Echocardiographic evaluation of mitral regurgitation

mitral regurgitation echo

1. Echocardiographic evaluation of mitral regurgitation S.R.Sruthi Meenaxshi MBBS,MD,PDF

2. Causes of mitral regurgitation Mitral valve prolapse ( myxomatous prolapse ) Rheumatic heart disease Infective endocarditis Post MI papillary muscle rupture Connective tissue disorder - Marfans , Ehler Danlos syndrome , Pseudoxanthoma elasticum SLE,Scleroderma Dilated cardiomyopathy HOCM

3. Indications of echocardiography in MR Diagnosis and evaluation of the etiology/mechanism of MR • Asessment of hemodynamic severity, including impact on ventricular size, function, and hemodynamics • Initial assessment and re-evaluation of asymptomatic and symptomatic patients with MR • Assessment of effects of medical and surgical therapies in MR, including mitral valve repair or replacement

4. Mitral valve

5. CARPENTIER CLASSIFICATION

6. Mitral valve prolapse Classic MVP exists when there is exaggerated (>2 mm) superior displacement (“buckling” or “hammocking”) of thickened mitral leaflets (>5 mm thick in diastole) beyond the plane of the mitral annulus during late systole. One of the most common reasons for MVP is fibro myxomatous degeneration of the mitral valve, which can lead to leaflet prolapse, chordal rupture, or partial flail of a segment of one or both leaflets

7. Thickened myxomatous mitral leaflet more than 5 mm suggest MVP

8. Mitral valve prolapse

9. M MODE M MODE – PSAX VIEW MVP shows posterior displacement of C-D segment in mid and late systole

10. DOPPLER METHODS IN GRADING MR SEVERITY MR jet area Vena contracta width EROA by PISA METHOD Systolic flow reversal of pulmonary veins

11. Determination of severity

12. Coanda effect Larger color jet areas indicate more severe MR when the jet is centrally directed, but can be misleading with eccentrically directed jets. Hugging or entertainment ( Coanda effect) of the eccentric jet to the LA wall results in smaller jet areas even when MR is severe.

13. COLOR FLOW JET AREAS

14. WRAP AROUND EFFECT IN SEVERE MR

15. VENA CONTRACTA WIDTH The vena contracta is the narrow neck of the MR jet as it traverses the regurgitant orifice Semi quantitative method of assessment of severity of MR Assessed in 2 chamber and 4 chamber view

16. VC WIDTH

17. PROXIMAL FLOW CONVERGENCE AND PROXIMAL ISOVELOCITY SURFACE AREA This method can be used for estimating the area ofthe regurgitant orifice— As regurgitant blood converges toward the regurgitant orifice at the proximal convergence zone, the size and velocity of the innermost shell or hemisphere can be m easured Furthermore, according to the continuity principle the amount of fluid that passes through the regurgitant orifice is the same as amount that flows in the regurgitant jet (the law of conservation of mass). Therefore, total flow at the proximal isovelocity surface area (PISA) will equal total flow in the distal MR jet.

18. EROA BY PISA METHOD Apical 4 chamber is used The velocity at which blue red colour shift occurs identify the PISA shell The pisa radius (R) is then measured and multiplied by PISA velocity ie aliasing velocity to give regurgitant flow rate .

19. PISA METHOD

20. Calculation of regurgitant volume

21. CW DOPPLER IN MR Peak MR jet velocities by continuous-wave (CW) Doppler typically range between 4 and 6 m/s—a reflection of the systolic pressure gradient between LV and LA.

22. Notching cw envelope in severe MR

23. Systolic flow reversal in pulmonary veins The presence and the degree of reversal of blood flow from the LA into the pulmonary veins can indicate the hemodynamic impact of the MR jet. Visualization of flow reversal into one or more pulmonary veins on colour flow Doppler.

24. PW in upper pulmonary artery produces a negative S wave

25. PW at mitral valve produces a E dominance E dominance of more than 1.2m/s , marked early diastolic flow Typical of in severe MR

26. Structural parameters left atrial size LV size appearance of the mitral apparatus.

27. LA SIZE

28. LA will dilate in response to chronic volume and pressure overload Acute onset MR due to papillary muscle rupture can produce LA dilatation Increased LA diameter and systolic flow reversal of pulmonary veins may be only echocardiographic diagnosis in severe MR

29. Left ventricular performance Acute MR phase Chronic compensated MR Chronic decompensated MR

30. Index of severity Color Doppler regurgitant jet width and penetration Color Doppler proximal isovelocity surface area diameter Continuous wave Doppler characteristics of the regurgitant jet Tricuspid regurgitant jet-derived pulmonary artery pressure by continuous wave Doppler Pulse wave Doppler pulmonary venous flow pattern Left atrial size by 2D echocardiography

31. Quantitative measurements in mitral regurgitation Using the PISA method and various volumetric methods, quantitative measures regurgitant volume, regurgitant fraction effective regurgitation orifice area (EROA) can be calculated 

32. Quantitative parameters

33. THANKYOU