Nope, not exactly. The color flow here shows flow acceleration in diastole and a small amount of regurgitation. The regurg is not concerning, but the flow acceleration in diastole should worry you. On further evaluation this patient had severe mitral stenosis.

Take a moment to review the quantification of mitral stenosis. The cutoff for severe is 10 mmHg by mean gradient.

Whoops, not quite! Take another look at quantification of mitral stenosis. The cutoff for mean gradient is 10 mmHg. Above that is considered severe.

Not quite, try again! In the classic midesophageal 4 chamber we generaly see the coaptation between A2 and P2, with the anterior leaflet (A2 in this case) on the left, appearing longer, and near the LVOT.

Dang, you were so close. But this is most likely the P2 segment of the mitral valve. The classic 4 chamber cuts through A2 and P2 most commonly (though you’ll want to confirm by hitting the “Live 3D” button, right?)

Remember your orientation here. This is a transgastric short axis of the LV, which means the “back” of the LV is at the top of the screen. Also remember that the anterior and posterior leaflets of the MV are not exactly A-P in orientation. The anterior leaflet is sort of “anteromedial” and the posterior is more “posterolateral” but hey, I didn’t name them!

Whoops, got you eh? Remember the orientation of the mitral valve from the transgastric short axis. The posterior leaflet is more posterolateral.

Nope, not quite. Remind yourself of the orientation of the mitral leaflets in the transgastric short axis and think on this.

Don’t feel too badly, this view confuses people sometimes. This is a great opportunity to think on the orientation of the ultrasound plane as it bisects the widest portion of the mitral valve (the commisural view.) In the middle will be the A2 segment, and it will help cement this if you combine both 2D and 3D imaging in your exams.

Don’t be too hard on yourself. This view can be confusing and this is a good opportunity to review your anatomy. Remember that A1 and P1 are more anterior (which in this case is on the right of the screen, notice the left atrial appendage which is an anterior structure.)

Take a second to reorient yourself. This view of the mitral valve should be showing us the more anterior portion of the valve because we see part of the aortic valve. We’re seeing the flail of P1/2 with at least two cords in the atrium and a huge defect. Clearly severe MR, even without color flow or other quantification.

Take a second to reorient yourself. This is a 3D view of the mitral valve seen 180 degrees rotated from the surgeon’s view. We’re seeing the flail of P2 with at least two cords in the atrium and a huge defect. Clearly severe MR, even without color flow or other quantification.

Well, no. The 2D appearance is concerning for prolapse or possibly flail of the posterior leaflet. The color flow is a little hard to interpret, but there’s a lot of it. Sometimes MR is hard to assess in this view, get used to looking at it. This is severe…

Don’t let this clip fool you. The mitral valve is clearly not coapting well at all, and there is a large vena contracta. But the volume of regurgitation is small because the LV is failing. This is significant MR with LV failure.

OK, couple of things to discuss here. The first image by itself shows the mitral ring. The appearance of a ring is different from mitral annular calcification because it is often on the mitral valve rather than all the way at the annulus. And the color flow shows flow outside that ring. Not good! Then the 3D confirms a large defect outside the ring. Those sutures just tore loose, had to go back on bypass to try again.

Look again and don’t be fooled by the first view. There is a large area of flow acceleration and a wide jet, look more closely and quantify severity. Careful with your calculation, check your units, and look at the Nyquist limit again maybe.

Whoops, I got you! This is PWD in the left atrial appendage (with normal flow, for that matter.) Look again at the first image.

Sorry, but better to get it wrong now than when it really counts. This is classic systolic reversal of flow in the pulmonary vein, specific for severe MR.

OK, it’s always difficult to make the call of moderate.  But that’s what this is.  I know, I know, you’d like more quantitative info.  That’s good, that’s what you’d do in reality, but this is a chance to put a moderate case in your CPU.

This is a great case! What you see in the first image is a partial disruption of a papillary muscle (remind me which one that is again?) What would you expect to see with color flow? Severe MR, which is what we see in the second image.