3. Objectives:
▪ Anatomy of MitralValve
▪ Etiology
▪ Assesment of Severity
▪ 2D
▪ Color Doppler
▪ Pulse wave
▪ Continous wave Doppler
▪ Supportive signs
▪ Feasibility of Repair
▪ Role of Exercise Echo in MR
4. Role Of Echocardiography in MR
Echocardiogram report of MR patients should evaluate
• Mechanism
• Etiology
• Severity of regurgitation
• Consequences
• Possibility of repair
5. Mitral Valve Analysis: Recommendations
• TTE is recommended as the first-line imaging modality for mitral
valve analysis.
• TEE is advocated whenTTE is of non-diagnostic value or when further
diagnostic refinement is required.
• 3D-TEE orTTE is reasonable to provide additional information in
patients with complex mitral valve lesion.
• TEE is not indicated in patients with a good-qualityTTE except in the
operating room when a mitral valve surgery is performed.
6. Anatomy Of Mitral valve
Two leaflets (thickness about 1 mm)
▪ Posterior leaflet
Quadrangular shape
Three individual scallops (P1–P2–P3)
Anterior leaflet
Semi-circular shape
Artificially divided into three portions
(A1–A2–A3)
11. Mitral Annulus
▪ Annular dilatation (PLAX)
Annulus/anterior leaflet ratio > 1.3
or
Diameter > 35 mm
▪ The normal contraction of the mitral
annulus (decrease in annular area in
systole) is 25%.
13. Etiology
(i) Billowing valve: part of the
mitral valve body protrudes
into the LA; the coaptation is
preserved beyond the annular
plane. Mild MR
(ii) Floppy valve is a morphologic
abnormality with
thickened leaflet (diastolic
thickness >5 mm) due to
redundant tissue
Degenerative mitral regurgitation
18. Etiology
Rheumatic MR is characterized by
▪ Variable thickening of the leaflets
▪ Fibrosis
Rheumatic mitral regurgitation
19. Etiology
▪ Ischaemic heart disease or
dilated cardiomyopathy.
▪ Imbalance between tethering
forces and closing forces
Functional mitral regurgitation
20. Assessment of severity
1. Settings: Adjust 2D and color gain, NL, ECG, B.P
2. 2D visual Assessment
3. Color flow Doppler
Color flow imaging
Vena Contracta
The flow convergence method
4. Pulsed Doppler
Doppler volumetric method
Mitral to aortic time-velocity integral (TVI) ratio
Pulmonary venous flow
5. Continuous wave Doppler of mitral regurgitation jet
22. Algorithm for distinguishing severe from nonsevere MR in patients with clinically significant
mitral regurgitation (MR) jets on color Doppler imaging.
Paul A. Grayburn et al. Circulation. 2012;126:2005-2017
33. Color Flow Imaging
▪ Less accurate & Most common
▪ Depends on many technical and haemodynamic
factors.
▪ Not recommended to quantify the severity of
MR.
▪ should only be used for diagnosing MR.
▪ Better in Mild and Severe Mitral regurgitation.
34. Vena ContractaWidth
• PLAX and AP-4CV
• Identify the three components of the
regurgitant jet (VC, PISA, jet into LA)
• Smallest vena contracta
• Mean vena contracta width (four- and
twochamber views) better correlated with
the 3D vena contracta.
• TheVC is the area of the jet as it leaves the
regurgitant orifice; it reflects thus the
regurgitant orifice area
Mild MRVC < 3 mm
Severe MRVC > 7 mm
35.
36.
37. Flow converges toward a restrictive orifice remaining
laminar and forming isovelocity surfaces that
approximate hemispheres
Proximal isovelocity surface area (PISA)
38. 1. Apical 4CV
2. Zoom the image of the regurgitant mitral
valve
3. Decrease the Nyquist limit
4. Measure the PISA radius at mid-systole
using the first aliasing and along the
direction of the ultrasound beam
5. Measure MR peak velocity and TVI (CW)
6. Calculate flow rate, EROA, R Vol
Proximal isovelocity surface area (PISA)
39. Proximal isovelocity surface area (PISA)
Flow = Area x Velocity
EROA = Flow/Peak velocity
EROA = (2πr2 × Va)/Peak velocity
Reg Vol = EROA × TVI
44. • Velocity itself does not provide useful
information about the severity of MR.
• A dense MR signal with a full envelope indicates
more severe MR than a faint signal.
CW Doppler of MR jet
45. Pulmonary venous flow
• Both the pulsed Doppler mitral to
aorticTVI ratio and the systolic
pulmonary flow reversal are specific
for severe MR.
• They represent the strongest
additional parameters for evaluating
MR severity.
46. Consequences of mitral regurgitation
• Left ventricle size and function
• LA size andVolumes
• Pulmonary Artery Pressure
50. 36 Years old Asymptomatic female with severe
MR and LVEDs 38mm and EF 65% presents for
routine clinic visit
A. Admit for surgery
B. Followup after 6 months with Echocardiogram
C. Followup after 1 year and echo after 2 years
D. Followup after 1 year and echo after 1 year
51. Recommended Follow-up
Severity Cinical Exam Echocardiogram
Moderate organic MR 1Year 2 Year
Severe organic MR 6 Months 1 Year
EF borderline
or 6 months 6 months
LVEDs close to 40 mm
53. Aetiology
Primary MR (organic/structural): Primary pathology of the valve
Non-ischaemic: degenerative disease (Barlow, fibroelastic degeneration,
Marfan,Ehler–Danlos, annular calcification), rheumatic disease, toxic
valvulopathy, infective endocarditis
Ischaemic: ruptured (complete/partial) papillary, scarred/retracted papillary
muscle.
Secondary MR (functional/non-structural):
malcoaptation related to LV (LA) remodelling with no structural abnormalities
of the valve → non-ischaemic and ischaemic Secondary MR (functional/non-
structural):
malcoaptation related to LV (LA) remodelling with no structural abnormalities
of the valve → non-ischaemic and ischaemic
Editor's Notes
Algorithm for distinguishing severe from nonsevere MR in patients with clinically significant mitral regurgitation (MR) jets on color Doppler imaging. Severe MR corresponds to angiographic grades 3+ and 4+ per American College of Cardiology/American Heart Association guidelines.9 The first step is to determine whether MR severity is obviously mild or severe by American Society of Echocardiography/European Association for Echocardiography criteria (see text).11,12 If not, quantitative parameters are applied in a systemic, integrated fashion to determine whether MR is severe. Unless the MR is unequivocally mild in step 1, no attempt is made to distinguish mild from moderate MR (nonsevere), because studies comparing quantitative echocardiographic measures to an independent reference standard show substantial overlap.49 VCW indicates vena contracta width; MV, mitral valve; VCA, vena contracta area; 3D, 3-dimensional; EROA, effective regurgitant orifice area; PISA, proximal isovelocity surface area; RV, regurgitant volume; RF, regurgitant fraction; VC, vena contracta; CW, continuous-wave Doppler; and LA, left atrium.
Colour-flow imaging in MR
◆ Optimize colour gain/scale
◆ Evaluate in two views
◆ Need blood pressure evaluation
Usefulness/Advantages
◆ Ease of use
◆ Evaluates the spatial orientation of MR jet
◆ Good screening test for mild vs severe MR
Limitations
The colour flow area of the regurgitant jet is not recommended
to quantify the severity of MR. The colour
flow imaging should only be used for diagnosing MR.
◆ Can be inaccurate for estimation of MR severity
◆ Influenced by technical and haemodynamic factors
◆ Underestimates eccentric jet adhering the LA wall (Coanda
effect)