Standard Views of the Mitral Valve
Part 1
· Dr. Colleen Koch · Dr. Mariel Manlapaz · Dr. Andrej Alfirevic ·
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Education>Expert TEE>Mitral Valve>Mitral Valve 2D Views>1
Part 1 of 4
 
 
Editor's Note:  Some confusion exists about which scallops are being viewed in the midesophageal views because the ASE-SCA guidelines are different than some later published articles from Lambert or Foster .  The Lambert and Foster systematic method of examination of the mitral valve correctly identified the scallop in 92% and 96% of cases respectively.  The ASE-SCA views do not include multiple views in the zero degree multiplane angle (the 5 and 4 chamber views).  Lambert or Foster have multiple views from the same acoustic window with the probe cycling thru A1/P1-A2/P2-A3/P3 as the probe is advanced/withdrawn, flexed/retroflexed or changes in the multiplane angle occur.  The test questions will include the standard views of the ASE-SCA guidelines.  The alternate views, which are frequently presented or included in meetings, are shown in the following pages and are noted to be from Lambert or Foster.

Standard Views of the Mitral Valve
 
The standard views of the mitral valve complex are the listed below.  From each view, components of the mitral valve complex can be identified and assessed to indicate the mechanism of mitral valve dysfunction.   All of the standard views, if possible, should be included in the evaluation of the mitral valve. Listed below are the standard views based upon the SAC/ASE guidelines, views from the Foster article, and views from the Lambert article. 
 
Views of the Mitral Valve
ASE/SCA
  ME 5CV not a Standard view
ME 4CV A3/P1
ME MCV P3/A2/P1
ME ACV A3/A2/A1
ME PCV P3/P2/P1
ME 2CV P3/A1
ME LAX A2/P2
bTG SAX
TG 2CV
Views of the Mitral Valve
Foster et al
ME 5CV A1/P1
ME 4CV A2/P2
ME 4CV A3/P3
ME MCV P3/A2/P1
ME ACV A3/A2/A1
ME PCV P3/P2/P1
Views of the Mitral Valve
Lambert et al
ME 5CV A1-2/P1-2
ME 4CV A2-3/P2-3
ME 2CV (Ant) P3/A3-2 
ME 2CV(Mid) P3/A2/P1 *
ME 2CV(Post)  P3/P2/P1 *
bTG SAX
  * This view is consistent with the MCV

 
Probe Position Base of Heart Beam Angle View

Probe Position/Views
 
All of the above views can be incorporated into an echo exam of the mitral valve.  The probe is then advanced to the standard 4 chamber view.  The multiplane plane may have to be slightly rotated up to 20 degrees to obtain an optimal view of the 4 chamber view. 

The probe can be either slightly anteflexed or withdrawn to obtain an anteriorly directed beam which shows a 5 chamber view. 

The probe is slightly retroflexed or advanced from the standard 4 chamber view to obtain a posteriorly directed 4 chamber view. 

Returning to the standard 4 chamber view, the multiplane plane is rotated to 30 - 60 degrees to obtain the mitral commissural view. 

The probe is rotated to the right to obtain the anterior commissural view and rotated to the left for the posterior commissural view. 

Returning to the mitral commissural view, the multiplane plane is rotated to 90-110 degrees to obtain the standard 2 chamber view. 

Rotating the multiplane plane to 130 degrees obtains the aortic valve long axis view. 

The short axis view of the mitral valve is obtained by returning the multiplane plane to 0 degrees, advancing the probe to the basal transgastric acoustic window, and slightly flexing the probe. 

The transgastric 2 chamber view is obtained by advancing the probe to the mid transgastric acoustic window and rotating the multiplane angle to 90 degrees. 

From the systematic examination of the mitral valve, the mechanism of mitral regurgitation and/or stenosis is usually evident.
   
Midesophageal 5 Chamber View (ME 5CV)
 
The 5 chamber view is not a standard SCA/ASE view.  The 5 chamber view is obtained by withdrawing or slightly ante flexing the probe from the 4 chamber view. The 5 chamber view cuts through the aortic valve and the anterior aspect of the mitral valve.  The A1/P1 scallops are that are visualized according to Foster.  The A1/P1 or A2/P2 scallops are visualized according to Lambert.  The midesophageal 5 chamber view contains the left atrium, left ventricular outflow tract, mitral valve annulus, anterior mitral valve leaflet, posterior mitral valve leaflet, chordae, anterolateral papillary muscle and the lateral myocardial wall. 
 
TEE Echo Probe Base of Heart Beam Angle TEE View
A1/P1 View (Foster)         
A1-2/P1-2 View (Lambert)
 
   
script

Foster el al
script
Image of 5CV (A1/P1) Video of 5CV(A1/P1)
   
script

Lambert el al
script
Image of 5CV (A1/2 - P1/2) Video of 5CV  (A1/2-P1/2)
Midesophageal 4 Chamber View (ME 4CV)
 
The 4 chamber view cuts through the middle of the mitral valve and the middle or posterior portion of the tricuspid valve (posterior and septal leaflets).  The A3/P1 scallops are present in this view according to the ASE/SCA guidelines. The midesophageal 4 chamber view contains the lateral and septal walls of the myocardium and the anterolateral papillary muscle.
 
Foster shows that flexing/withdrawing and retro flexing/advancing the probe from the 4 chamber view will cycle through the A1/P1, A2/P1, and A2-3/P1 scallops.  The standard 4 chamber view contains the A2/P2 mitral valve scallops and the posterior/septal leaflets of the tricuspid valve.  Withdrawing or slightly ante flexing the probe will show the A1/P1 mitral valve cups and the tricuspid valve leaflets will disappear.  Advancing or slightly retro flexing the probe will show the A3/P3 scallops of the mitral valve.  Further advancement results in the loss of the mitral valve with only the tricuspid valve present.  By cycling through the A1/P1, A2/P1, and A2-3/P1 scallops, an indication of the mitral valve pathology should be evident.
TEE Echo Probe
Foster et al
  Heart Beam Angle 1X 2X 3X 4X
  Advance/Withdraw
  Ante flex/Retro flex
 
 

Lambert has the 4 chamber view showing the A2/3 and P2/3 scallops.  Withdrawing the probe from the 4 chamber view shows the 5 chamber view.

 
TEE Echo Probe Base of Heart Beam Angle TEE View
ASE/SCA Foster et al Lambert et al
  ME 5CV - Anteriorly Directed    
ME 4CV - Neutrally Directed    ME 4CV - Neutrally Directed    ME 4CV - Neutrally Directed   
  ME 4CV - Posteriorly Directed  
 
script

script
ME 5CV (A1/P1)  (Foster) ME 5CV (A1/P1)  (Foster)
   

Foster  (A2/P2):: 1X 2X 3X 4X           
ASE/SCA  (A1/P3): 1X 2X 3X 4X      
Lambert  (A2/3-P2/3): 1X 2X 3X 4X
script
ME 4CV ME 4CV
   
script
script
ME 4CV (A3/P3)  (Foster) ME 4CV (A3/P3)   (Foster)
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User Comments
 
 
Re: (StandardViewsoftheMitralValve) .    Webmaster Comment     Rating:   Add a Star to the Comment   Subtract a Star to the Comment   Star Star Star Star Star 
Comment  Webmaster    #228
Comment:
Trying to decide which scallop you are viewing can be difficult because the orientation of the heart may not follow the standard ASE-SCA format (which is on the exam). I prefer to advance the probe in the zero degree plane just until the mitral valve scallops are viewed. This should be the A1/P1 scallops and the LVOT should be in the plane also. Further advancement causes the LVOT to just barely disappear and the mitral valve scallops in the zero degree plane should be A2/P2. Further advancement will bring the tricuspid valve into full view and the mitral valve scallops should be A3/P3. I then confirm the location of the lesion and scallop using the commissural view and the 2 Chamber view and the Aortic Valve long axis view - again sweeping the probe from posterior to anterior in the mid commissural view, from anterolateral to posteromedial in the 2 chamber view, and anterior to posterior in the aortic valve long axis view - again recognizing which scallops are in view. Hearts that are not correctly oriented to the standard views can be interrogated using the this technique to find the scallop and lesion location.
 
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