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, http://links.lww.com/AA/A440). 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.
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).
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, http://links.lww.com/AA/A441). 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, http://links.lww.com/AA/A441). The en face view of the MV from the LA perspective can then be imaged (Video 4, see Supplemental Digital Content 4, http://links.lww.com/AA/A442). 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, http://links.lww.com/AA/A443).
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, http://links.lww.com/AA/A445). The displayed image is dynamic, i.e., “probe sensitive” and moves with the TEE probe movement (Video 5, http://links.lww.com/AA/A443). 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, http://links.lww.com/AA/A444). 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.
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