The mitral valve consists of two leaflets, the anterior (A) and the posterior valve leaflet (P), which together have a surface area of 4-6cm. At the inner edges of the leaflets chordae tendinae are attached, which ensure that the leaflets did not prolapse back into the atria during systole. The chordae attach to two large papillary muscles, that are part of the muscular tissue of the left ventricle.
The mitral valve can be visualized in many views: PLAX, PSAXmv, AP4Ch, AP5Ch, AP2Ch, AP3Ch and subcostaal4Ch. A prolapse of the MV is best assessed on PLAX. However, mitral regurgitation should be assessed in all views. In case of major abnormalities of the mitral valve 3D TEE has additional value in assessing the anatomy and function.
Scallop partition of mitral valve
Quantification of mitral valve regurgitation
|Jet Area/LA (%)||<20||20-40||>40|
|Jet Area (cm²)||<4||4-10||>10|
|Vena contracta (mm)||<3||3-7||>7|
Echocardiographic criteria for the definition of severe mitral valve regurgitation: an integrative approuch
|Valve morphology||Flail leaflet/ruptured pappilairy muscle/large coaptation defect|
|Colour flow regurgitant jet||Very large central jet or eccentric jet adhering, swirling and reaching the posterior wall of the LA|
|CW signal of regurgitant jet||Dense/triangular|
|Other||Large flow convergence zone *|
|Vena contracta width (mm)||≥7 (>8 for biplane) **|
|Upstream vein flow||Systolic pulmonary vein flow reversal|
|Inflow||E-wave dominant ≥1.5 m/s ***|
|Other||TVI mitral/TVI aortic >1.4|
|Regugitant volume (mL/beat)||≥60||≥30|
|Enlargement of cardiac chamber/vessels||LV, LA|
|* At Nyquist limit of 50-60 cm/s.
** For average between AP4Ch an AP2Ch.
*** In the absence of other causes of elevated LA pressure and of mitral stenosis.
**** Different thresholds are used in secondary mitral regurgitation where an EROA >20mm² and regurgitant volume > 30mL identify a subset of patients at increased risk of cardiac events.
Severe MR because of prolaps
Causes of mitral valve regurgitation
|Annulus dilation||Degeneracy||Acquired valve deviation||Secundary|
|Atriumfibrillation||Malcaptation in mitral valve stenosis||Billowing||Rhythm disorders (LBBB-->diastolic MR)|
|LV dilation||Prolaps||SAM in HCM|
|LA dilation||Floppy valve|
|Ruptured Papillary muscle|
Ruptured mitral chordae tendineae assessed with 3D TEE
Quantification of mitral stenosis
|MVA (cm²)||> 1.5||1.5 - 1.0||< 1.0|
|PGmean (mmHg)||< 5||5 - 10||> 10|
|PHT (m/s)||< 90||90 - 150||> 150|
Causes of mitral stenosis
|Rheumatic fever||Cor triatriatum sinistrum|