Transoesophageal echocardiography in mitral valve surgery

Blog Post by Barbora Parizkova, Stephen Webb 

Mitral valve (MV) repair and MV replacement are classified as Class I and IIA indications for intraoperative transoesophageal echocardiography (TOE) by the American College of Cardiology and the American Heart Association.

Recently the cause of MV pathology in most industrialised nations has changed over the last decades from predominantly rheumatic to degenerative and ischemic valve disease. Rheumatic heart disease usually presents as mitral stenosis, while myxomatous degeneration is the most common cause of native mitral regurgitation. Mitral regurgitation can also develop in patients with left ventricular (LV) dysfunction, endocarditis or acute myocardial infarction with papillary muscle rupture.

The MV consists of a fibrous annulus, two leaflets and the subvalvular apparatus. The anterior mitral valve leaflet originates from the anterior part of the MV annulus and is continuous with the aortic root. The posterior mitral valve leaflet originates from the free LV wall, enclosing the greater part (about 70%) of the MV annulus, which is poorly supported and therefore prone to dilatation under pathological conditions. The subvalvular apparatus consists of the left ventricular wall, papillary muscles and chordae tendineae. 

To determine the feasibility of valve reconstruction, TOE is vital. The TOE examination consists of four standard mid-oesophageal views (four-chamber, commissural, two chambers and long-axis) and two transgastric views (basal short axis, two chamber). In each view the valve should be assessed with 2-D imaging and colour flow Doppler.  Evaluation of the transmitral and pulmonary venous Doppler waveforms should be part of the complete examination. The annulus should be screened for calcification and annulus dilatation is determined by measuring the anteroposterior diameter. A diameter of less than 35 mm may be considered normal. The MV leaflets should be screened for thickening, calcification or excessive leaflet tissue.

The information from TOE examination is important for the choice of treatment. The postoperative TOE examination assesses the result of the surgical procedure.

Following MV repair, the presence of residual regurgitation, systolic anterior motion (SAM) or valvular stenosis must be assessed. After MV replacement any significant paravalvular leak must be excluded.

For more information, please see Core Topics in Cardiac Anaesthesia, 2nd edition, edited by Joseph Arrowsmith and Jonathan Mackay, published by Cambridge University Press.


2 Responses to Transoesophageal echocardiography in mitral valve surgery

  1. stephentwebb says:

    Reblogged this on Heart & Lungs and commented:
    Update on TOE for mitral valve surgery

  2. Sanford Brookins says:


    I am a Pastor and Navy veteran. Earlier this year I was hospitalized for six days and the Non-invasive echo-doppler echocardiography revealed that I had moderated concentric left ventricular hypertrophy. LV apex is heavily trabeculated suggestive of apical HCM vs. LV noncompaction. The right ventricle is not well seen. The “Color Flow and Doppler” study showed trace mitral regurgitation based on the color flow doppler analysis: Impression: The left ventricle is normal in size with normal systolic function, LVEF=60%. There is moderate concentric left ventricular hypertrophy. LV apex is heavily trabeculated suggestive of apical HCM vs. LV noncompaction.

    This was during an April 14-19 stay at a VA hospital. The changed my medication to Carvedilol 12.5MG and it makes me feel the most normal. The other medications that I had been taking, HCTZ 25/Lisinopril 20mg does not lower my BP so I stopped taking them. Nifedipine 60mg cause shortness of breath and little mobility so I stopped taking that. My primary problem now is my throat area gets tight and its not normal. I have changed my diet and I am also a vegitarian with the exception of occasional fish. My throat is still a problem and I can not move around or run due to the enlarged heart. The VA has basically given me a clean bill of health with no disability. I am no where close to what I was before April 14th of this year. What do you think about my situation?

    Sanford Brookins
    (863) 529-7485
    (863) 686-9053
    1007 W. 6th Street
    Lakeland, FL 33805

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