assessment of mitral regurgitation with echocardiography · degenerative mitral valve disease...
TRANSCRIPT
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Theodora A Zaglavara, MD, PhD
BSCI/BSCCT Accredited for Cardiac CT
Advanced Cardiac Imaging
INTERBALKAN MEDICAL CENTER
THESSALONIKI, GREECE
Assessment of Mitral Regurgitation with Echocardiography
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Mitral Valve: One of the Most Complex Structures in the Human Body
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Role of Echo in Mitral Regurgitation
• Mechanism :
lesion/deformation resulting in valve dysfunction
• Severity of regurgitation
• Consequences of MR
• Possibility of repair /suitability for MC/percutaneous intervention
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Mitral Valve Analysis: Transthoracic Echo
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Transthoracic versus Transesophageal Echo
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Challenges in Imaging a Structure with
Complex 3-D Geometry with 2-D Imaging
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The Complex Structure of the Mitral Annulus
Cannot be Fully Imaged in 2D
Normal Saddle Shaped
Dilated and Flattened
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Normal Mitral Valve 3D Anatomy
LA surgeon’s VIEW
LV VIEWAnatomic View
Anterior
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Volumetric Quantification of the Mitral Valve
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Carpentier Classification of MR
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Degenerative Mitral Valve Disease
Affects 2% of population
Leaflet prolapse most common finding
A wide spectrum of degenerative disease resulting in MR
In contrast to functional MR, which is a disease of the LV, degenerative MR is a disease of the valve and therefore repair of the valve results in cure of the disease.
The annulus is always dilated
in Barlowsdisease
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A case of P3 prolapse
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BarlowsValve
EUROECHO 2009 - Madrid
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Functional Mitral Valve Disease
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Assessment of MR Severity
• Mitral Valve Morphology
• Colour-flow imaging
• Vena Contracta
• PISA
• EROA, Regurgitant Volume,
Regurgitant Fraction
• Doppler volumetric
quantitation (Non applicable
in case of significant AR)
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Colour Flow Imaging• Optimize colour
gain/scale• Evaluate in multiple
views• Need blood pressure
evaluation• Good screening for mild
vs severe MR• Influenced by technical
and haemodynamicfactors
• Underestimates eccentric jets
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Vena Contracta for MR Quantitation• Colour scale 40-70cm/s• VC reflects ROA• Relatively independent of
haemodynamic and instrument factors
• Good for extreme MR : mild vs severe
• Not affected by other regurgitation
• not valid for multiple jets
• Mild MR VC< 3 mm• Severe MR > 7 mm
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Proximal Isovelocity Surface Area (PISA)
• Flow across any isovelocity surface = flow through orifice (Conservation of Mass principle)
• Can be used in eccentric jet• Quantitative : estimate lesion severity (EROA) and
volume overload (R vol)• Flow convergence at 50 cm/s alerts to significant MR
• Mild MR EROA< 20 mm²• Severe MR EROA >40 mm²
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3-D Vena Contracta (VC) – PISA in MR
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Mitral Inflow and Outflow Stroke Volume Measurement
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Supportive Findings
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2017
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2017
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Consequences of MR
LV size and function• LVESD > 4.5 cm • LV EF : load dependent• GLS < 18%• TDI E’medial <10.5 m/s
LA size• LA volume index > 40 ml/m²
(significant enlargement)
PASP> 50 mmHg at rest
Tricuspid Annular Dilatation ( > 40 mm or 21 mm/m²)
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Probability of successful mitral valve repair in MR
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Unfavourable characteristics for mitral valve repair in functional MR
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Echocardiographic Evaluation of Mitral Valve for Patient Selection for Mitral Clip
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The Anatomy Lesson of Dr. Nicolaes TulpRembrandt 1632, The Hague Netherlands