Echocardiography is used to evaluate the mitral valve and assess mitral regurgitation (MR). Key questions addressed include the mechanism of MR, severity of MR, and impact on heart structures. Severity is determined semiquantitatively by measuring jet size, density, and width of the vena contracta, as well as assessing pulmonary vein flow. Leaflet morphology, motion, chordae, annulus, and left ventricular size and function are evaluated to identify the etiology and type of MR based on the Carpentier classification system. Anatomic features are also assessed for surgical or transcatheter treatment options.

1. ECHOCARDIOGRAPHIC
Evaluation of Mitral Valve
*****DR JITENDRA SINGH , SR, CARDIOLOGY, CMCH, LUDHIANA*****

2. Q-Main questions to be answered by
cardiac imaging?

3. Q-MAIN QUESTIONS TO BE ANSWERED
BY CARDIOVASCULAR IMAGING?
WHAT IS THE MECHANISM OF MR?
 Leaflet morphology
 Leaflet motion (Carpentier type)
 Subvalvular involvement
 Annulus (dilation, calcium)
 LV size and function
 LA size and function
IS THE MR SEVERE?
 Quantitative (EROA, RV, RF)
 Qualitative (multiple)
WHAT IS THE EFFECT OF MR ON LV AND LA SIZE AND
LA/PULMONARY VENOUS PRESSURE?
 LV diameters, volumes, LVEF, GLS, fibrosis
 LA volume, pressure
 Estimated PA systolic pressure

4. ARE THERE ANATOMIC FEATURES THAT SUPPORT OR PRECLUDE A GIVEN
SURGICAL OR TRANSCATHETER APPROACH?
 Annulus size
 Leaflet length/thickening
 Subvalvular pathology
 Mitral annular calcium
 Potential for LVOT obstruction
 Others (device-specific)
Q-MAIN QUESTIONS TO BE ANSWERED
BY CARDIOVASCULAR IMAGING?

5. ANATOMIC ASSESSMENT OF
MITRAL VALVE
1. Leaflet
2. Chordae tendinae
3. Papillary muscle
4. Annulus
5. Commissures, LA & LV
 2 Leaflets with 3 Scallops
 Anterior Leaflet (AML): larger & thicker
 Dome-shaped
 Scallops: A1 (lateral), A2 (central), A3 (medial)
 Posterior Leaflet (PML): thinner & more flexible
 Crescent shaped
 Scallops: P1 (lateral), P2 (central), P3 (medial)
 Leaflets thin & pliable
 Scallops serve as segmental markers of leaflets

6. ANATOMIC ASSESSMENT OF
MITRAL VALVE
1. Leaflet
2. Chordae tendinae
3. Papillary muscle
4. Annulus
5. LV & LA
 Posterior leaflet is short in length, usually,
11–14 mm.
 Anterior leaflet is longer, normally 18–24
mm.

7. ANATOMIC ASSESSMENT OF
MITRAL VALVE
1.Leaflet
2. Chordae tendinae
3. Papillary muscle
4. Annulus
5. LV & LA

8. ANATOMIC ASSESSMENT OF
MITRAL VALVE
1. Leaflet
2. Chordae tendinae
3. Papillary muscle
4. Annulus
5. LV & LA
 Fibrous strings that attach specific portions of
mitral leaflets to papillary muscle tips.
 Normal average length is around 20mm
 Normal average thickness is 1-2mm
 Look for: thickening, fusion, calcification,
elongation, rupture.

9. ANATOMIC ASSESSMENT OF
MITRAL VALVE
1. Leaflet
2. Chordae tendinae
3. Papillary muscle
4. Annulus
5. LV & LA
 Primary chords insert into the FREE EDGE of the
leaflets, adjacent to the zone of coaptation.
Primary chords prevent leaflet prolapse by
ensuring leaflet tip coaptation throughout
systole.
 Secondary chords insert into the BODY OF THE
VENTRICULAR SURFACE OF THE LEAFLETS and
bear the significant systolic load by spreading it
evenly throughout the leaflets.
 Tertiary chords insert into both THE BASE OF THE
POSTERIOR LEAFLET AND BASAL LV WALL,
connecting the posterior leaflet and annulus to
the papillary muscle.

10. ANATOMIC ASSESSMENT OF
MITRAL VALVE
1. Leaflet
2. Chordae tendinae
3. Papillary muscle
4. Annulus
5. LV & LA
 ANTERO-LATERAL (A-L) PM is usually the
largest, comprised of two heads arising
from a single projection at the mid to apical
border between the lateral and infero-
lateral wall.
 POSTERO-MEDIAL (P-M) PM extends from
multiple myocardial projections from the
mid to apical inferior wall, comprising three
heads (anterior, intermediate and posterior)

11. ANATOMIC ASSESSMENT OF
MITRAL VALVE
1. Leaflet
2. Chordae tendinae
3. Papillary muscle
4. Mitral annulus
5. LV & LA
 Posterior mitral annulus is muscular.
 Anterior annulus consists of fibrous tissue
made up of the left and right trigones.

12. ANATOMIC ASSESSMENT OF
MITRAL VALVE
1. Leaflet
2. Chordae tendinae
3. Papillary muscle
4. Annulus
5. Commissures, LV & LA  2 specific sites where the leaflets insert and
join into mitral annulus
 Anterolateral Commissure
 Posteromedial Commissure

13. ANATOMIC ASSESSMENT OF
MITRAL VALVE
1. Leaflet
2. Chordae tendinae
3. Papillary muscle
4. Annulus
5. Commissures, LV & LA

14. MITRAL VALVE ZONES:
 Body (‘Smooth’) Zone: surface area on
leaflet body
 Coaptation (‘Rough’) Zone: represents
the coaptation area of leaflets.
 Crucial area to observe in assessment
of mitral valve function

15. MITRAL VALVE IMAGING
ORIENTATION:
4 standard views to visualize the mitral valve:
1. Parasternal long axis (PLAX)
2. Parasternal short axis (PSAX)
3. Apical 4 Chamber (AP4)
4. Apical 2 Chamber (AP2)

16. PARASTERNAL SHORT AXIS (PSAX)
MITRAL VALVE IMAGING
ORIENTATION:

17. MITRAL VALVE IMAGING
ORIENTATION:
APICAL 4 CHAMBER (AP4)

18. ETIOLOGICAL ASSESSMENT OF
MITRAL VALVE
Primary chronic MR
Primary MR is caused by a primary
abnormality of one or more
components of the valve
apparatus.
secondary chronic MR
Associated with LA dilation is
commonly associated with atrial
fibrillation or heart failure (HF) with
preserved ejection fraction

19. ETIOLOGY AND MECHANISM OF
MITRAL REGURGITATION:
ETIOLOGY OF MITRAL REGURGITATION MECHANISM OF MITRAL REGURGITATION
Atrial fibrillation Annular dilation, leaflet mal-coaptation
Acute ischemia Papillary muscle dysfunction or rupture
Congenital or genetic disorders; Marfan syndrome,
Ehlers-Danlos syndrome, Down syndrome
Leaflet prolapse, cleft or rudimentary leaflets
Endocarditis; infective and marantic Leaflet perforation, mal-coaptation, chordal rupture
Drugs; fenfluramine and dexfenfluramine Leaflets, chordae
Functional/secondary; dilated cardiomyopathy Left ventricular remolding, papillary muscle
displacement leading to leaflet tethering and
annulus dilation
Hypertrophic obstructive cardiomyopathy Systolic anterior motion of anterior mitral valve
leaflet
Myxomatous degeneration (primary)
(1) Barlow’s disease
(2) Fibroelastic deficiency
Leaflets prolapse
Rupture chordae
Mitral annular calcifications Annulus, leaflets
Rheumatic heart disease Leaflets, chordae
Radiation Leaflets, chordae

20. CARPENTIER FUNCTIONAL
CLASSIFICATION OF MR:
TYPE-1 TYPE-2 TYPE-3a TYPE-3b
Normal leaflet motion.
mitral annular dilatation
with normal leaflets.
Eg. DCM, Endocarditis
Excess leaflet motion.
Ruptured chordae and
the posterior leaflet flail
Eg.Degenrative valve ds,
Barlow's ds, Marfan synd.
Trauma, ICMP
Restricted leaflet motion
during systole and
diastole.
Leaflets are shown
thickened and retracted
Eg.RHD, Carcinoids
Restricted leaflet motion
during systole only.
Tethering of the posterior
leaflet secondary to
myocardial infarct
Eg. DCM, ICM

21. CARPENTIER FUNCTIONAL
CLASSIFICATION OF MR:

22. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 Valve Morphology
 Color Flow Imaging
 CW Doppler
 PW Doppler
 Pulmonary Venous flow reversal
 Vena contracta
 Doppler volumetric method
 PISA

23. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 COLOR FLOW IMAGING:-
• Size & extent of Jet into the LA increase with severity of MR.
• Regurgitant jet more than 40% of the LA area  Severe MR.
• Large eccentric jet adhering, swirling and reaching the posterior wall of
the left atrium  significant MR.
• Small jets appearing just beyond the mitral leaflets usually  Mild MR.
<4 cm2 or 20% of LA size Mild MR
4-10cm2 or 20-40% of LA size Moderate MR
>10cm2 or >40% of LA size Severe MR

24.  CW DOPPLER:
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
• Color flow Doppler is the primary method to evaluating the presence of
regurgitation. It provides us information on:
1. Location of regurgitation jet
2. Size of jet
3. Spatial orientation of jet area (width & length)
4. Flow convergence into regurgitant orifice

25. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION

26. SOFT DENSITY & INCOMPLETE ENVELOPE MILD MR
DENSE SIGNAL & TRIANGULAR ENVELOPE SEVERE MR
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION

27.  MR Vmax 4 m/s : indicate a low BP and high LAP
 MR Vmax 6 m/s : indicate a high BP and low LAP
 CW DOPPLER:
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION

28.  CW DOPPLER:
• The contour and density of the jet can also provide qualitative information.
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION

29. 2).SEMIQUANTITATIVE ASSESSMENT:
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 PW DOPPLER:
• The inflow pattern and velocity can help us identify supportive signs of severe
MR.
• Apical 4 window.
• Ultrasound beam parallel to direction of flow.
• Velocity informs us of the forward stroke volume (SV) across the mitral valve.
• E-Wave Dominant: supportive sign of severe MR
Increased E Wave (> 1.2 m/s)
Increased E/A Ratio
Shortened Deceleration Time
• Reliable to assess primary MR
Challenge for secondary
Unable to differentiate between LV filling pressures or regurgitation
• Dominant A-Wave inflow pattern excludes severe MR

30. 2).SEMIQUANTITATIVE ASSESSMENT:
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 PW DOPPLER:

31. 2).SEMIQUANTITATIVE ASSESSMENT:
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 PW DOPPLER PULMONARY VEINS:
• Evaluate for flow reversal and the hemodynamics due to MR..
• Apical 4 window.
• Sample volume of Doppler 1 cm into pulmonary vein.
S Wave: systolic
D Wave: diastolic
A Wave: peak reversal flow
Ar Duration: time of peak reversal flow
(atrial contraction)
Flow reversal pattern is present,
there is > 85% probability of severe
MR.

32. 2).SEMIQUANTITATIVE ASSESSMENT:
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 PW DOPPLER PULMONARY VEINS:

33. 2).SEMIQUANTITATIVE ASSESSMENT:
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 PW DOPPLER PULMONARY VEINS:

34. 2).SEMIQUANTITATIVE ASSESSMENT:
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 PW DOPPLER PULMONARY VEINS:
• Normal flow pattern suggest low LAP & non-severe MR.
• Less valuable in secondary MR due to unable to exclude diastolic dysfunction.

35. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
2).SEMIQUANTITATIVE ASSESSMENT:
 VENA CONTRACTA:
• Narrowest portion of jet as emerges from orifice
• Good marker to distinguish mild MR from severe MR
MR DIAGNOSTIC CRITERIA (JET WIDTH)
<0.3CM MILD MR
>0.7CM SEVERE MR
0.3-0.7 CM

36. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
2).SEMIQUANTITATIVE ASSESSMENT:
 MR VENA CONTRACTA WIDTH: STEP-BY-STEP
 Parasternal long-axis view
 Ultrasound beam perpendicular to flow
 Adjust the focus setting to the level of the MV
Zoom image
 Color Doppler sector NARROW around the valve
(maximize lateral & temporal resolution)
 Color scale 50-70 cm/sec
 Scroll frame by frame through the systolic cycle
for the largest jet area
 Measure the vena contracta- Narrowest portion
of the jet
 Toggle the color on and off to better visualize the
orifice

37.  MR VENA CONTRACTA WIDTH: PROS
 Semi-quantitative measure.
 A good marker to distinguish mild from severe.
 Can be used for both central and eccentric jets.
 Independent of driving pressure (blood pressure, etc.) for a fixed
MR orifice – Eg. Rheumatic heart, annular calcification,
endocarditis, etc
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 MR VENA CONTRACTA WIDTH: CONS
 Small measurement errors lead to misclassification of MR
severity.
 MR NOT holosystolic (MVP) = overestimation
 Multiple jets = underestimation
 Elliptical-shape orifice (secondary MR) = underestimation

38. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 Proximal Isovelocity Surface Area (PISA):
 Doppler volumetric method
 flow through the regurgitant orifice = flow through the isovelocity surface.
 PISA method is able to provide us with:
 Regurgitant Flow
 EROA
 Regurgitant Volume

39.  Zoom MV
 Color Doppler
 Shift Color Baseline DOWN (TTE) to 20-
40 cm/sec
 Freeze to obtain mid-systolic frame
 Measure radius (r): point of color
aliasing to vena contracta.
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 Proximal Isovelocity Surface Area (PISA):

40. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 Proximal Isovelocity Surface Area (PISA):
PISA = 2πr2
r
REGURGITANT FLOW RATE (RFR) = PISA x Valias (cm/sec)
Valias= aliasing velocity

41. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
EROAmax = RFR /VMRjet
RV = EROA x VTIMRjet

42. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION

43. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION

44. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
 Doppler volumetric method:
SV Method provides us with:
1. Regurgitant Volume (RVol)
2. Regurgitant Fraction (RF)
3. Effective Regurgitant Orifice Area (EROA)
calculate the SV of an orifice by obtaining two measures:
 Cross-sectional Area (CSA)
 Inflow VTI at the Annulus

45. ASSESSMENT OF SEVERITY
MITRAL REGURGITATION
Calculate SV Aortic Valve Outflow
and SV Mitral Valve Inflow

46. CW DOPPLER MR JET VELOCITY
ASSESSMENT OF SEVERITY
MITRAL REGURGITATION

47. GRADING THE SEVERITY OF
MITRAL REGURGITATION
MILD MODERATE SEVERE
QUALITATIVE PARAMETERS
MV morphology Normal/abnormal Normal/abnormal Flail leaflet/chordal rupture
Color flow Doppler of MR jet* < 20% of LA size 20%-40% of LA size > 40% of LA size
CONTINUOUS WAVE Doppler
MR jet density
MR jet contour
Faint
Parabolic
Dense
Parabolic
Dense
Early peaking-triangular
Flow convergence zone* No or small Intermediate Large
SEMI-QUANTITATIVE PARAMETERS
Vena contracta < 0.3 cm 0.3-0.69 cm ≥ 0.7 cm
Mitral valve inflow A-wave dominant E-wave dominant, > 1.2 m/s
Mitral to aortic TVI ratio < 1
m/s
Mitral to aortic TVI ratio 1 to
1.4 m/s
Mitral to aortic TVI > 1.4 m/s
Pulmonary veins flow Systolic dominance Normal or systolic blunting Systolic flow reversal in > 1 vein

48. MILD MODERATE SEVERE
LA/LV size Normal Intermediate Enlarged, particularly with
normal LV function
QUANTITATIVE PARAMETERS
Effective regurgitant orifice
area by PISA or 3D color
Doppler echo
< 0.2 cm2 0.2-0.29 cm2; Mild to moderate
0.3-0.39 cm2; Moderate to
severe
≥ 0.4 cm2
Regurgitant volume < 30 mL/beat 30-44 mL/beat; Mild to
moderate
45-59 mL/beat; Moderate to
severe
≥ 60 mL/beat
Regurgitant fraction < 30% 30%-39%; Mild to moderate
40%-49%; Moderate to severe
≥ 50%
CONTINUED…………..

49. SEVERITY OF MITRAL
REGURGITATION
 In patients with proportionate MR,
the magnitude of MR is equal to the
LVEDV.
 symmetrical displacement of the
papillary muscles, resulting in equal
tethering of the mitral valve leaflets.
 In patients with disproportionate
MR, the magnitude of MR exceeds
LVEDV. Unequal or discoordinated
activation or contraction of the
papillary muscles leading to
asymmetrical valve closure

50. SEVERITY OF MITRAL
REGURGITATION

51. MITRACLIP THERAPY IS A
SAFE, PROVEN,
MINIMALLY INVASIVE
TREATMENT OPTION

52. INDICATIONS FOR INTERVENTION
IN SEVERE PRIMARY MITRAL
REGURGITATION

53. INDICATIONS FOR MITRAL VALVE
INTERVENTION IN CHRONIC SEVERE
SECONDARY MITRAL REGURGITATION

54. MANAGEMENT OF PATIENTS WITH
SEVERE CHRONIC PRIMARY MR

55. MANAGEMENT OF PATIENTS WITH
CHRONIC SEVERE SECONDARY
MITRAL REGURGITATION

56. ECHOCARDIOGRAPHIC PARAMETERS
FOR MITRACLIP FEASIBILITY
FAVORABLE UNFAVORABLE CONTRAINDICATED
Etiology of MR Myxomatous valve
disease
Severe annular
dilation, > 50 mm or
EROA > 70.8 mm2
Rheumatic or endocarditis
valve disease
Location of MR Central, A2/P2
segments
Peripheral, A1/P1 or
A3/P3 segments
Perforated mitral leaflets or
clefts
Grasp zone
Calcification
Length
None
> 10 mm
Mild
7-10 mm
Moderate to severe
< 7 mm
Mitral valve
Area
Gradient
Length of posterior
leaflet
Leaflet mobility
> 4 cm2
< 4 mmHg
> 10 mm
Mobile
> 3.5 and < 4 cm2
> 4 and < 5 mmHg
7-10 mm
Restricted motion
< 3.5 cm2
> 5 mmHg
< 7 mm
Immobile
Primary MR Flail gap < 10 mm
Flail width < 15 mm
Flail gap > 10 mm
Flail width > 15 mm
Secondary MR Coaptation depth <
11 mm
Coaptation length > 2
mm
Coaptation depth >
11 mm
Coaptation length < 2
mm

57. UNFAVOURABLE
PARAMETERS FOR
PERCUTANEOUS MV REPAIR.
UNFAVOURABLE PARAMETERS FOR
MITRACLIP: PRIMARY MR
UNFAVOURABLE PARAMETERS FOR
MITRACLIP: SECONDARY MR
Large flail gap: separation of
prolapsing segment from
opposing leaflet >10 mm
LV end diastolic (LVED)
dimensions >70 mm
Flail width (size of prolapsing
segment) >15 mm
LVED volume >200 mL
Small MV orifice <4 cm2 LVED volume index >96 mL/m2
Posterior leaflet length:
Ideally >10 mm
Can be considered >6 mm