Figure 20-1 Mitral valve anatomy (looking toward the left ventricle from posterior to anterior). The mitral valve consists of the mitral annulus, anterior and posterior leaflets, chordae tendineae, and the papillary muscles. Mitral regurgitation may be due to a disease that affects primarily the valve leaflets, such as mitral valve prolapse or rheumatic mitral valve disease, or may result from alterations in the function or structure of the left ventricle, such as those induced by ischemic disease or dilated cardiomyopathy.

Figure 20-2 Schematic diagram of the mitral valve based on Carpentier’s classification. The posterior mitral leaflet consists of three scallops. P1 is the smallest scallop, toward the left atrial appendage (LAA), and rarely prolapses. P2, the largest scallop of the posterior leaflet, is located at the middle of the leaflet. P3 is the small scallop toward the medial aspect of the mitral valve. The anterior mitral leaflet does not have real scallops but can be arbitrarily divided into three segments called A1, A2, and A3. The anterolateral commissure of the mitral valve is located between A1 and P1. The posteromedial commissure of the mitral valve is located between A3 and P3.

Figure 20-3 This diagram was designed in 1995 by the Toronto General Hospital Echocardiography Laboratory to identify the anatomopathology of the mitral valve by transesophageal echocardiography (TEE) to predict suitability for repair.¹ In this diagram, the mitral valve is viewed as if looking from the apex to the base of the heart. The transesophageal probe is positioned in the esophagus and is directed toward the mitral valve from posterior to anterior. Starting at the 9 o’clock position, to the left of the diagram, the corresponding TEE picture is shown. At 0 degrees, the ultrasound beam from right to left is crossing the mitral valve; therefore, P2 and A2 are visualized on this view as corresponding with the four-chamber TEE view. At 45 degrees, the ultrasound beam is cutting across the mitral valve from right to left. The beam crosses the large P2 scallop and will then cut through A2 and A3 in the anterior leaflet. At 75 degrees, the ultrasound beam crosses the left atrial appendage (LAA) from right to left, then the small P1 scallop, then, in the middle, P2 and A2 together, and finally, P3 of the posterior leaflet. This view also is called a commissural view. The LAA should be seen at the right side of the image and is the landmark for this view. At 105 degrees, the ultrasound beam, from anterior to posterior, crosses A1 first, followed by A2 and P2. At 135 degrees, which is the long axis of this view of the heart, the ultrasound beam crosses the aortic root and then A2 and P2. A1, anterior segment; A2, middle segment; A3, posterior segment; Ao, aorta; P1, anterolateral scallop; P2, middle scallop; P3, posteromedial scallop.

Figure 20-4 Transgastric short-axis view of the mitral valve at the level of the base of the left ventricle. This diagram was designed in the Toronto General Hospital Echocardiography Laboratory using the same classification as the illustration in Figure 20-3. Note the anterior (anterolateral) commissure (AC) at the bottom of the illustration and the posterior (posteromedial) commissure (PC) at the top. On this view, the site of origin of the mitral regurgitation can be defined by color Doppler flow mapping. A1, anterior segment; A2, middle segment; A3, posterior segment; P1, anterolateral scallop; P2, middle scallop; P3, posteromedial scallop; RV, right ventricle.

Figure 20-5 The same view as Figure 20-4, rotated 90 degrees to mimic the surgical view of the mitral valve looking from the left atrium toward the left ventricle. A1, anterior segment; A2, middle segment; A3, posterior segment; Ao, aorta; LAA, left atrial appendage; P1, anterolateral scallop; P2, middle scallop; P3, posteromedial scallop.

Figure 20-6 A, Nomenclature of mitral valve anatomy in the transgastric short-axis view. A1, anterior leaflet; lateral segment; A2, anterior leaflet, middle segment; A3, anterior leaflet, medial segment; AC, anterior commissure; LV, left ventricle; P1, posterior leaflet; lateral scallop; P2, posterior leaflet; middle scallop; P3, posterior leaflet; medial scallop; PC, posterior commissure; RV, right ventricle. B, Transgastric short-axis view of the mitral valve showing a flail P2 segment. C, Transgastric short-axis view of the mitral valve showing severe mitral regurgitation due to flail P2. The regurgitant jet is originating from the site marked by the arrow. D, Midesophageal transesophageal echocardiography (TEE) provides a long-axis view of the mitral valve showing flail P2 with a ruptured chorda tendina. Mild prolapse of the middle segment (A2) of the anterior leaflet can be seen. E, Pulsed-wave Doppler interrogation of the left upper pulmonary vein shows late systolic reversal flow, compatible with severe MR, as also demonstrated by color Doppler flow mapping (F). G, Postoperative assessment of mitral valve repair showing good coaptation of the mitral leaflets. The posterior annuloplasty ring can be appreciated. H, Color flow assessment of the mitral valve after repair shows no residual mitral regurgitation. Doppler assessment of mitral inflow after mitral valve repair revealed a mean gradient of 2 mm Hg, which is normal. Note that in the postoperative assessment of mitral inflow gradient, the patient usually is tachycardic, and it is better to measure the gradient following a premature ventricular contraction.

Figure 20-7 A, Preoperative transesophageal echocardiography (TEE). A four-chamber view of the mitral valve is obtained to measure mitral annular (MA) dilation at end-diastole. MA = 5.1 cm, which is categorized as severely dilated. B, Four-chamber view of the mitral valve showing severe prolapse of P2 and mild prolapse of A2 and A3. The mitral annular disjunction of the posterior annulus measured 1 cm, consistent with advanced Barlow’s disease, which makes mitral valve repair technically more demanding. A2, middle segment; A3, posterior segment; P2, middle scallop. C, Four-chamber color-flow view of the mitral valve, depicting a severe anteriorly directed jet of mitral regurgitation consistent with more severe involvement of the posterior leaflet. No central or posteriorly directed jet of MR is seen, indicating that prolapse of the anterior mitral valve leaflet (AMVL) is not creating any mitral regurgitation. D, Low esophageal TEE view of the mitral valve shows severe bulky mitral leaflets with increased aneurysmal surface area of the leaflets, which is seen in very advanced Barlow’s disease. E, Postoperative TEE assessment of the mitral valve in systole after repair, illustrating very nice coaptation. This mitral valve had a complex repair with quadrangular resection of P2 and two Gore-tex loops to P1. A posterior annuloplasty ring was inserted. Preoperative prolapse of A2 was due to lack of apposition and was resolved without the need for any intervention. F, Postoperative assessment of the mitral valve with color flow Doppler showing no residual mitral regurgitation.

Figure 20-8 A, Postoperative transesophageal echocardiographic (TEE) assessment after mitral valve repair shows good coaptation of mitral leaflets. Note echodensity at two sides of the mitral annulus, identifying the annuloplasty ring. B, Color flow assessment of the mitral valve immediately after the patient has come off the cardiopulmonary bypass pump showing a brief flash of moderate mitral regurgitation at early systole. This phenomenon is seen in some cases immediately after mitral valve repair with insertion of the semi-rigid Carpentier ring. It usually occurs at the early systolic phase and disappears after 10 to 15 minutes in response to remodeling of the new mitral annulus. It is not necessary to return the patient to the bypass pump to revise the repair. C, Same view as (B) showing color Doppler assessment of the mitral valve 10 minutes after the first evaluation, with no residual mitral regurgitation at early systole.

Figure 20-9 A, Preoperative transesophageal echocardiography (TEE). Four-chamber view of the mitral valve shows isolated flail middle scallop of the posterior leaflet (P2). The anterior mitral valve leaflet (AMVL) is normal. B, Preoperative TEE color Doppler assessment of the mitral valve showing a severe anteriorly directed jet of mitral regurgitation due to flail P2. C, Postoperative TEE assessment of mitral valve repair showing a posterior annuloplasty ring. Note that the cut-off sutures are visualized. D, Postoperative TEE assessment of mitral valve repair showing no residual mitral regurgitation.

Figure 20-10 A, Preoperative midesophageal transesophageal echocardiography (TEE) at 70 degrees (commissural view) illustrates isolated flail medial scallop (P3) of the posterior mitral leaflet. B, Same view as in (A) with color Doppler showing severe mitral regurgitation originating from isolated P3, directed anterolaterally and hitting the left atrial appendage (LAA), which is the classic regurgitation direction for isolated P3 flail. This color jet might be missed on the four-chamber view at 0 degrees. C, Preoperative transgastric short-axis view of the mitral valve showing absent P3 segment and a large gap at the posterior commissure (at the top of the figure). D, Same view as (C) with color Doppler showing MR jet from large gap at P3 and posterior commissural area. E, Postoperative assessment of mitral valve repair with posteromedial commissuroplasty and insertion of Cosgrove ring. F, Postoperative assessment of mitral valve repair with color Doppler showing no residual mitral regurgitation. Note that there is no regurgitant color inside the LAA (when compared to B).

Figure 20-11 A, Preoperative transesophageal echocardiographic (TEE) four-chamber view shows redundant, myxomatous anterior mitral valve leaflet (AMVL) with flail A2 and ruptured chorda tendina. B, Color Doppler flow mapping demonstrates a posterolaterally directed jet of severe mitral regurgitation (MR) due to flail A2. C, Severe posteriorly directed jet of MR seen on long-axis view. D, Preoperative transgastric TEE view of the mitral valve shows a large deficit at the area of A2 and A1. E, Postoperative TEE assessment of the mitral valve after repair with chordal transfer from P2 to A2 and insertion of a Gore-tex loop to A2 and an annuloplasty ring. The AMVL is seen billowing at the belly of the leaflet, but the tip of the leaflet is not prolapsing into the left atrium. This result is acceptable. F, Same view as (E) with color Doppler depicting no residual MR.

Figure 20-12 A, Preoperative midesophageal view shows a flail middle segment of the anterior mitral leaflet (A2) with a ruptured chorda. B, Same view as (A) with color Doppler identifying a severe posteriorly directed jet of mitral regurgitation (MR) due to flail A2. C, Doppler interrogation of the left upper pulmonary venous inflow shows systolic blunting consistent with significant MR. D,

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