Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
ECHOCARDIOGRAPHIC
EVALUATION OF
MITRAL REGURGITATION
Dr.PRAVEEN NAGULA
Contents
 Introduction
 Brief review of Mitral apparatus,MR
 Etiology of MR
 Evaluation
 Differentiation of Primary a...
Introduction
 Mitral Regurgitation (MR) represents a pathologic leak of
blood under systolic pressure from LV to LA.
 MR...
Brief Review of MR
Mitral valve apparatus
 Normal mitral apparatus is a saddle shaped ellipse with its
most apical points seen in the apical...
 Posterior part is easily dilated compared to Anterior part of
annulus. All current operative mitral valve repair techniq...
Pathophysiological triad
 Described by Dr. Alain Carpentier.
 Understanding of mitral valve pathology.
 Long term progn...
Functional classification
 Describes the mechanism of Mitral valve dysfunction.
 Opening and closing of the mitral leafl...
Etiology
of
MITRAL REGURGITATION
Mitral
Regurgitation
Primary (organic)
Rheumatic
Endocarditis
Fibroelastic
deficiency
Flail
Prolapse
Myxomatous
degenerati...
At the leaflets
 Excessive motion of the leaflets.
 Leaflet perforation.
 Prolapse of leaflets
Flail leaflet
 Sequelae of a myxomatous mitral valve.
 Degree of resultant regurgitation is directly related to the exte...
Echo views
 The scallops A1 and P1 are when viewed Left from LA view by
the surgeon; whereas right and inferior on TEE.
...
Specimen picture showing the base of the heart with the location of two- and four-
chamber echocardiographic views superim...
Three-dimensional transesophageal images, surgical view (live 3D zoom mode).
McCarthy K P et al. Eur J Echocardiogr 2010;1...
“Tiger stripes”
video
 feigenbaum echoFig 12.57 a video.flv
 feigenbaum echoFig 12.57 b video.flv
 feigenbaum echoFig 12.58 a video.flv...
 In more than 70% cases,it affects the posterior
leaflet and leads to severe MR.
Infective Endocarditis
 Type I
 Leaflet destruction
 Perforation
 Deformity
 Large vegetations can preclude leaflets ...
 C:UsersLAPTOPDocumentsendocarditis_large
vegetation on both leaflets of the mitral
valve_(360p).mp4
Myxomatous Mitral Valve
 Thickened redundant leaflets and chordae with excessive motion
and sagging of portions of the le...
Billowing mitral valve
 When a part of the mitral valve body protrudes into the left
atrium. However,the coaptation line ...
Floppy valve
 Morphological abnormality with thickened leaflet (diastolic
thickness >5 mm) due to redundant tissue.
Video of MVP
 feigenbaum echoFig 12.84 a video.flv
 feigenbaum echoFig 12.84 b video.flv
Marfan syndrome
 Long redundant anterior leaflet that sags into the LA in
systole.
Subvalvular apparatus
 Chordae
 Papillary muscles
Rheumatic MR
 Commissural fusion
 Chordal shortening and fusion are more prominent.
 Central jet
 Fibrosis of the chor...
Chordal disruption or elongation
 Inadequate tensile support of the closed leaflets in systole.
 Severe bowing of the le...
Papillary Muscle Rupture
 Acute severe MR.
 Normal sized left atria.
 Opposite to the direction of the
papillary muscle...
Mitral annulus
 Normal contraction of the mitral annulus(decrease in
annular area in systole) is 25%.
 Increased echogen...
Mitral Annular Calcification
 Seen in elderly, younger patients with hypertension, renal failure.
 Increased rigidity of...
Ischemic MR
 Regional LV dysfunction with abnormal contraction of the
papillary muscle or underlying ventricular wall.
 ...
Drugs
 Fenfluramine
 Pergolide
 Cabergoline
 Benfluorex
 Restriction of leaflet mobility.
EVALUATION
What do guidelines say?
Primary MR
 TTE is useful – for evaluation of LV,RV,PAP, mechanism of MR.
 Valve disruption or perforation from IE, chor...
Chronic Primary MR
 Anatomic
 Chambers
 LV dimensions/size
 Left atrial dilation
 Left ventricular volume and stroke volume
 Flail or p...
 Color doppler imaging is the primary echocardiographic tool
for detection and quantification of MR.
 Spectral doppler –...
“ Not all color doppler signals appearing
within LA represent mitral regurgitation”.
Several potential sources of color
doppler flow signal in LA
 Normal posterior motion of blood pool caused by mitral valv...
 feigenbaum echoFig 12.43
video.flv
Normal posterior motion of blood pool
caused by mitral valve closure Reverberation fr...
Characteristics of True MR jet
 Evidence of proximal flow acceleration.
 Flow conforms to appearance of true jet
 The d...
 feigenbaum echoFig 12.46 video.flv
Differentiation of Primary MR from
Secondary MR
Primary MR
 2D echo is recommended as first imaging modality.
 PSax view permits the assessment of the six scallops and ...
 3D imaging is superior to describe mitral pathology, especially
for anterior leaflet defects in degenerative disease and...
Secondary Mitral Regurgitation
 Mitral annulus
 Incomplete leaflet coaptation.
 Either due to LA dilation or LV dilatio...
LV remodelling and mitral valve
distortion
 Unbalance between the increased tethering forces and the decreased
closing fo...
Seagull sign
 Traction on the AML by the secondary chordae.
 Altered geometry of the mitral valve apparatus is quantified by
the tenting area and the coaptation distance.
 The tent...
Papillary muscle distance
Sphericity index
Acute vs chronic MR
Acute MR Chronic MR
Etiology Leaflet perforation
Flail leaflet
Papillary muscle rupture
DCMP
LA pressu...
DOPPLER evaluation…an integrative approach
How to grade Mitral Regurgitation
Mitral Regurgitation
Qualitative
1.Valve
morphology
2.Color flow
imaging
3.CW doppler
Semi
quantitative
1.PW doppler
2.Pul...
Valve morphology
 Flail leaflet
 Ruptured papillary muscles
 Large coaptation defect .
 Acute elevation of left atrial...
Color flow imaging
 Regurgitant jet is frequently measured by planimetry.
 The size and the extent of the jet into the L...
Color flow area
 Identifying central MR jets
 Evaluation of spatial orientation of the jet.
 Not recommended for use in...
Influenced by hemodynamic and technical factors:
 Low blood pressure, acute MR – underestimate.
 Eccentric jet - underes...
Imp note.
 There is now a general consensus as reflected in the recent
guidelines by both the American Society of Echocar...
 feigenbaum echoFig 12.48 video.flv
 feigenbaum echoFig 12.49 a video.flv
 feigenbaum echoFig 12.49 b video.flv
 feige...
Color M mode
 Apical 4 chamber view
 Rheumatic MR does not change in systole or drops
in late systole
 Functional MR ea...
Functional MR
Functional MR
Rheumatic MR
MyxomatousMVP
CW doppler
 Qualitative approach to evaluate MR severity.
 Useful adjunct to other quantitative measurements.
 Adequate...
Continuous wave doppler
 Qualitative guide to MR severity.
 Dense MR signal with a full envelope indicates more severe
M...
V wave cut off sign
Mitral Regurgitation
Qualitative
1.Valve
morphology
2.Color flow
imaging
3.CW doppler
Semi
quantitative
1.Vena contracta
2...
Vena contracta width
 Easy and quick method
 Relatively independent of hemodynamic factors.
 Limited by its narrow rang...
< 0.3 cm mild MR
0.3 – 0.7 cm moderate MR
> 0.7 cm severe MR
•Can be used in eccentric jet.
•Accurate in acute MR.
•Not va...
 The accuracy of vena contracta is based on the assumption
that the regurgitant orifice is circular,which is often the ca...
Pulmonary veins
 Adds additional information to MR severity.
 Complement to other methods.
 Normal flow pattern is asso...
Systolic dominance mild MR
Systolic flow reversal severe MR
Influenced by LA pressure and LV relaxation
Not accurate in at...
EAE guidelines for evaluation of VHD
2010
Mitral inflow pattern
 Qualitative and complementary approach to MR severity.
 Semiquantitative
 Mitral to aortic time ...
Quantitative approaches
 Effective Regurgitant Orifice Area (EROA)
 Regurgitant volume
 Regurgitant fraction
Useful to ...
 European recommendations for MR quantification have taken
into account the different characteristics of primary and
seco...
2D Proximal Isovelocity Surface Area
 Current recommended quantitative approach.
 Qualitatively, presence of flow conver...
 PISA method assumes that the ROA is constant through out
systole and is hemispheric in shape.
 PISA based methods tends...
Functional MR
Functional MR
Rheumatic MR
MyxomatousMVP
SIMPLIFIED
 ERO= 0.38R2
 MRV=2R2 negative alaising
velocity.
 Alaising velocity kept at 30 5 cm/sec
Quantitative volumetric methods
 Pulse wave doppler is used.
 Flow rates and stroke volumes
SV = TVI annulus  CSA annul...
 MR volume = Mitral inflow – aortic outflow
 Mitral inflow volume = TVI  CSA (mitral annulus)
 Aortic outflow = TVI  ...
drawbacks
 Time consuming
 Potential errors that may arise from the multiple
measurements required at different views to...
Mitral Regurgitation severity
I (MILD) II III IV(SEVERE)
LV size Normal normal Increased
↑↑
Left atrial size normal normal...
Other parameters
 LVEF < 55%
 DT-E <150 msec
 E/E’ (lateral ) >15
 PVF-s/PVF-d <0.5
 Vp < 45 cm/sec
 PASP > 35 mHg
...
3D Echocardiography
 Better definition of mitral morphology
 Pathological changes
 Improves the characterization of mit...
3D VC area
 Eccentric or functional regurgitations.
 3D guided planimetry of VCA – relatively fast, highly feasible,
ver...
VCA should be measured at aliased velocities to avoid the
possibility of color bleeding that may occur at lower non
aliase...
3D PISA
 True proximal flow convergence region is rather more
hemielliptical than hemispheric
 Yosety and colleagues – c...
Limitations
 Low temporal resolution.
 “Volume” or “voxel” rates in real time is low even with small
angles of view.
 S...
Ischemic Mitral Regurgitation
 Frequent complication of MI,CAD
 Adverse prognosis.
 Developed in setting of coronary di...
 feigenbaum echoFig 12.68 a video.flv
 feigenbaum echoFig 12.68 b video.flv
 feigenbaum echoFig 12.69 a video.flv
 fei...
Chronic IMR
 Mitral leaflets coapt apically within the LV – restricting
leaflet closure in a pattern known as incomplete ...
 Posterolateral displacement of the papillary muscles.
 Stretching of the chordae tendinae
 Increased tethering forces ...
 feigenbaum echoFig 12.68 a video.flv
 feigenbaum echoFig 12.68 b video.flv
 feigenbaum echoFig 12.69 a video.flv
 fei...
Cleft mitral valve
 feigenbaum echoFig 12.55 a video.flv
 feigenbaum echoFig 12.55 b video.flv
Consequences of MR
 Left ventricle
 Left atrium
 Pulmonary artery pressure
 Right Ventricle
LV
 In the chronic compensated phase (the patient could be
asymptomatic), the forward stroke volume is maintained
through...
 In the current guidelines, surgery is recommended in
asymptomatic patients with severe organic MR when the
LV ejection f...
New parameters
 A systolic tissue Doppler velocity measured at the
lateral annulus < 10.5 cm/s has been shown to
identify...
Strain Imaging
 It is not influenced by translation or pathologic tethering to
adjacent myocardial segments, which affect...
LA size and Pulmonary pressures
 The LA dilates in response to chronic volume and pressure
overload.
 A normal sized LA ...
Key point
Sequential evaluation
Risk of SAM after surgery
 Myxomatous mitral valve with redundant leaflets (excessive
anterior leaflet tissue)
 A non di...
Exercise echocardiography
Conclusion.
Echocardiography is an important diagnostic tool in the
evaluation of mitral regurgitation and helps to
differ...
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION
Upcoming SlideShare
Loading in …5
×

ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION

11,803 views

Published on

Mitral valve apparatus,functional classfication,acute vs chronic,primary vs secondary,echo evaluation,severity assessement.....3D echo also included.

Published in: Education

ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE -MITRAL REGURGITATION

  1. 1. ECHOCARDIOGRAPHIC EVALUATION OF MITRAL REGURGITATION Dr.PRAVEEN NAGULA
  2. 2. Contents  Introduction  Brief review of Mitral apparatus,MR  Etiology of MR  Evaluation  Differentiation of Primary and Secondary MR  Acute and Chronic MR  Grading the severity of MR  Conclusion
  3. 3. Introduction  Mitral Regurgitation (MR) represents a pathologic leak of blood under systolic pressure from LV to LA.  MR occurs during systole, which constitutes 1/3 of cardiac cycle at normal resting Heart rate.  Can be due to primary disease of mitral leaflets.  Secondary to abnormality of mitral apparatus.  Acute MR – Acute pulmonary congestion.  Chronic MR – compensated, well tolerated for decades.
  4. 4. Brief Review of MR
  5. 5. Mitral valve apparatus  Normal mitral apparatus is a saddle shaped ellipse with its most apical points seen in the apical four chamber view and its most basal points seen in the long axis view.  Mitral annulus is smaller in systole than in diastole.  Normal area of overlap or apposition, some degree of mitral annular dilation may be tolerated without significant regurgitation. Normal Dilated cardiomyopathy Non planar mitral annulus shape present reduced,flattened Area,cm2 7-12 11-20 circumference 7-11 8-18 % area change diastole/systole 20-42 13-23
  6. 6.  Posterior part is easily dilated compared to Anterior part of annulus. All current operative mitral valve repair techniques are based on this principle of asymmetric annular dilatation.  Mitral valve annuloplasty reduces the mitral valve inlet area by reducing the circumference of the posterior leaflet. This is the rationale for using a partial posterior annuloplasty ring.  Anterior mitral leaflet area to MA area ratio of 1.5-2.0 has been found sufficient to prevent mitral regurgitation.* *Chaput et al, Mitral leaflet adaptation to ventricular remodelling occurrence and adequacy in patients with functional MR,Circulation 2008;118:845-52
  7. 7. Pathophysiological triad  Described by Dr. Alain Carpentier.  Understanding of mitral valve pathology.  Long term prognosis depends upon etiology, treatment strategy depends on dysfunction, surgical management depends upon lesion. Carpentier A, Adams DH, Filsoufi F. Carpentier’s Reconstructive Valve Surgery. From Valve Analysis to Valve Reconstruction. 2010 Saunders Elsevier.
  8. 8. Functional classification  Describes the mechanism of Mitral valve dysfunction.  Opening and closing of the mitral leaflets.  Carpentier A. Cardiac valve surgery – “the French correction” J Thorac Cardiovasc Surg 1983;86:323-37
  9. 9. Etiology of MITRAL REGURGITATION
  10. 10. Mitral Regurgitation Primary (organic) Rheumatic Endocarditis Fibroelastic deficiency Flail Prolapse Myxomatous degeneration Flail Prolapse Secondary (functional) Annular dilation Dilated cardio myopathy Papillary muscle rupture Acute MI
  11. 11. At the leaflets  Excessive motion of the leaflets.  Leaflet perforation.  Prolapse of leaflets
  12. 12. Flail leaflet  Sequelae of a myxomatous mitral valve.  Degree of resultant regurgitation is directly related to the extent of anatomic disruption.  Rupture of only a few isolated chordae – may not result in loss of normal coaptation –absence of MR.  Eccentric direction of MR – orientation opposite in direction of the leaflet with anatomic defect.  A1:P1 – anterolaterally – LA appendage.  A3:P3 – inferomedial location, close to tricuspid annulus.
  13. 13. Echo views  The scallops A1 and P1 are when viewed Left from LA view by the surgeon; whereas right and inferior on TEE.  TEE - 120 longitudinal plane – imaging plane intersects A2/P2 boundary.  Confusion – orthogonal to the above view -60 .P1,A2,A3 visualized.(confusion between a flail P3 and A3 scallop in this view).  In general, Posterior flail is easier to repair than an anterior flail.
  14. 14. Specimen picture showing the base of the heart with the location of two- and four- chamber echocardiographic views superimposed (double-headed arrows). McCarthy K P et al. Eur J Echocardiogr 2010;11:i3-i9 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org
  15. 15. Three-dimensional transesophageal images, surgical view (live 3D zoom mode). McCarthy K P et al. Eur J Echocardiogr 2010;11:i3-i9 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org
  16. 16. “Tiger stripes”
  17. 17. video  feigenbaum echoFig 12.57 a video.flv  feigenbaum echoFig 12.57 b video.flv  feigenbaum echoFig 12.58 a video.flv  feigenbaum echoFig 12.58 b video.flv  feigenbaum echoFig 12.59 a video.flv  feigenbaum echoFig 12.59 b video.flv  FLAIL MITRAL LEAFLET - ECHOCARDIOGRAPHY SERIES BY DR.ANKUR.K.CHAUDHARI_(360p).mp4
  18. 18.  In more than 70% cases,it affects the posterior leaflet and leads to severe MR.
  19. 19. Infective Endocarditis  Type I  Leaflet destruction  Perforation  Deformity  Large vegetations can preclude leaflets coaptation and can lead to severe MR.
  20. 20.  C:UsersLAPTOPDocumentsendocarditis_large vegetation on both leaflets of the mitral valve_(360p).mp4
  21. 21. Myxomatous Mitral Valve  Thickened redundant leaflets and chordae with excessive motion and sagging of portions of the leaflets into the LA in systole.  Severity of disease ranges from mitral valve prolapse (minimal displacement of the leaflets into the LA in systole),to severely involvement of both leaflets by myxomatous disease with frankly prolapsed or flail leaflet segments.
  22. 22. Billowing mitral valve  When a part of the mitral valve body protrudes into the left atrium. However,the coaptation line is preserved beyond the annular plane.  MR is usually mild in this condition.
  23. 23. Floppy valve  Morphological abnormality with thickened leaflet (diastolic thickness >5 mm) due to redundant tissue.
  24. 24. Video of MVP  feigenbaum echoFig 12.84 a video.flv  feigenbaum echoFig 12.84 b video.flv
  25. 25. Marfan syndrome  Long redundant anterior leaflet that sags into the LA in systole.
  26. 26. Subvalvular apparatus  Chordae  Papillary muscles
  27. 27. Rheumatic MR  Commissural fusion  Chordal shortening and fusion are more prominent.  Central jet  Fibrosis of the chordae attached to the posterior valve is more frequent and explains the rigidity and reduced motion of the posterior leaflet in diastole.  Semi open position of the PML through out cardiac cycle,the motion of anterior leaflet in systole produces a false aspect of prolapse.
  28. 28. Chordal disruption or elongation  Inadequate tensile support of the closed leaflets in systole.  Severe bowing of the leaflet or the leaflet segment, into the LA, with the tip of the leaflet still directed towards the ventricular apex.  Chordal rupture – flail segment of the leaflet such that the leaflet is displaced into the LA in systole, tip of leaflet pointing away from left ventricular apex.  3DTEE imaging is imp. in evaluation.  Delineation of the precise segments of anterior and posterior leaflets involved will help in approach surgically.
  29. 29. Papillary Muscle Rupture  Acute severe MR.  Normal sized left atria.  Opposite to the direction of the papillary muscle the jet impinges on
  30. 30. Mitral annulus  Normal contraction of the mitral annulus(decrease in annular area in systole) is 25%.  Increased echogenicity with acoustic shadowing on the left ventricular side of the posterior annulus in the elderly or in patients with renal failure is a typical finding.
  31. 31. Mitral Annular Calcification  Seen in elderly, younger patients with hypertension, renal failure.  Increased rigidity of the annulus.  Impairs systolic contraction of the annulus.  Area of increased echogenicity on the LV side of the annulus immediately adjacent to the attachment point of the posterior leaflet.  Acoustic shadowing due to calcium.  Short axis view – annular calcium can be focal or extensive, involving the entire U shaped posterior annulus.  Region of anterior mitral leaflet – posterior aortic wall continuity is involved only rarely.
  32. 32. Ischemic MR  Regional LV dysfunction with abnormal contraction of the papillary muscle or underlying ventricular wall.  In patients with MI, myocardial scarring results in MR at rest.  MR may be intermittent in patients with inducible ischemia.  Restricted leaflet motion.  Tethering of valve closure resulting in appearance of tenting or tethering of mitral valve in systole.
  33. 33. Drugs  Fenfluramine  Pergolide  Cabergoline  Benfluorex  Restriction of leaflet mobility.
  34. 34. EVALUATION
  35. 35. What do guidelines say?
  36. 36. Primary MR  TTE is useful – for evaluation of LV,RV,PAP, mechanism of MR.  Valve disruption or perforation from IE, chordal rupture ,papillary muscle rupture  Hyperdynamic LV.  TEE when TTE is inconclusive  Valvular vegetations,annular abscesses.  TEE to be performed as soon as possible in presence of acute and hemodynamic instability after MI with hyperdynamic LV function by TTE and no other cause for deterioration, looking for severe MR due either to a papillary muscle or chordal rupture. Nishimura et al,ACC/AHA 2014 VHD Guidelines.
  37. 37. Chronic Primary MR
  38. 38.  Anatomic  Chambers  LV dimensions/size  Left atrial dilation  Left ventricular volume and stroke volume  Flail or perforated leaflet  Doppler  Color flow  Jet area  Jet area indexed to left atrium  Central vs eccentric jets  Vena contracta width  Proximal isovelocity surface area  Size/qualitative  Volumetric flow/regurgitant volume  Effective regurgitant orifice  Pulmonary vein flow reversal  Spectral  Forward flow calculation at the mitral annulus  Signal density  Elevated E/A ratio (with normal left ventricular function)
  39. 39.  Color doppler imaging is the primary echocardiographic tool for detection and quantification of MR.  Spectral doppler – for confirmation, define duration of MR.
  40. 40. “ Not all color doppler signals appearing within LA represent mitral regurgitation”.
  41. 41. Several potential sources of color doppler flow signal in LA  Normal posterior motion of blood pool caused by mitral valve closure.  Reverberation from aortic flow.  Normal pulmonary vein flow.  Atrial blood pool motion of overall low velocity inappropriately visualised because of inappropriate gain and nyquist limit.  MR when suspected to be confirmed in multiple views.
  42. 42.  feigenbaum echoFig 12.43 video.flv Normal posterior motion of blood pool caused by mitral valve closure Reverberation from aortic flow
  43. 43. Characteristics of True MR jet  Evidence of proximal flow acceleration.  Flow conforms to appearance of true jet  The down stream appearance is consistent with a volume of blood being ejected through a relatively constraining orifice(vena contracta).  Flow signal appropriately confined to systole.  Color doppler signal are appropriate in color for the anticipated direction and/or reveal appropriate variance or turbulence encoding.
  44. 44.  feigenbaum echoFig 12.46 video.flv
  45. 45. Differentiation of Primary MR from Secondary MR
  46. 46. Primary MR  2D echo is recommended as first imaging modality.  PSax view permits the assessment of the six scallops and with color doppler imaging, the localisation of the origin of the regurgitant jet may identify prolapsing segments.  PLax view classically shows A2 and P2.  Angulation of probe towards aortic valve allows the visualisation of A1 and P1.  Towards the tricuspid , the visualisation of A3 and P3.  Apical four chamber view –A3,A2,P1 (internal to external)  Two chamber view – P3,A2,A1( left to right).
  47. 47.  3D imaging is superior to describe mitral pathology, especially for anterior leaflet defects in degenerative disease and commissural fusion in rheumatic process.  Enface view is identical to the surgical view in the operating room.
  48. 48. Secondary Mitral Regurgitation  Mitral annulus  Incomplete leaflet coaptation.  Either due to LA dilation or LV dilation.  The diameter of the mitral annulus is compared with the anterior leaflet measured in diastole.  Annular dilation is present when the annulus/ anterior leaflet ratio is more than 1.3 or when the diameter of the mitral annulus is more than 35 mm.  Annulus becomes more circular (saddle shape usually). Caldarera et al,Multiplane TEE and morphology of regurgitant mitral valves in surgical repair. Eur Heart J. 1995;16(7):999-1006
  49. 49. LV remodelling and mitral valve distortion  Unbalance between the increased tethering forces and the decreased closing forces. Reduced closing forces – altered systolic annular contraction reduced LV contractility. global LV dyssynchrony at the level of basal segments Reduced synchrony between the papillary muscles.  Asymmetric pattern 95% cases – systolic restriction of the PML (posterior MI)  Seagull sign – traction on the anterior leaflet by secondary chordae.  Symmetric pattern - NICMP,MVD
  50. 50. Seagull sign  Traction on the AML by the secondary chordae.
  51. 51.  Altered geometry of the mitral valve apparatus is quantified by the tenting area and the coaptation distance.  The tenting area is measured in mid systole as the area enclosed between the mitral annulus plane and the mitral leaflets body.  Coaptation distance represents the apical displacement of the coaptation point and is measured as the distance between the mitral annular plane and the point of leaflet coaptation in the apical four chamber view.  Leaflet length.  Distance between the posterior papillary muscle head and the intervalvular fibrosa.  Lateral and posterior displacement of the papillary muscles.
  52. 52. Papillary muscle distance
  53. 53. Sphericity index
  54. 54. Acute vs chronic MR Acute MR Chronic MR Etiology Leaflet perforation Flail leaflet Papillary muscle rupture DCMP LA pressure Significantly elevated normal LA size normal Dilated (compliant) Doppler signal High initial velocity with a rapid fall in late systole High velocity through out systole Pulmonary pressure high normal LV dimensions normal increased Eccentric hypertrophy
  55. 55. DOPPLER evaluation…an integrative approach How to grade Mitral Regurgitation
  56. 56. Mitral Regurgitation Qualitative 1.Valve morphology 2.Color flow imaging 3.CW doppler Semi quantitative 1.PW doppler 2.Pulmonary venous flow 3.Vena contracta Quantitative 1.Doppler volumetric method 2.PISA
  57. 57. Valve morphology  Flail leaflet  Ruptured papillary muscles  Large coaptation defect .  Acute elevation of left atrial pressure can lead to underestimation of MR severity with color flow imaging.
  58. 58. Color flow imaging  Regurgitant jet is frequently measured by planimetry.  The size and the extent of the jet into the LA increase with the MR severity.  Regurgitant jet more than 40% of the LA area – SevereMR.  Source of technical errors.  Large eccentric jet ahering,swirling and reaching the posterior wall of the left atrium is in favor of significant MR.  Small jets appearing just beyond the mitral leaflets usuallt indicate mild MR.
  59. 59. Color flow area  Identifying central MR jets  Evaluation of spatial orientation of the jet.  Not recommended for use in the grading of MR severity of eccentric jets, significantly underestimates the regurgitant volume (upto 40%) when compared with central jets with the same volume. Yoshida et al, Color doppler evaluation of valvular regurgitation,Circulation 1988:78(4):840-7 < 4cm² or <20 cm² of LA size mild MR 4 - 10 cm² or 20 – 40cm²of LA size moderate MR >10 cm²or 40 cm² of LA size severe MR
  60. 60. Influenced by hemodynamic and technical factors:  Low blood pressure, acute MR – underestimate.  Eccentric jet - underestimate.  Color gain and nyquist scale optimization.
  61. 61. Imp note.  There is now a general consensus as reflected in the recent guidelines by both the American Society of Echocardiography and the European Assosciation of Echocardiography, that color flow jet assessment should only be used for diagnosing MR and not for MR quantification.  Precise quantification is by using vena contracta width and the flow convergence method.
  62. 62.  feigenbaum echoFig 12.48 video.flv  feigenbaum echoFig 12.49 a video.flv  feigenbaum echoFig 12.49 b video.flv  feigenbaum echoFig 12.50 a video.flv  feigenbaum echoFig 12.51 video.flv  feigenbaum echoFig 12.52 video.flv  feigenbaum echoFig 12.53 video.flv  feigenbaum echoFig 12.54 video.flv
  63. 63. Color M mode  Apical 4 chamber view  Rheumatic MR does not change in systole or drops in late systole  Functional MR early and late systole rise  MVP –progressive increase.
  64. 64. Functional MR Functional MR Rheumatic MR MyxomatousMVP
  65. 65. CW doppler  Qualitative approach to evaluate MR severity.  Useful adjunct to other quantitative measurements.  Adequate alignment of the beam with MR jet profile is crucial for an accurate representation of MR severity.  Difficult to obtain in eccentric jet. Soft density, incomplete envelope mild Dense signal with triangular shape severe
  66. 66. Continuous wave doppler  Qualitative guide to MR severity.  Dense MR signal with a full envelope indicates more severe MR than a faint signal.  CW envelope may be truncated (notch) with a triangular contour and an early peak velocity. – elevated pressure and a prominent regurgitant pressure wave in the left atrium due to severe MR.  Difficult in case of eccentric MR.
  67. 67. V wave cut off sign
  68. 68. Mitral Regurgitation Qualitative 1.Valve morphology 2.Color flow imaging 3.CW doppler Semi quantitative 1.Vena contracta 2.PW doppler 3.Pulmonary venous flow Quantitative 1.Doppler volumetric method 2.PISA
  69. 69. Vena contracta width  Easy and quick method  Relatively independent of hemodynamic factors.  Limited by its narrow range.  Image optimization needed  Zoom mode with narrow sector and plane perpendicular to the jet is essential to improve spatial and temporal resolution.  2 chamber view (commissural view) is parallel to the mitral leaflet coaptation line, even mild degrees of functional regurgitation can appear to show a wide VC(not recommended)
  70. 70. < 0.3 cm mild MR 0.3 – 0.7 cm moderate MR > 0.7 cm severe MR •Can be used in eccentric jet. •Accurate in acute MR. •Not valid for multiple MR Jets.
  71. 71.  The accuracy of vena contracta is based on the assumption that the regurgitant orifice is circular,which is often the case in organic MR. However,regurgitant orifice in functional MR is rather elongated and non circular,limiting the validity of vena contracta measurement.  To note,the respective values of vena contracta width are not additive for multiple jets.
  72. 72. Pulmonary veins  Adds additional information to MR severity.  Complement to other methods.  Normal flow pattern is assosciated with mild to moderate MR  Reversal of a systolic wave is highly reliable marker of severe or moderate to severe regurgitation.  Blunted systolic waves – less predictive value.  Non significant MR jet can be selectively directed at a pulmonary vein, causing reversal of flow in that particular vein, potential overestimation of MR severity.  Assess the flow pattern in 2 or more different pulmonary veins before concluding a positive finding of blunting or reversal systolic flow compatible with significant MR.
  73. 73. Systolic dominance mild MR Systolic flow reversal severe MR Influenced by LA pressure and LV relaxation Not accurate in atrial fibrillation
  74. 74. EAE guidelines for evaluation of VHD 2010
  75. 75. Mitral inflow pattern  Qualitative and complementary approach to MR severity.  Semiquantitative  Mitral to aortic time velocity integral (TVI) ratio of the pulsed wave doppler profile of mitral and aortic valves could be used to quantify isolated organic MR.  A ratio greater than 1.4 suggests severe MR.  < 1.0 mild MR.  A wave dominant excludes severe MR.  E wave >1.5 cm/sec – severe MR  Influenced by LA Pressure and LV relaxation.  Not accurate in Atrial Fibrillation
  76. 76. Quantitative approaches  Effective Regurgitant Orifice Area (EROA)  Regurgitant volume  Regurgitant fraction Useful to define the intermediate degrees of MR.
  77. 77.  European recommendations for MR quantification have taken into account the different characteristics of primary and secondary MR.  EROA 40 mm² Primary MR 20 mm² Secondary MR Guidelines on the management of valvular heart disease 2012 , ESC,Eur J Cardiothoracic Surg 2012;42(4):S1-44
  78. 78. 2D Proximal Isovelocity Surface Area  Current recommended quantitative approach.  Qualitatively, presence of flow convergence at a Nyquist limit of approximately 50 -60 cm/sec(routine examination) would suggest significant MR.  PISA calculations are based on following parameters. EROA = 2r²  Va/Peak MRV(CW) EROA = effective regurgitant orifice area Va = alaising velocity RV (cc) = EROA  TVI MR (cm) RV = regurgitant volume TVI = MV time –velocity integral
  79. 79.  PISA method assumes that the ROA is constant through out systole and is hemispheric in shape.  PISA based methods tends to be more accurate for organic than for functional MR.  PISA radius is constant in patients with organic rheumatic MR, increases progressively along the systole period in patients with mitral valve prolapse.  In functional MR, an early peak is followed by a progressive midsystolic decrease, sometimes with another late systolic peak(bimodal pattern).
  80. 80. Functional MR Functional MR Rheumatic MR MyxomatousMVP
  81. 81. SIMPLIFIED  ERO= 0.38R2  MRV=2R2 negative alaising velocity.  Alaising velocity kept at 30 5 cm/sec
  82. 82. Quantitative volumetric methods  Pulse wave doppler is used.  Flow rates and stroke volumes SV = TVI annulus  CSA annulus
  83. 83.  MR volume = Mitral inflow – aortic outflow  Mitral inflow volume = TVI  CSA (mitral annulus)  Aortic outflow = TVI  CSA(LVOT)  TVI at the level of mitral annular plane, as this is where the cross- sectional area is measured.  Cross sectional area of mitral annulus is assumed to be circular and calculated as r²,where r is the diameter measured in the apical chamber view divided by 2.  Anatomically mitral annulus is D shaped,more like an ellipse rather than a circle.  Circular assumption is reasonable for who have developed atleast moderate MR(annular dilation)  Ellipse -  ab - diameters measured in A2C,A4C views.  This method assumes there is no aortic regurgitation.  In that case, pulmonary outflow can be used, assuming no pulmonary regurgitation.
  84. 84. drawbacks  Time consuming  Potential errors that may arise from the multiple measurements required at different views to calculate RV, EROA.  Significant training required.  Small errors in measurement are amplified and accurate resolution of the annulus is important in minimizing measurement errors.
  85. 85. Mitral Regurgitation severity I (MILD) II III IV(SEVERE) LV size Normal normal Increased ↑↑ Left atrial size normal normal ↑ ↑↑ MR Jet (% LA) <15 15-30 35-50 >50 Spectral doppler density faint - - dense Vena contracta < 3 mm - - >6 mm Pulmonary vein flow S >D - - Systolic reversal RV (ml) < 30 30-44 45-59 >60 ERO (cm²) < 0.2 0.2-0.29 0.3-0.39 >0.4 PISA small - - large
  86. 86. Other parameters  LVEF < 55%  DT-E <150 msec  E/E’ (lateral ) >15  PVF-s/PVF-d <0.5  Vp < 45 cm/sec  PASP > 35 mHg  LA size >55 mm  LVDD >70 mm
  87. 87. 3D Echocardiography  Better definition of mitral morphology  Pathological changes  Improves the characterization of mitral regurgitant jets.  Spatially visualize the shape, size,orientation of MR jets in real time,thus enhancing the accuracy of quantification of MR severity.
  88. 88. 3D VC area  Eccentric or functional regurgitations.  3D guided planimetry of VCA – relatively fast, highly feasible, very precise indicator of MR severity in clinical practice.  VC width vary depending on the image plane.  Commissural views can be inaccurate.  When True short axis imaging in 2D echo, for the real shape of VC to be visualized is challenging.  Most reproducible and accurate method to establish the ERO.  VCA to be slightly smaller than the real anatomic orifice.  Can be used in multiple jets.
  89. 89. VCA should be measured at aliased velocities to avoid the possibility of color bleeding that may occur at lower non aliased velocities.
  90. 90. 3D PISA  True proximal flow convergence region is rather more hemielliptical than hemispheric  Yosety and colleagues – calculation of EROA by 3D can greatly improve the accuracy of 2D based PISA assessment.  Underestimation can be significantly corrected.
  91. 91. Limitations  Low temporal resolution.  “Volume” or “voxel” rates in real time is low even with small angles of view.  Stitching artifacts(AF).  Color doppler gain(effect on size,no effect on area)  Instantaneous ROA should be integrated throughout systole.(midsystole)
  92. 92. Ischemic Mitral Regurgitation  Frequent complication of MI,CAD  Adverse prognosis.  Developed in setting of coronary disease.  Mitral leaflets are intrinsically normal.  Initiating insult is ventricular remodelling.  Acute MR – ruptured papillary muscle following MI.(<1%)  Papillary muscle ischemia – uncommon.(MR resolves once ischemia improves)  Chronic MR –secondary to ventricular remodelling due to IHD –common.
  93. 93.  feigenbaum echoFig 12.68 a video.flv  feigenbaum echoFig 12.68 b video.flv  feigenbaum echoFig 12.69 a video.flv  feigenbaum echoFig 12.69 b video.flv  feigenbaum echoFig 12.70 a video.flv  feigenbaum echoFig 12.70 b video.flv
  94. 94. Chronic IMR  Mitral leaflets coapt apically within the LV – restricting leaflet closure in a pattern known as incomplete mitral leaflet closure.  Mitral valve function depends upon the ventricular support structures, should not be seen as free standing leaflets attached at the annulus.  Papillary muscles and chordae tendinae serve to anchor the leaflets at the annular level during coaptation.  Predominant role of tethering as the final common pathway in inducing functional MR.
  95. 95.  Posterolateral displacement of the papillary muscles.  Stretching of the chordae tendinae  Increased tethering forces on the mitral valve leaflets.  Apical leaflet coaptation  Restricted leaflet closure  Regurgitation  Annular dilation can also result in MR
  96. 96.  feigenbaum echoFig 12.68 a video.flv  feigenbaum echoFig 12.68 b video.flv  feigenbaum echoFig 12.69 a video.flv  feigenbaum echoFig 12.69 b video.flv  feigenbaum echoFig 12.70 a video.flv  feigenbaum echoFig 12.70 b video.flv
  97. 97. Cleft mitral valve  feigenbaum echoFig 12.55 a video.flv  feigenbaum echoFig 12.55 b video.flv
  98. 98. Consequences of MR  Left ventricle  Left atrium  Pulmonary artery pressure  Right Ventricle
  99. 99. LV  In the chronic compensated phase (the patient could be asymptomatic), the forward stroke volume is maintained through an increase in LV ejection fraction typically >65%.  In the chronic decompensated phase (the patient could still be asymptomatic or may fail to recognize deterioration in clinical status), the forward stroke volume decreases and the LA pressure increases significantly.  The LV contractility can thus decrease silently and irreversibly. However, the LV ejection fraction may still be in the low normal range despite the presence of significant muscle dysfunction.
  100. 100.  In the current guidelines, surgery is recommended in asymptomatic patients with severe organic MR when the LV ejection fraction is ≤60%.  The ESD (end-systolic diameter) is less preload dependent than the ejection fraction and could in some cases be more appropriate to monitor global LV function.  An end-systolic diameter >45 mm (or ≥40 mm or >22 mm/m2, AHA/ACC) also indicates the need for mitral valve surgery in these patients.
  101. 101. New parameters  A systolic tissue Doppler velocity measured at the lateral annulus < 10.5 cm/s has been shown to identify subclinical LV dysfunction and to predict post-operative LV dysfunction in patients with asymptomatic organic MR.  Strain imaging allows a more accurate estimation of myocardial contractility than tissue Doppler velocities.
  102. 102. Strain Imaging  It is not influenced by translation or pathologic tethering to adjacent myocardial segments, which affect myocardial velocity measurements.  In MR, strain has been shown to decrease even before LV ESD exceeds 45 mm.  A resting longitudinal strain rate value <1.07/s (average of 12 basal and mid segments) is associated with the absence of contractile reserve during exercise and thus with subclinical latent LV dysfunction.  By using the 2D-speckle tracking imaging (an angle independent method), a global longitudinal strain <18.1% has been associated with postoperative LV dysfunction.  Practically, the incremental value of tissue Doppler and strain imaging for identifying latent LV dysfunction remains to be determined.
  103. 103. LA size and Pulmonary pressures  The LA dilates in response to chronic volume and pressure overload.  A normal sized LA is not normally associated with significantMR unless it is acute, in which case the valve appearance is likely to be grossly abnormal.  LA remodelling (diameter >40–50 mm or LA volume index >40 mL/m2) may predict onset of AF and poor prognosis in patients with organic MR.  Conversely, MV repair leads to LA reverse remodelling, the extent of which is related to preoperative LA size and to procedural success.  The excess regurgitant blood entering in the LA may induce acutely or chronically a progressive rise in pulmonary pressure.  The presence of TR even if it is mild, permits the estimation of systolic pulmonary arterial pressure.  Recommendation for mitral valve repair is a class IIa when pulmonary arterial systolic pressure is >50 mm Hg at rest.
  104. 104. Key point
  105. 105. Sequential evaluation
  106. 106. Risk of SAM after surgery  Myxomatous mitral valve with redundant leaflets (excessive anterior leaflet tissue)  A non dilated hyperdynamic LV  Short distance between the mitral valve coaptation point and the ventricular septum after repair.
  107. 107. Exercise echocardiography
  108. 108. Conclusion. Echocardiography is an important diagnostic tool in the evaluation of mitral regurgitation and helps to differentiate acute from chronic,organic from functional,the consequtive effect of MR ,feasibility of repair in the patients and as an effective guide during the interventions,and also during follow up.

×