 Greetings and welcome. My name is Annette Vegas. This session will show examples of mitral valve pathology using 3DTE. I have no conflict of interest. Mild mitral regurgitation is a normal finding in 40% of patients. There are many causes of mitral regurgitation, which in part reflects the complexity of the mitral valve apparatus. Common pathologies involving the mitral leaflets include prolapse, flail, myxomatous, perforation, cleft, endocriditis, calcific, and rheumatic. The annulus may be dilated or calcified and the cordae may rupture or become restricted, resulting in mitral regurgitation. The muscular portion of the apparatus, the poplary muscle, or underlying myocardium, may become ischemic, leading to mitral regurgitation. Patients with abnormal left ventricular outflow tract anatomy may experience SAM and mitral regurgitation, which may require additional surgical or medical management. When examining the mitral valve using 3D, the most common display is the on-fast view. But how do you approach analyzing what you see? First, I typically will ensure the valve is orientated correctly with the aortic valve at 12 o'clock and the left atrial appendage at 10 o'clock. The other easy way is to make sure the valve smiles at you. Then identify the posterior leaflets' scallops and corresponding anterior leaflet segments and commissures. Look at leaflet morphology. Is it rough or smooth? Is there excessive tissue or masses? Do the leaflets co-apt or are there gaps? Is there excessive motion? Are there torn cordae? And finally for the annulus, is there mitral annular calcification? Can we just use 3D imaging to assess the mitral valve? Typically, 2D and 3D are complementary techniques and both should be used to interrogate the mitral valve. Let's challenge ourselves, however, and see if we can make a diagnosis using different options to manipulate the 3D data sets. Have a look at this on-fast view. What do you think the diagnosis is? Is it A, A2, P2, B, A1, P1, C, A1, A2, P1, P2, D, A2, A3, P1, P2, P3, or E? All of the segments. Let's do something simple and apply the angle view. Shown here are clips from rotation of the mitral valve around 360 degrees. The multiple choice options remain the same. Another option is to use multi-planar reconstruction, in this case using specialized software. Cuts taken through the on-fast view are shown. Again, the multiple choices are the same. Any thoughts? So what did the surgeon find? The surgeon found a Barlow's valve with a prolapse of all segments except for A1. This was best shown using NPR, which did not show prolapse of A1. This is worn out by the literature. In a 3D TEE study that looked at leaflet pathology prior to mitral valve repair, the majority of disease involved monoleaflet monosegment for P2. The least affected region was the A1 segment. This patient presents with an obvious mitral valve pathology. See if you can figure it out, which segments are pathological. Look at the 3D on-fast view. Can you see a smooth looking valve with severe prolapse and a flail segment with torn cordae? This is confirmed by the 2D color compare at 0 degrees with an eccentric anterior directed jet of mitral regurgitation. And the 3D live cut through A2 P2. This static 3D paramedic model also confirms the showing the prolapse in red. This is an example of fibroelastic P2 flail that required resection of P2 and a band. This patient is a 59 year old female with mitral regurgitation. Examine the on-fast view and try to identify the pathology. Look at the leaflets, leaflet mobility, and annulus. Here are some 2D color compare views. Why does the mitral valve leak? There is a P3 prolapse seen in the circle in the 3D on-fast view, and the lower color compare view showing an anterior directed mitral regurgitation jet. There is also restriction of the posterior leaflet from significant mitral annular calcification. The extent is nicely seen by the arrow in the 3D on-fast view. This patient underwent a successful but challenging tissue mitral valve replacement. A larger skeleton around the mitral valve can become calcified, a common condition called mitral annular calcification. MAC has a prevalence of 10% and affects the posterior more than the anterior mitral valve annulus. In most cases, leaflet mobility is unaffected, and mitral valve function is preserved with little hemodynamic consequences. MAC can be seen easily with 2D imaging as an echogenic region on the annulus with shadowing beneath, and the extent can be defined using 3D imaging. The presence of significant MAC presents a management conundrum as it can complicate mitral valve repair and replacement. This is a 74 year old male with mitral regurgitation and coronary artery disease. Based on the on-fast view, what is the mechanism of mitral regurgitation? Does a 3D color help at all? What about this 2D mitosophageal mitral valve view of the mitral valve with color? The diagnosis is fibroelastic disease with an A3P3 prolapse. The patient underwent a mitral valve replacement in ACB with a 90 minute bypass time. This is a 63 year old male with mitral regurgitation. Here is the on-fast view. Comment on the leaflets, leaflet mobility, and annulus. Now look at the 2D mitosophageal mitral valve view with color. And finally, the sagittal cup through the mitral valve. So what do you think the diagnosis is? This is an isolated A1 prolapse, as confirmed by the parametric model. The patient underwent a successful complex mitral valve repair. This is a 67 year old female intubated with congestive heart failure, presenting for urgent cardiac surgery. Here is the on-fast view of the mitral valve. Take a moment to examine leaflet morphology, leaflet mobility, and the annulus. What looks abnormal? Here are the mitosophageal 4-chamber view with color. And finally, a 3D view with color of the left ventricular outflow tract. Did you spot all the pathologies associated with this mitral valve? There is calcification of the posterior annulus, flail P3, and turbulence in the left ventricular outflow tract, likely from SAM. This is a 62 year old female with mitral regurgitation. Look at the on-fast view. What abnormality is present? Does it involve leaflet morphology, leaflet mobility, or the annulus? Here are some 2D color compare images from the mitosophageal and transgastric levels. What is the diagnosis? There is a localized thickening of the posterior annulus in the PT region. This patient had a granuloma. The valve could not be spared, and the patient underwent mitral valve replacement. This is a 74 year old female with mitral regurgitation. What is the pathology based on the 2D on-fast view? Again, think about leaflet morphology, leaflet mobility, and the annulus. Here are some additional 3D views from the left atrium and the left ventricular sides. And finally, a 3D mitosophageal 4-chamber view which confirms the diagnosis. Which is rheumatic stenosis. Note on the 3D on-fast view the fusion of both commissures, which is pathodemonic or rheumatic mitral stenosis. This is a 59 year old female with mitral regurgitation and coronary disease. Look at the on-fast view and comment on the leaflet morphology, leaflet mobility, and annulus. Not surprisingly, when looking at the 2D and 3D live images, it makes it clear what the diagnosis might be. Here both leaflets of the mitral valve are restricted in mobility, and there is central male co-optation suggesting ischemic mitral regurgitation. The 3D mitral model shows the funnel shape of the valve and can help quantify the tending height and volume. In this example of a 59 year old female with mitral regurgitation, the patient presents with a significant amount of mitral regurgitation. The 2D color compare imaging, there appears to be at least two origins for the mitral regurgitation jet. The 3D on-fast view confirms the perforation of the anterior mitral valve leaflet. The patient underwent a tissue mitral valve replacement. So this is a 40 year old female with shortness of breath. Look at the 3D view taken at zero degrees. What do you think the diagnosis is? Here is the 2D view also at zero degrees and a zoom of the prosthetic valve. What is the diagnosis? How many think the mitral valve is normal? Well, that would be the correct diagnosis. As this patient had LTGA as shown in the apical displacement of the atrophentricular valve on the right side of the display and co-planar aortic and pulmonic valves. This patient in fact had a thrombose tissue, tricuspid valve. We are going to close by looking at clefts in the mitral valve. Clefts are notoriously difficult to diagnose with 2D TEE and one might think are easier to diagnose with 3D. We commonly think of clefts associated with congenital heart disease, specifically AVSDs, shown in this example. It's an AVSD with a cleft of the anteromunchal valve leaflet, which should be called a co-optation with bridging leaflets. Isolated clefts can also appear independent of congenital heart disease and by definition involve greater than 50% indentation of the leaflet to about the annulus. Confusingly, these are sometimes referred to as profound indentation rather than clefts. Isolated clefts rarely involve the anterior leaflet and even more rarely affect the posterior leaflet. What about this 3D on fast view? Cleft or no cleft? With this amount of mitral regurgitation, how should the surgeon deal with mitral regurgitation? Repair or replace? Just when you think you are starting to understand something, someone comes along and says, well there are a third entity called the trile leaflet mitral valve. Characteristics of this pathology include the presence of three commissures and zones of co-optation. This contrasts with an isolated cleft which has a single cleft with two zones of co-optation. All of these are different from the trifolate valve. On that note, we will end. Thank you very much.