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Cardiovascular Anesthesiology: Technical Communication

En Face View of the Mitral Valve: Definition and Acquisition

Mahmood, Feroze MD*; Warraich, Haider Javed MD*; Shahul, Sajid MD*; Qazi, Aisha MD*; Swaminathan, Madhav MD; Mackensen, G. Burkhard MD, PhD; Panzica, Peter MD*; Maslow, Andrew MD

Author Information
doi: 10.1213/ANE.0b013e3182662dd9

Intraoperative precardiopulmonary bypass transesophageal echocardiography (TEE) is integral to surgical mitral valve (MV) repair.1,2 Three-dimensional (3D) echocardiography provides a dynamic display of the entire MV from different angles as well as different perspectives, e.g., left atrium (LA) and left ventricle (LV). The view from the LA, which corresponds to the surgeon's view from an LA perspective, has been referred to as the “en face” or “surgeon's” or “surgical” view of the MV. However, despite the widespread use of this particular view, only abbreviated explanations are provided regarding the orientation of the MV and its relations to surrounding anatomical landmarks. To address these inconsistencies, we drew upon our experience to suggest a comprehensive definition and image orientation of the LA perspective of the en face view of the MV as seen using 3D TEE. A definition of the en face view would aid communication among caregivers (anesthesiologists, cardiologists, surgeons, sonographers) and may enhance the understanding of the en face view when it is described in the literature or discussed in academic meetings. Because 3D datasets allow echocardiographers to visualize the MV from both the LA and the LV perspective, we present a definition of the LV en face view of the MV as well. This description is based on MV imaging performed using IE-33 systems equipped with the X7-2t “matrix” probe (Philips Medical Systems, Andover, MA).

A search of the English medical literature database (PubMed [NLM]), using keywords such as “en face,” “surgical view” and “surgeon's view” with “mitral valve” starting from 1993, when 3D-TEE technology was introduced, until February 2012, at the time this manuscript was written. Both full-text and abstract-only English-language articles available via institutional subscriptions were accessed. These included both TEE and transthoracic echocardiography articles using real-time/“live” (instantaneous online 3D image acquisition dynamically responsive to probe manipulation, e.g., live 3D, 3D zoom) as well as R-wave gated acquisition. The en face and surgical view of the MV were used interchangeably to describe the LA perspective of the MV. There are significant variations in the description of this view, and image orientation relating to positioning of the surrounding anatomical structures such as the aortic valve and the LA appendage.321 Description of the position of the aortic valve, which is useful to identify the anterior mitral leaflet, varied from 9 o'clock to 1 o'clock position.320 Other reports have described the orientation of the MV without delineating specific anatomical landmarks. The recent guidelines published by the American Society of Echocardiography have only mentioned the en face view of the MV as the view from the LA perspective with aortic valve at 1 o'clock position.22


The LA en face view refers to a forward-facing view of the MV from the LA perspective reflecting the surgeon's view through a left atriotomy with the patient in the supine position (Figs. 1 and 2) (Video 1, see Supplemental Digital Content 1, Important landmarks to orient the viewer include the LA appendage at 9 o'clock and aortic valve at 12 o'clock positions. The image should include a clear and uninterrupted line of coaptation extending from the anterolateral commissure, seen on the left at 9 o'clock, to the posteromedial commissure, on the right at 3 o'clock position. The anterior mitral leaflet lies above the line of coaptation and the posterior mitral leaflet below it. The posterior leaflet consists of 3 scallops (P1, P2, and P3) and the adjoining portions of the anterior leaflet are classified into 3 corresponding segments (A1, A2, and A3).2 This classification scheme has also been used with success for description of perivalvular mitral regurgitation jets.23

Figure 1
Figure 1:
Artistic rendition of the left atrial en face view of the mitral valve. AV = aortic valve; CS = coronary sinus; LAA = left atrial appendage; LCC = left coronary cusp; NCC = noncoronary cusp; RCC = right coronary cusp; TV = tricuspid valve; A = anterior; P = posterior. Adapted from Biaggi et al.21 with permission from Elsevier.
Figure 2
Figure 2:
Left atrial en face view of the mitral valve, acquired using full-volume R-wave gated imaging. AV = aortic valve; CS = coronary sinus; LAA = left atrial appendage; TV = tricuspid valve.

Additional anatomical landmarks for orientation include the coronary sinus, which may be visualized along the atrioventricular groove below the posterior mitral leaflet, and the tricuspid valve and right ventricle, which may be visualized on the right side of the display. Additionally, left upper and lower pulmonary veins may be visualized adjacent to the left atrial appendage. This image allows anatomical and functional assessment of the mitral leaflets; however, in some cases, tilting of the image may be required to appreciate MV pathology.

Although the en face view refers to the surgical view, the acquisition of volumetric data permits the rotation of the 3D image, so that the MV can be seen from the LV side. This is achieved by rotating the image 180 degrees horizontally such that the aortic valve maintains its 12 o'clock position. From this view, the anterior and posterior mitral leaflets, their line of coaptation, and the LV outflow tract above the anterior leaflet can be seen (Fig. 3) (Video 2, see Supplemental Digital Content 2, This image allows a dynamic assessment of the ventricular aspect of the mitral leaflets. This view is particularly useful in visualizing the relationship of the mitral leaflets to the LV outflow tract.

Figure 3
Figure 3:
Left ventricular en face view of the mitral valve, acquired using full-volume R-wave gated imaging. IVS = interventricular septum; LVOT = left ventricular outflow tract; RVOT = right ventricular outflow tract; TV = tricuspid valve; A = anterior; P = posterior.


Three-dimensional echocardiographic imaging for acquisition of the en face views can be accomplished in 3 different imaging modes: 3D zoom, full-volume R-wave gated, and full-volume single-beat imaging (Table 1).

Table 1
Table 1:
Three-Dimensional (3D) Modes for Left Atrial En Face Imaging

3D Zoom Mode

Three-dimensional zoom is a live imaging mode that displays a smaller but magnified pyramidal-shaped 3D image from within the main beam of the 3D TEE probe. This view provides the best spatial resolution but the frame rate is relatively low and color flow Doppler (CFD) information cannot be incorporated. For 3D zoom acquisition, an optimal midesophageal view of the MV is acquired as the first step. By activating the preset 3D zoom on the ultrasound system, the original and its orthogonal image are shown together, side by side with a default scalene box demarcating the region of interest (ROI), i.e., the MV (Fig. 4) (Video 3, see Supplemental Digital Content 3, The ROI must include the entire MV annulus and leaflets in systole and diastole, which is achieved by adjusting the x, y, and z dimensions of the ROI. For improved spatial orientation, the aortic valve should be included in the ROI (Video 3, The en face view of the MV from the LA perspective can then be imaged (Video 4, see Supplemental Digital Content 4, Because of the live nature, the acquired image is probe sensitive, i.e., the image moves with TEE probe motion (Video 5, see Supplemental Digital Content 5,

Figure 4
Figure 4:
Two midesophageal orthogonal planes are displayed before live zoom image acquisition. The green region of interest box can be adjusted to acquire the area required for 3-dimensional (3D) acquisition. Care should be taken that the entire mitral valve apparatus is enclosed throughout the cardiac cycle in both orthogonal planes.

Full-Volume R-Wave Gated Mode

In full-volume R-wave gated imaging (Fig. 2) (Video 1, see Supplemental Digital Content 1,, multiple pyramid-shaped datasets also called “frustums” are sequentially acquired over 4 to 10 cardiac cycles, digitally stitched together and displayed as the final image. Unlike 3D zoom imaging, the entire display is included in the acquisition in 3 dimensions without the option for ROI selection. During full-volume R-wave gated imaging, the ultrasound system presets can also be adjusted to optimize the acquisition for frame rate (more cardiac cycles), size of the volume of tissue to be acquired (lower frame rate), or time (acquisition over fewer cardiac cycles). The full-volume R-wave gated mode can incorporate CFD at the expense of image quality (Video 6, see Supplemental Digital Content 6, It is important to avoid irregular R-R intervals (arrhythmias or electrical interference from electrical diathermy) or movement (TEE probe or ventilation), so that sequentially acquired subvolumes are matched in time and space. Otherwise, “stitch artifacts” make the image appear “choppy” (Fig. 5).

Figure 5
Figure 5:
Multiple stitch artifacts are demonstrated in this full-volume R-wave gated acquisition with arrows.

Full-Volume Single-Beat Mode

Full-volume single-beat imaging mode also generates a wide-angle (90° × 90°) pyramidal-shaped beam, which can visualize the entire MV apparatus by capturing the datasets over a single beat (Video 7, see Supplemental Digital Content 7, The displayed image is dynamic, i.e., “probe sensitive” and moves with the TEE probe movement (Video 5, Hence, it is possible to acquire en face views of the MV in patients with arrhythmias, during periods of electrical interference of the electrocardiogram, and without suspension of respiration. Additionally, CFD information can also be incorporated during data acquisition, with a significant compromise on spatial and temporal resolution (Video 6, Whereas the 3D zoom and full-volume single-beat modes are based on the same principle, full-volume single-beat mode acquires the entire 2D echo sector width similar to full-volume R-wave gated imaging. However, unlike 3D zoom mode, there is no provision to select a particular ROI for acquisition, because the entire 2D sector is automatically selected for acquisition. Full-volume single-beat imaging mode was introduced in mid-2010 (Software Revision 11, Source: Vendor) to the Philips IE-33 imaging system compatible with the X7-2t “matrix” probe (Philips Medical Systems).

Using the system controls, multiple adjustments in the ultrasound system can be made before or immediately after acquisition of the acquired MV datasets to optimize image quality. The detailed description of such adjustments is beyond the scope of this article, but depends on the 2D image quality and patient-specific characteristics. After image acquisition and optimization, the acquired datasets can be cropped using multiplanar reconstruction planes, which allow for exclusion of extra details/tissues. Furthermore, images can be rotated to display the en face views of the MV.


The en face view of the MV from the LA or LV perspective can be acquired using any of the aforementioned 3D echocardiographic imaging modes. Ideally, such an image should clearly delineate the surrounding anatomical structures and their relationship to the MV with the highest spatial and temporal resolution. Uniformity in image acquisition protocol and nomenclature can possibly lead to better communication across specialties (cardiologists, surgeons, and anesthesiologists) and improved patient care.


Name: Feroze Mahmood, MD.

Contribution: This author helped design the study and prepare the manuscript.

Name: Haider Javed Warraich, MD.

Contribution: This author helped analyze the data and prepare the manuscript.

Name: Sajid Shahul, MD.

Contribution: This author helped prepare the manuscript.

Name: Aisha Qazi, MD.

Contribution: This author helped prepare the manuscript.

Name: Madhav Swaminathan, MD.

Contribution: This author helped prepare the manuscript.

Name: G. Burkhard Mackensen, MD, PhD.

Contribution: This author helped prepare the manuscript.

Name: Peter Panzica, MD.

Contribution: This author helped prepare the manuscript.

Name: Andrew Maslow, MD.

Contribution: This author helped design the study and prepare the manuscript.

This manuscript was handled by: Martin J. London, MD.


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