determining the suitability of the mitral valve for repair most likely in patients with mitral regurgitation due to myxomatous degeneration and is least likely in patients with regurgitation due to endocarditis most likely with posterior prolapse or flail, whereas ileaflet involvement and isolated anterior leaflet prolapse reduce the likelihood of successful repair substantially.

1. DR.PV.NISHANTH,DM
NIMS,Hyderabad,India.

3.  Dysfunction or altered anatomy of any one of
the components of the mitral valve apparatus
can result in mitral regurgitation.

5. • determining the suitability of the mitral valve
for repair
• most likely in patients with mitral
regurgitation due to myxomatous degeneration
and is least likely in patients with regurgitation
due to endocarditis
• most likely with posterior prolapse or flail,
whereas bileaflet involvement and isolated
anterior leaflet prolapse reduce the likelihood
of successful repair substantially

6.  thorough examination of the mitral valve and
mitral apparatus and to determine the origin
and geometry of the regurgitant jet
 long-axis imaging planes are best for
determining which mitral leaflet is involved
 TTE-PLAX/apical long axis/SHORT
AXIS/A4C

8.  Long-axis views of the mitral valve are
obtained by imaging from midesophageal TEE
planes
 Typically, when viewing the left ventricle in a
longitudinal plane (120 degrees), the imaging
plane intersects the A2/P2 boundary

9.  Imaging at a multiplane angle of about 135
degrees cuts perpendicular to this
intercommissural line.
 short-axis views also are useful for determining
which portion of the anterior or posterior
leaflet is involved.

11.  approximately 50 to 60 degrees in most
patients, the imaging plane parallel to a line
between the commissures, is very useful for
determining which portion of the anterior or
posterior leaflet is involved.

13.  papillary muscles and chordae usually are well
visualized from the transgastric long-axis
views of the left ventricle

14. Etiology Presumed Mechanism
Annular dilation Inadequate leaflet coaptation
MAC Increased rigidity of annulus impairing
systolic contraction
Myxomatous mitral valve disease Inadequate coaptation and apposition, fail
segments
Rheumatic mitral valve disease Increased rigidity of leaflets
Endocarditis Leaflet perforation or deformity
Age-related degenerative leaflet changes Abnormal coaptation
Hypertrophic cardiomyopathy Abnormal leaflet motion and anatomy
Chordae disruption or elongation Inadequate systolic support of leaflet
Regional left ventricular dysfunction Inadequate systolic support of leaflets
Left ventricular dilation Abnormal papillary muscle orientation
Papillary muscle rupture Inadequate systolic support of leaflets

18.  elongation or disruption of any portion of the
mitral valve or of the mitral apparatus,
including the papillary muscles and chordae
 Myxomatous disease
 endocarditis
 papillary muscle infarction

19.  Flail leaflet-not uncommon sequela of a
myxomatous mitral valve
 anatomic disruption of a portion of the mitral
apparatus results in aneccentric direction of the
regurgitation jet with an orientation opposite in
direction to the leaflet with the anatomic defect

21.  regurgitant jet is directed away from the affected
leaflet
 chordae to the commissures are ruptured, then
a jet originating at the commissures is seen in
the transgastric short-axis view.
 Jets originating at the commissure also are
seen in infarction of a papillary muscle, most
commonly the posteromedial one

22.  papillary muscle ruptures in an acute
myocardial infarct-differentiated from acute
chordal rupture by detecting a mass attached to
the flail leaflet that is a portion of the muscle
 Postoperative prognosis is best in those with
excessive leaflet motion.

26.  rheumatic disease
 ischemic heart disease
 the chronic phase oflupus
 acquired valvular disease caused by certain
drugs such as ergot derivatives and
anorexigenic drugs such as the fen-phen

27.  rheumatic, lupus, and drug-induced diseases,
the leaflets are thickened
 rheumaTIC-pml more affected than AML
 relatively normal anterior leaflet "over-rides"
the restricted posterior leaflet.
 The direction of the regurgitant jet in this
situation is posterior, toward the affected leaflet

28.  Echocardiographic findings consistent with
rheumatic valve involvement include
 (1) leaflet thickening, deformation, and
retraction
 (2) fusion, shortening, and fibrosis of the
subvalvular apparatus
 (3) accompanying aortic and/or tricuspid
valve involvement

29.  Chordal rupture is mc in chordae to AML in
rheumatic while it is MC in chordae to PML in
myxomatous valve.
 Rheumatic valve is more likely to have IE than
spontaneous rupture.

30.  commonly seen in patients with mitral
regurgitation secondary to left ventricular
dilation of any cause
 dilated cardiomyopathy,or severe ischemic
cardiomyopathy

31.  Perforation of the valve leaflet causing mitral
regurgitation occurs most commonly because
of endocarditis or because of a congenital cleft
in the valve
 Occasionally it is iatrogenic, after attempted
repair.
 jet origin is eccentric, arising from the
midportion of the leaflets rather than from the
coaptation line.

32.  Chronic MR, occurring >2 weeks after
infarction and in the absence of structural
mitral valve disease
 disease of abnormal left ventricular (LV) shape
and function with a valvular manifestation

38.  Greater degrees of morphologic disturbance
are predictive of greater likelihood of
persistence of MR following mitral
annuloplasty, with the optimal cut-offs for
distinguishing patients with persistent MR
being a
 coaptation distance of .0.6 cm
 tenting area of >2.5 cm2
 posterior leaflet angle >45u.
 Annular dilatation more than 40 mm

39.  Post annuloplasty PL is relatively fixed ,it is the
AL that has to coapt.
 So instead of PL angle/AL base angle ,AL tip
angle is more determining factor

44.  Evaluation of mechanisms of MR needs a
systematic approach utilising both TTE and
TEE for visualising all scallops of leaflets.
 Excessive leaflet motion has the best chance of
surgical correction
 Ischemic MR/ventricular annular dilatation is
a complex and needs evaluation by multiple
variables to predict result of annuloplasty.

45.  3D echo gives excellent visualisation of mitral
valve and its structures and provides both
aetiological and prognostic information

46. THANK YOU