diagnostic Accuracy of Identification of Mitral Regurgitant Defects by Correlation withSurgical Findings Defect Location Sensitivity (%) Specificity (%) A1 97.1 98.3 A2 96.3 97.7 A3 98.5 97.9 P1 98.7 97.8 P2 99.6 92.4 P3 94.7 96.9 JASE. 2003; 16: 61 – 66.

  22. Frequency of Valve Repair According to Location of Flail Leaflet and Scallop Location n Repaired (n) Repaired (%) Posterior 45 30 67    Middle 28 20 71    Medial 5 5 100    Lateral 5 3 60    Multiple 4 1 25    Not specified 3 1 33 Anterior 6 0 0 Bileaflet 3 2 67 Total 54 32 59 JASE.1998;11:966-71.

  23. Pathologic Anatomic Changes to Assess During Transesophageal Echocardiographic Examination of the Mitral Valve • Calcification • Dilatation • Perivalvular Leak (Prosthetic Valves) Mitral Annulus

  24. Midesophageal View of the Mitral Valve Mitral Annular Calcification Cardiol Clin. 2000; 18: 731-50.

  25. Circulation. 2000;101:695.

  26. Mitral Leaflets Billowing leaflet • Coaptation level of anterior and posterior leaflet relative to annulus • Systolic anterior motion of anterior leaflet • Leaflet thickening • Leaflet fusion (rheumatic); doming of fused leaflets in diastole (mitral stenosis) • Calcification of leaflets • Prolapse • Deformation of leaflet free margin • Thickening, retraction of free margin into ventricle (curling under) • Endocarditis • Vegetation, leaflet aneurysm, perforation, associated regurgitant jet of aortic insufficiency hugging ventricular side of anterior leaflet (possible source of infectious seeding)

  27. Circulation. 2000;102:1400.

  28. Apical Displacement of Mitral Coaptation (aka “Tenting”) Circulation. 2000;102:1400.

  29. Mitral Valve Prolapse Diagnostic Criteria • Classic MVP • Displacement > 2 mm • Thickness ≥ 5 mm • Non-Classic MVP • Displacement > 2 mm Cardiol Clin. 2000; 18: 731-50.

  30. Atrial Views of Prolapse of the Anterior Mitral Valve Leaflet

  31. Chordae • Chordal systolic anterior motion • Thickening • Fusion • Calcification • Elongation • Rupture

  32. Posterior Mitral Leaflet Prolapse (Flail Posterior Leaflet) Ruptured Chord Cardiol Clin. 2000; 18: 731-50.

  33. Papillary Muscles • Ruptured papillary muscle • LV-papillary muscle dysfunction

  34. Subtotal Ruptured Papillary Muscle Cardiol Clin. 2000; 18: 731-50.

  35. Miscellaneous Findings Left atrial enlargement Atrial appendage thrombus, LV dilation/aneurysm, TV annulus dilation, tricuspid regurgitation, right ventricular enlargement Systolic anterior motion Mitral valve repair Narrow LVOT Small LV diameter Increased anterior and posterior leaflet area Miscellaneous

  36. And After Before Post-Operative Assessment: Residual Mitral Regurgitation Am Heart J. 1996; 131: 162-76.

  37. And After Before Post-Operative Assessment: Residual Mitral Regurgitation Cardiol Clin. 1998; 16: 477-89.

  38. Post-Operative Assessment: Exclude Systolic Anterior Motion of the Mitral Valve Crit Care Clin. 1996; 12: 321-81.

  39. Post-Operative Assessment: Exclude Mitral Stenosis Crit Care Clin. 1996; 12: 321-81.

  40. Anesth Analg 1999;88:1205–12.

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