Written by Andrea Fields MHA, RDCS

Finally… Mitral Valve Orientation Explained!

Last week, we covered the basic anatomy of the mitral apparatus. We reviewed in detail, the various structures and their function.  As we continue with our mitral regurgitation blog series, we want to touch next on, specific imaging windows to evaluate the mitral valve.  Remember, when we examine the valve, we need to make sure we include all structures of the apparatus.

Mitral Valve: Echo Perspective

When we talk about the mitral apparatus, we need to understand how the image varies depending on the angle and viewpoint we are scanning from. As sonographers, we need to remember that echo images of the mitral valve are displayed upside down & backwards! First, let’s get our basic orientation down:

Ultrasound Image Slice Orientation

Heart Valves Transverse Imaging Plane

This can get a little confusing when trying to communicate with surgeons.  Surgeons think of the heart in the anatomical orientation and look at the mitral valve from the left atrium. Sonographers/cardiologists, often think from an ultrasound orientation and look at the mitral valve from the left ventricle.

Surgeon View vs TTE View Mitral Valve

For this blog, we are going to review anatomy, from the orientation of looking at the mitral valve from the left ventricle.  Just as we do during a transthoracic echo.  Remember, we scan upside down & backwards with the ventricles ‘on-top’ of our sector.

Regardless of the angle you’re viewing the mitral valve from, these anatomical tips will always help orientate you:

  • A1/P1 –  lateral
  • A3/P3 –  medial
  • Aorta (AO) –  anterior
  • Left atrial appendage (LAA) –  lateral with A1/P1

Mitral Valve Imaging

We have 4 standard views to visualize the mitral valve:

  1. Parasternal long axis (PLAX)
  2. Parasternal short axis (PSAX)
  3. Apical 4 Chamber (AP4)
  4. Apical 2 Chamber (AP2)

TTE Echo Mitral Scallops Identification

By angulating our transducer from our standard views, we can image more than the ‘set standard’ scallops seen. Let’s break down the four views to better explain!

Parasternal Long Axis (PLAX)

PLAX Parasternal Long Axis View Mitral Valve Scallops MV Echo

From the PLAX viewing window, we are able to see A2 & P2 of the mitral valve.

PLAX Parasternal Long Axis View Mitral Valve Scallops MV Echo

We are able to view additional scallops by a simple change in angulation of the transducer:

  • Angle transducer superior (towards RV outflow) identify: A1/P1
  • Angle transducer inferior (towards RV inflow) identify: A3/P3

Parasternal Short Axis (PSAX)

Mitral Valve Leaflets & Scallops:

PSAX Mitral Valve Scallops

From the PSAX window, we can visualize all 6 scallops of the anterior & posterior leaflets!

Parasternal short axis view PSAX Mitral Valve Scallops Echo

Papillary Muscles:

PSAX Papillary Muscles

Papillary Muscles Echo Mitral Valve

Apical 4 Chamber (AP4)

Apical 4 Chamber AP4 Mitral Valve Scallops Echo

From the AP4 standard view, we can identify A3/A2/P1!

Apical 4 Chamber AP4 Mitral Valve Scallops Echo

This imaging window is easy to slightly angle our transducer in order to visualize more scallops!

  • Angle anterior (bringing in apical 5 chamber view) to visualize A1/P1 and the anterolateral commissure.
  • Angle inferior (visualizing long-axis of coronary sinus) to visualize A3/P3 and the posteromedial commissure.

Apical 2 Chamber (AP2)

Apical 2 Chamber AP2 Mitral Valve Scallops Echo

From the AP2 standard view, we can visualize P3, A2 & P1. This view can be confusing: Why do we see the middle scallop of A2? This is because we are viewing the mitral valve at an angle where both coaptation points occur, causing A2 disappears during diastole.

Apical 2 Chamber AP2 Mitral Valve Scallops Echo

We can identify more scallops by angulating our transducer:

  • If we angle the transducer anterior, we will visualize a longer anterior leaflet with a shorter posterior.
  • If we angle posterior, we will not visualize a coaptation zone, imaging the posterior leaflet (and mostly P2).

Summary

By the end of this blog, we hope that you can know the 4 standard views for imaging the mitral valve and corresponding scallops.

Mitral Scallops Summary Table Transthoracic Echo TTE

Remember that just because you’re imaging a specific window does not mean you are seeing the standard scallops associated with that view. The mitral scallops are small segments and can easily be viewed by a simple angulation of the transducer.

Mitral Scallops Summary Table Transthoracic Echo TTE

We hope you are enjoying our mitral regurgitation blog series. Now that we have our basic anatomy, structure and imaging planes covered–keep an eye out for our blog next week over mechanisms of mitral regurgitation!

Want to earn Cat. 1 AMA CME for this blog? Click HERE!

Andrea Fields MHA, RDCS

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References: 

Prokšelj, K. (2015). Echocardiography Of The Mitral Valve. International Symposium MITRAL VALVE DISEASES IN CHILDREN AND ADULTS. doi:10.5644/pi2017.168.03

Zoghbi, W. A., MD, Adams, D., RCS, RDCS, FASE, & Bonow, R. O., MD. (2017). Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation. JASE,30(4), 318-334. Retrieved June 6, 2017.

Zamorano, J. L., MD, & Badano, L. P. (2011). EAE/ASE Recommendations for the Use of Echocardiography in New Transcather Interventions for Valvular Heart Disease. JASE,24(9), 957-960. Retrieved June 6, 2017.

adult echoASE guidelinescardiac chamber quantificationechoechocardiographyinterpretive qualityleft atriumleft ventricleMitral AnnulusMitral ApparatusMitral CommissuresMitral LeafletsMitral Regurgitationmitral scallopsMitral ValveMitral Valve ApparatusMRMVpapillary muscles

LET US KNOW WHAT YOU THINK...

JULIO FARJAT RUIX
EXCELENT
Dr SJS Randhawa
Thanks for the detailed blog. Very useful
Meena Sumathy
Exemplary blog. Great work.
cfpedersen@optusnet.
Fantastic information - wish it was available when I was training!
sameera
i like this new methode of clarification of MV anatomy
Sellami
Thank you
Thanks for sharing
It was great .hope u 'll also tell about mitral valve repair echo criteria from surgeon point of view
Sellami
Thanks
Sellami
Merci
Luz Dinora Sandoval
Anatomía de mitral
Bayo
Great Job
Bayo
Well done
Adnan hussien
Vey informative
Dr Ejazul Haq
Good
Dana R Parker
Thanks for the excellent review of mitral valve imaging. This blog is very interesting. Thanks.
Thanks for sharing
Pls tell about mitral valve repair echo Regards
Naheed Ali
Well done. Given that most cardiologists and Sonographer would never actually see the "surgeons view" of mitral anatomy, adding TEE views to this blog with further clarify anatomical details.
Kris maahs
Thanks
Elizabeth
Excellent, congratulations. Thanks a lot
Juan
Thanks
DRAGANA ŠARENAC
Very usefull, practic and applicable Thanx
Alex Fishkov
EXCELLENT
Alex Fishkov
Thank you for your article!
ahmed al masry
very good demonstration I hope to see other valves if you can provide video clips it will be a great thing
Muhammad Aslam
Very informative Blog
ALISON
Great!
Dr.Khaled
Thank you very much.you made it very interesting.

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