Intraoperative transesophageal echocardiography: the roadmap for successful mitral valve repair

Figures

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  Video 1. Transesophageal echocardiography considerations for intraprocedural guidance.

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  Figure 1. Mitral valve anatomy.

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  Figure 2. Fibroelastic deficiency & Barlow’s disease.

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  Figure 3. ME & TG 2D TEE views of the mitral valve. 2D, two-dimensional; LAX, long axis view; ME, midesophageal; SAX, short axis view; TEE, transesophageal echocardiography; TG, transgastric.

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  Figure 4. Cannulation & device placement during robotic MV surgery. (A) GW in RA; (B) femoral venous cannula in RA; (C) GW across interatrial septum; (D) endoballoon in the ascending aorta; (E) GW in the descending aorta; (F) percutaneous retrograde coronary sinus catheter. GW, guidewire; MV, mitral valve; RA, right atrium.

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  Figure 5. Echocardiographic anatomy of the MV. (A) 3D TEE en-face image from the left atrium perspective (surgical view), showing the lateral (A1), middle (A2) and medial (A3) segments of the anterior mitral leaflet; and lateral (P1), middle (P2) and medial (P3) scallops of the posterior mitral leaflet. (B) 3D TEE surgical view, demonstrating a flail middle scallop (P2) of the posterior leaflet of the MV with ruptured chords in fibroelastic deficiency. (C) 3D TEE surgical view, showing bileaflet prolapse in Barlow’s disease. 3D, three-dimensional; MV, mitral valve; TEE, transesophageal echocardiography.

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  Video 2. 3D TEE en-face view of (A) the mitral valve; (B) P2 flail fibroelastic deficiency; (C) bileaflet prolapse in Barlow’s disease.

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  Figure 6. Modified en-face views of the mitral valve. (A) 3D TEE modified en-face posteromedial view from the LA perspective, demonstrating bileaflet prolapse. The direction of view is from the posteromedial toward the anterolateral commissure. (B) Tissue realistic 3D TEE modified en-face anterolateral view from the LA perspective, showing prolapse of A3, P3 and the posteromedial commissure. The direction of view is from the anterolateral toward the posteromedial commissure. (C) 3D TEE color flow Doppler modified en-face view from the left ventricle perspective, demonstrating two jets of MR. The secondary jet of MR located between A3-P3 was obscured by the main jet of MR and not identified from the left atrium perspective. 3D, three-dimensional; LA, left atrium; MR, mitral regurgitation; TEE, transesophageal echocardiography.

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  Video 3. D TEE anterolateral (A) and posterolateral (B) view of the mitral valve; (C) color 3D TEE left ventricular view.

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  Figure 7. Multiplanar reconstruction of the mitral valve. (A) 3D TEE MPR showing three 2D images (mid-esophageal mitral commissural view, inverted mid-esophageal long-axis view, and en-face mitral valve view) and one 3D rendered-image (surgical view). The red plane transects the mitral valve exactly through the middle of A2-P2. (B) 3D TEE live MPR demonstrating prolapse of P2. The green line transects though P2. The green square shows the presence of P2 prolapse. (C) 3D TEE MPR with color flow Doppler demonstrating mitral regurgitation. (D) 3D TEE MPR with color flow Dopler measuring the 3D vena contracta area of the jet of mitral regurgitation. 2D, two-dimensional; 3D, three-dimensional; MRP, multiplanar reconstruction; TEE, transesophageal echocardiography.

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  Figure 8. Three-dimensional transesophageal echocardiography volume slicing of the MV. (A) The MV is transected in multiple anteroposterior parallel planes from the lateral to the medial aspect of the mitral valve annulus (white, dotted lines in top image). (B) The tomographic planes are shown simultaneously on display. The blue and red squares show the exact location of the prolapse and flail at the medial aspect of the middle scallop of the posterior mitral leaflet (P3 side of P2). The blue and red squares correspond with the blue and red lines in the top image in (A). (C) Volume slicing with color flow Doppler. The blue and red squares show the exact origin of the jet of mitral regurgitation at the medial aspect of the middle scallop of the posterior mitral leaflet (P3 side of P2). MV, mitral valve.

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  Figure 9. Parametric models of the mitral valve. (A) 3D TEE parametric model of the mitral valve, demonstrating a flail middle scallop (P2) of the posterior leaflet. (B) 3D TEE parametric model of the mitral valve, showing bileaflet prolapse. The red color represents leaflet tissue that is located above the annular plane during systole due to prolapse or flail. 3D, three-dimensional; A, anterior; AL, anterolateral; EROA, effective regurgitant orifice area; MV, mitral valve; P, posterior; PM, posteromedial; TEE, transesophageal echocardiography.