Echocardiography of Mitral regurgitation

Presenetation includes assessment of echocardiographic features of Mitral regurgitation

1. MITRAL REGURGITATION

2. Objectives: Anatomy of Mitral Valve Etiology Assesment of Severity 2D Color Doppler Pulse wave Continous wave Doppler Supportive signs Feasibility of Repair Role of Exercise Echo in MR

3. Role Of Echocardiography in MR Echocardiogram report of MR patients should evaluate Mechanism Etiology Severity of regurgitation Consequences Possibility of repair

4. Mitral Valve Analysis: Recommendations TTE is recommended as the first-line imaging modality for mitral valve analysis . TEE is advocated when TTE is of non-diagnostic value or when further diagnostic refinement is required. 3D-TEE or TTE is reasonable to provide additional information in patients with complex mitral valve lesion. TEE is not indicated in patients with a good-quality TTE except in the operating room when a mitral valve surgery is performed.

5. 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)

6. MITRAL VALVE ANATOMY ON TTE

7. MITRAL VALVE ANATOMY ON TEE

8. 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%.

9. Mechanism of Mitral Regurgitation Carpentier's C lassification

10. Etiology Billowing valve : part of the mitral valve body protrudes into the LA; the coaptation is preserved beyond the annular plane. Mild MR Floppy valve is a morphologic abnormality with thickened leaflet (diastolic thickness >5 mm) due to redundant tissue Degenerative mitral regurgitation

11. Etiology Mitral valve prolapse

12. Cleft Mitral valve Etiology

13. Flail Mitral Leaflet Etiology

14. Etiology Flail Mitral Leaflet

15. Etiology Rheumatic MR is characterized by Variable thickening of the leaflets Fibrosis Rheumatic mitral regurgitation

16. Etiology Ischaemic heart disease or dilated cardiomyopathy. Imbalance between tethering forces and closing forces Functional mitral regurgitation

17. Assessment of severity Settings: Adjust 2D and color gain, NL, ECG, B.P 2D visual Assessment 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

18. Is It Easy? Severe MR MS

19. 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

20. Why Severity Assesment ?

21. Effect Of Blood Pressure

22. Settings & 2D visual Assessment Name Age Blood Pressure ECG Gain: 2D and Color Aliasing velocity

23. 2D visual Assesment :

24. 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.

25. Vena Contracta Width 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 . The VC is the area of the jet as it leaves the regurgitant orifice; it reflects thus the regurgitant orifice area Mild MR VC < 3 mm Severe MR VC > 7 mm

26. Flow converges toward a restrictive orifice remaining laminar and forming isovelocity surfaces that approximate hemispheres Proximal isovelocity surface area (PISA)

27. Apical 4CV Zoom the image of the regurgitant mitral valve Decrease the Nyquist limit Measure the PISA radius at mid-systole using the first aliasing and along the direction of the ultrasound beam Measure MR peak velocity and TVI (CW) Calculate flow rate, EROA, R Vol Proximal isovelocity surface area (PISA)

28. Proximal isovelocity surface area (PISA) Flow = Area x Velocity EROA = Flow/Peak velocity EROA = (2 π r 2 × Va )/ Peak velocity Reg Vol = EROA × TVI

29. Proximal isovelocity surface area (PISA)

30. Doppler volumetric method Calculate LVOT stroke volume (SV) SVLVOT = LVOT diameter2 × 0.785 × TVI LVOT Calculate mitral inflow (MI) stroke volume SVMI = mitral annulus diameter2 × 0.785 × TVI MI Subtract LVOT SV from MI SV = Regurgitant Volume

31. Mitral To Aortic TVI Ratio TVI ratio >1.4 Severe MR TVI ratio <1 Mild MR Peak E velocity >1.5 m/s Severe MR

32. CW Doppler of MR jet

33. 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

34. Pulmonary venous flow Both the pulsed Doppler mitral to aortic TVI ratio and the systolic pulmonary flow reversal are specific for severe MR . They represent the strongest additional parameters for evaluating MR severity.

35. Consequences of mitral regurgitation Left ventricle size and function LA size and Volumes Pulmonary Artery Pressure

36. Lets Summarize

37. Probability of successful mitral valve repair in MR

38. 36 Years old Asymptomatic female with severe MR and LVEDs 38mm and EF 65% presents for routine clinic visit Admit for surgery Followup after 6 months with Echocardiogram Followup after 1 year and echo after 2 years Followup after 1 year and echo after 1 year

39. Recommended Follow-up Severity Cinical Exam Echocardiogram Moderate organic MR 1 Year 2 Year Severe organic MR 6 Months 1 Year EF borderline or 6 months 6 months LVEDs close to 40 mm

40. Thanks for your patience listening

41. 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