The operative view is shown (left), and the corresponding "surgical view" obtained with real-time 3D transesophageal echocardiography volume rendering (right). Abbreviations: A1, A2, A3 = anterior mitral valve scallops, AL = anterolateral; P1, P2, P3 = posterior mitral valve scallops, PM = postero-medial. From Mount Sinai Medical Center and University of Chicago.

(A) 4-chamber view obtained at 0° depicting A2 on the left and P2 on the right. (B) Bicommissural view obtained by electronically rotating the transducer tip to 55° showing P3 on the left, A2 in the middle, and P1 on the right. (C) 2-chamber view obtained by rotating the transducer to 90° to visualize P3 on the left and the 3 scallops of the anterior mitral valve leaflet on the right. (D) Long-axis view obtained by further rotating the transducer to 120° to view P2 on the left and A2 on the right. The left column correspond to MV images (as visualized from the left atrial perspective) obtained with the use of real-time 3D-TEE volume rendering. Red lines represent the approximate cut planes from which the respective 2D TEE images were obtained. Ao = aorta; Lat = lateral aspect of MV; Med = medial aspect of MV; MV = mitral valve; TEE = transesophageal echocardiography; other abbreviations as in Figure 1. From Mount Sinai Medical Center and University of Chicago.

Schematic (upper row) and 2D as well as 3D echocardiographic examples of a patient with a normal mitral valve (left panels), mitral valve prolapse (P1, middle panels) and a flail mitral valve (P2, right panels) as visualized with 2D TEE (long-axis mid esophageal TEE views (middle row) and real-time 3D TEE volume rendering from the left atrial perspective (bottom row). The surgical views obtained with real-time 3D TEE provide unique visualization and better understanding of the anatomic relationships of the mitral valve annulus, commissures and leaflets. Abbreviations as in Figures 1 and 2.

(A) Anatomical view. (B) Transesophageal view (MV view as visualized in the transgastric basal short axis view. (C) Surgeon’s view. All these examples were obtained with the use of real-time 3D transesophageal echocardiography volume rendering using zoomed views. The mitral valve is visualized from the left atrial perspective. From Mount Sinai Medical Center and University of Chicago. Abbreviations as in Figure 1.

Examples of patients with P1 prolapse (top left); P2 flail mitral valve scallop (black arrow) with a ruptured chord (red arrow, top right); P3 flail mitral valve (black arrow, bottom left); and Barlow’s syndrome with floppy mitral valve with multiple leaflet prolapse (P1, P2 and P3) (bottom right). All images were obtained with real-time 3D-TEE volume rendering. The mitral valves are visualized from the left atrial perspective.

Example of a patient with a P2 flail mitral valve. (A) Four-chamber view obtained at 0° depicting A2 on the left and P2 on the right; (B) Two-chamber view obtained by rotating the transducer to 90° to visualize P3 on the left and the 3 scallops of the anterior mitral valve leaflet on the right; (C) Long-axis view obtained by further rotating the transducer to 120° to view the flail P2 segment on the left and A2 on the right. The direction of the color jet in the long-axis view (bottom left) is away from the side of the flail lesion. The left column images correspond to the mitral valve image (as visualized from the left atrial perspective) obtained using real-time 3D-TEE volume rendering. The red arrows represent the approximate cut planes from which the respective 2D TEE images were obtained. A1, A2, A3 = scallops of the anterior mitral valve and P1, P2, P3 = scallops of the posterior mitral valve.

Examples of 3D renderings of the mitral valve obtained from 3D-TEE dataset using software designed for quantitative analysis of the mitral apparatus. (Top, Left) Antero-posterior diameter is shown in green. (Top, Right) Annular height. (Bottom Left) Anterior mitral leaflet surface area (hatched) with posterior middle scallop leaflet prolapse. (Bottom, Right) Angle between the mitral and aortic annuli. A = anterior, P = posterior, AL = anterolateral, PM = posteromedial, Ao = aorta, TEE = transesophageal echocardiography.

The flow convergence is indicated by the large open hemisphere observed in perspective and the jet of MR by the large arrow at the bottom. V1 is the velocity on the flow convergence hemisphere (white arrows) whereas the jet velocity is V2. The right side indicates the calculation of regurgitant flow (Flow 2) and effective regurgitant orifice area (ERO). R is the radius of the hemisphere of flow convergence. MR = mitral regurgitation; PISA = proximal isovelocity surface area.

The left image is a zoomed view of the flow convergence zone with color-flow imaging and down-shifting of the baseline resulting in an aliasing velocity of 22 cm/s. The radius (R) of the flow convergence is measured using the 2 crosses shown and the flow is calculated at 336 ml/s. The right image shows continuous-wave Doppler measurement of the peak regurgitant velocity (MR velocity). The ERO area is calculated at 67 mm² or 0.67 cm², as the ratio of flow to velocity. LV = left ventricle; other abbreviations as in Figure 8.

(A and B) Normal physiology (N) is contrasted with that of acute mitral regurgitation (MR). In acute MR, the volume overload of MR increases sarcomere length (SL), augmenting preload. Increased SL is reflected by an increase in end-diastolic volume (EDV). The new pathologic pathway for ejection into the left atrium (LA) reduces afterload as quantified by end-systolic stress (ESS), allowing the left ventricle to eject more completely. Enhanced ejection is reflected by a fall in end-systolic volume (ESV). As a result, the total stroke volume increases to 140 ml, but because 50% is regurgitated into the LA (regurgitant fraction [RF] 0.50), forward stroke volume (FSV) decreases. Ejection fraction (EF) increases, although contractile function (CF) is normal but not increased. (C) Chronic compensated mitral regurgitation. In this phase of MR, eccentric cardiac hypertrophy produces a further increase in EDV, which allows for a large increase in total stroke volume (190 ml) so that FSV returns to nearly normal. The enlarged and compliant LA can accommodate the regurgitant volume at a lower pressure, so that left atrial pressure declines. CF remains normal, and EF remains increased. (D) Chronic decompensated mitral regurgitation. In this phase, CF has been reduced from muscle damage caused by prolonged severe volume overload. Impaired CF reduces the effectiveness of left ventricular ejection and ESV increases. There is a further increase in diastolic volume, which is not compensatory for the increase in ESV, resulting in a decrease in total and forward stroke volumes. Concomitantly, increased EDV worsens the MR by annular dilation and papillary muscle malalignment and regurgitant fraction increases. Ejection fraction is reduced from the compensated state but often remains within the normal range.

Schematic of edge-to-edge MV repair (Alfieri procedure; (top) and percutaneous mitral annuloplasty (bottom), capitalizing on the relationship between the coronary sinus and the annulus.

(Left) Typical configuration of major cardiac veins. The volume-rendered computed tomography (CT) data show the anterior interventricular vein (AIV) draining into the great cardiac vein (GCV), which in turn becomes the coronary sinus (CS) upon receiving additional lateral vein branches. The posterior interventricular vein (PIV) is also noted. (Middle) Coronary sinus in a curved multiplanar CT format. This mode of rendering isotropic CT data allows for segmentation of the coronary sinus along its entire length (arrows). The arrowhead indicates the anterior interventricular vein. (Right) Coronary artery and coronary sinus anatomic relationship. Both the coronary sinus (arrow) and left circumflex coronary artery (arrowhead) lie in the atrioventricular groove, with the circumflex artery lying underneath the coronary sinus in this patient. The potential for myocardial ischemia induced by extrinsic compression from an overlying venous device exists. Ao = aortic valve, LV = left ventricle.