Rheumatic Valvular Heart Disease Assessment of Severity
Prof. P. Krishnam Raju
Care Hospitals, Hyderabad
Focus on
• Severity assessment
• Pitfalls / caveats
• Role of Exercise Echo
• Value of BNP
• Gender differences
VHD
Severe VHD+ Symptomatic
Severe VHD+ Asymptomatic
Mild VHD + Symptomatic
Mild VHD + Asymptomatic
VHD Assessment
History Physical
Exam EKG
Cath Angio
CT MRI Stress Echo
TDI SRI
TEE
CXR
2D Echo
VHD
Classification of Aortic Stenosis Severity
Aortic Sclerosis
Mild Moderate Severe
Aortic jet velocity (m/s) 2.5 m/s 2.6-3.0 3-4 > 4
Mean gradient (mmHg) <20 (<30**) 20-40* (30-50**) > 40* (>50**)
AVA (cm2) > 1.5 1.0-1.5 < 1.0
Indexed AVA (cm2/m2) > 0.85 0.60-0.85 < 0.6
Velocity ratio > 0.50 0.25-0.50 < 0.25
* AHA / ACC Guidelines, ** ESC Guidelines
Exercise Echo Aortic Valve Stenosis
? WHICH PARAMETERS
• Total Exercise Time • Maximum work load • Peak HR TVI/ STRAIN/SRI • Peak BP • Symptoms Low flow / Low Gradient AS • > 20% ↑ Forward SV = Good Contractile Reserve • > 20% ↑ LVOT TVI = as above • Peak Aortic Velocity • P mean • A.V.A
Grading of Aortic Regurgitation Severity
Mild Moderate Severe
Specific signs
for AR severity
• Central jet, width
<25% of LVOT
• Vena contracta < 0.3 cm1
• No or brief early
diastolic flow reversal in
descending aorta
Signs of AR> mild present but no criteria for severe AR
• Central jet, width
≥ 65% of LVOT
• Vena contracta >
0.6 cm
Supportive
Signs
• Pressure half-time
> 500 ms
• Normal LV size 2
Intermediat e values
• Pressure half-time
<200 ms
• Holodiastolic aortic
flow reversal in
descending aorta
• Moderate or
greater LV
enlargement
2
Grading of Aortic Regurgitation Severity
2
Mild Moderate Severe
RVol (ml/beat) <30 30-44 45-59 ≥ 60
RF (%) < 30 30-39 40-49 ≥ 50
EROA (cm2) <0.10 0.10-0.19 0.20-0.29 ≥ 0.30
Quantitative Parameters
1 At a Nyquist limit of 50-60 cm/s. 2 LV size applied only to chronic lesions
3. In the absence of other etiologies of LV dilatation’
. AR = aortic regurgitation; EROA = effective regurgitant office area; LV = left ventricle: LVOT = left ventricular outflow tract; R Vol = regurgitant volume; RF = regurgitant fraction
The information that can be obtained by echo includes
1. Valve disease – Present or absent 2. Valve morphology 3. Severity of regurgitation 4. Mechanism 5. Hemodynamics 6. Etiology 7. Complications 8. Effect on neighbouring structures 9. Choice of therapy – Medical / repair or replacement
Factors affecting assessment of AR by Doppler Color flow imaging include
Physiologic Factors 1. Loading conditions 2. Chamber compliance 3. Orifice size 4. Driving pressure 5. Gradient 6. Entrainment 7. Viscosity 8. Temporal variability
Technical Factors 1. Gain settings 2. Carrier frequency 3. Frame rate 4. Sector size 5. Scanning depth 6. PRF 7. Nyquist Limit 8. Processing algorithms (Maps) 9. Doppler angle
Doppler quantification – Limitations
1. Eccentric jets2. Poor sonic windows 3. Angle error 4. Pit falls in assessment of RV / RF
a. Operator b. Sample volume not at annulus c. Not tracing envelope properly d. Not averaging e. Incorrect annulus diameter f. Multivalvular lesions g. Shunts h. Dense calcification of valve i. Prosthetic valve shadowing
Severe AR
1. Jet width / LVOT diameter ratio ≥ 60% 2. Jet area / LVOT area ratio ≥ 60%3. Jet width at origin ≥ 12mm4. PHT of AR jet ≤ 250ms 5. Restrictive MV flow pattern (Acute AR) 6. Holo diastolic flow reversal in desc aorta 7. Dense CW signal 8. RF ≥55%9. RV ≥ 60%10. LV enddiastolic dimension ≥ 7.5 cm (chronic AR)11. LV endsystolic dimension ≥ 5.5 cm 12. ERO ≥ 0.3 sqcm
Aortic regurgitation severity : Utility, advantages, and limitations
Structural parameters
LV size
Aortic cusps alterations
Utility / Advantages
Enlargement sensitive for chronic significant AR, important for outcomes. Normal size virtually excluded significant chronic AR.
Simple, usually abnormal in severe AR; Flail valve denotes severe AR
Limitations
Enlargement seen in other conditions may be normal in acute significant AR
Poor accuracy, may grossly underestimate or overstimate the defect
I
Aortic regurgitation severity : Utility, advantages, and limitations
Doppler parameters
Jet width or jet cross – sectional area in LVOT – Color Flow Vena contracta Width
PISA method
Utility / Advantages
Simple, very sensitive, quick screen for AR
Simple, quantitative, good at identifying mild or severe AR
Quantitative. Provides both lesion severity (EROA) and volume overload (R vol)
Limitations
Exapands unpredictably below the orifice. Inaccurate for eccentric jetsNot useful for multiple AR jets. Small values; thus small error leads to larg % error.
Feasibility is limited by aortic valve calcifications. Not valid for multiple jets, less accurate in eccentric jets. Provides peak flow and maximal EROA. Underestimation is possible with aortic aneurysm. Limited experience.
II
Aortic regurgitation severity : Utility, advantages, and limitations
Flow quantitation –PW
Jet density –CW
Jet deceleration rate (PHT) –CW
Diastolic flow reversal in
descending aorta-PW
Utility / Advantages
Quantitative, valid with multiple jets and eccentric jets. Provides both lesion severity (EROA, RF) and volume overload (R Vol)
Simple. Faint or incomplete jet compatible with mild AR
Simple
Simple
Limitations
Not valid for combined MR and AR, unless pulmonic site is used.
Qualitive. Overlap between moderate and severe AR. Complementary data only
Qualitive; affected by changes in LV and aortic diastolic pressures
Depends on rigidity of aorta. Brief velocity reversal is normal
III
Exercise Echo AR
? WHICH PARAMETERS
• LV EDV • LV ESV • EF • Annular Systolic Velocities • TVI • SR • SRI • ? BNP
Classification of Mitral Stenosis Severity
Mild Moderate Severe
Specific findings
Valve area (cm2) > 1.5 1.0 – 1.5 < 1.0
Supportive findings
Mean gradient
(mmHg)
< 5 5 – 10 10
Pulmonary artery
Pressure (mmHg)
< 30 30- 50 > 50
* at heart rates between 60 to 80 beats per minute and in sinus rhythm
Exercise Echo Mitral Stenosis
? WHICH PARAMETERS
• Exercise Tolerance
• Trans Mitral Velocities / Gradients
• Trans Tricuspid Velocities / Gradients
• RVSP = PASP
MR• Severity • Etiology• Pathophysiology• Effects of MR on cardiac chambers• LV function• Other LV hemodynamic information from MR jet• Associated lesions• PAH• Prognosis• Stress Echo?• Timing of surgery• Type of surgery
Clinical Questions
Echo Evaluation
Grading of Mitral Regurgitation Severity Mild Moderate Severe
Specific signs of severtiy
• Small central jet < 4
cm2 or < 20% of LA area
• Vena contracta width
< 0.3 cm
• No or minimal flow
convergence
Signs of MR > mild present, but no criteria for severe MR
• Vena contracta width ≥ 0.7 cm with large central MR jet (area >40% of LA) or with a wall-impinging jet of any size, swirling in LA
• Large flow convergence1
• Systolic reversal in
pulmonary veins
• Prominent flail MV
leaflet or ruptured
papillary muscle
Supportive signs
• Systolic dominant flow in pulmonary veins
• A-wave dominant mitral inflow2
• Soft density parabolic CW Doppler MR signal
• Normal LV size3
Intermediate signs / findings
• Dense, triangular CW
Doppler MR jet.
• E-wave dominant mitral
inflow (E> 1.2 m/s)2
• Enlarged LV and LA size
(particularly when normal
LV function is present)
1
Grading of Mitral Regurgitation Severity 2
Mild Moderate Severe
RVol (ml/beat) < 30 30 - 44 45 - 59 ≥ 60
RF (%) < 30 30 - 39 40 - 49 ≥ 50
EROA (cm2) < 0.20 0.20 – 0.29 0.30 – 0.39 ≥ 0.40
Quantitative Parameters
Color Nyquist limit of 50-60 cm/s. 1. Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and ≥ 0.9 cm for central jet, respectively, with a baseline shift at a Nyquist of 40 cm/s.
2. Usually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA pressure.
3. LV size applied only to chronic lesions. CW = continuous wave; EROA = effective regurgitant orifice area; LA = left atrium; LV = left ventricle; MV = mitral valve ; MR = mitral regurgitaiton; R Vol = regurgitant volume; RF = regurgitant fraction.
MR
Technique Value Comments
Jet area + Technique dependant
Jet hugs LA wall ++ Upgrade MR by 1o
Jet enters LAA ++ Usually severe
Jet enters PV ++ Usually severe
Jet encircles LA ++ Upgrade MR by 1o
Agitated flow in LA + Technique dependant
PISA size ++ Dependant on NL
I
Color Doppler TEE
MR
PW/CW
Technique Value Comments
PV syst. reversal +++ Severe
E ht of MV inflow ++ 1.5 to 1.8 cm/sec(severe MR)
LVOT / Aortic velocities + with severe MR
MR jet density + Beam alignmentdependant
V wave cutoff sign + Severe MR
II
TEE
MR
2 D EchoTechnique Value CommentsLA auto contrast + Excludes severe MRLA dilation + Severe MR
(Except acute MR) LA systolic expansion + SevereIAS bulge to right + SevereAuto contrast in AO + Severe MR + ShockFlail MV ++ Severe Dilated RA / RV + PAH + Severe
III
TEE
MR
Grading
• Mild < 15%
• Moderate 15 to 35%
• Mod severe 35 to 55%
• Severe > 55%
TEEMR Jet area to LA area
MR (severe)Natural History
• Variable Estimates of long term survival97 – 27 % at 5 yrs
• Flail leaflet MR- Annual mortality 6.3%- 10 yr incidence of AF 30%- 10 yr incidence of CHF 63%- at 10 yr dead + MV surg 90%
• Flail leaflet MR Mortality- NYHA FC I / II 4.1% /yr- NYHA FC III / IV 34% /yr
• SCD - 1.8% / yr overall- 0.8% / yr in pts without risk factors
MRAssessment for early LV dysfunction
1. Exercise Testing
2. Exercise Echo
3. TDI
4. Exercise RNV
• Severe MR• LVEF < 60 %• LVSD (exercise)• LVIDs > 45 mm• A fib• RV dysfunction• PAH
Mitral regurgitation (severe)Asymptomatic
Golden Moment
MV Replacement Vs Repair
MV replacement MV repairHospital mortality 3% - 15% 1% - 3%Annual embolism / Thr 1 - 3% 0 - 1%Warfarin Usually RarelyLV function Yes NoLV anatomy affected Yes NoPap muscle function No YesAnnual failure rates 1 - 2% < 1%Annual IE 1 - 2% < 1%Suitable for all MV disease Yes NoAbsolute contraindications None Calcific severe RHDRelative contraindications None RHD, Isch MRIdeal pathology All Myxomatous
ECHO MR
Repairability of MVCarpentier• Type I Normal anatomy
Annular dilatationLeaflet perforation
• Type II Excessive leaftlet motion (prolapse)Chordal elongationPap muscle elongationPap muscle / chordal rupture
• Type III Restricted anatomyCommisural fusionLeaflet thickeningChordal thickening / fusion
Poor results – Type III• Commis. Prolapse, Extensive prolapse, dense calcification AML
prolapse
MV APPARATUS ECHO NORMAL MEASUREMENTS
• AML length (ED) 25 mm
• PML length (ED) 15 mm
• Chordae length (ES) 29 mm
• Mitral Annulus (ES) 3.4 cm
Mitral Valve Repair Measurements
Carpentier’s Type III B MV • Inter Pap muscle distance• Annulus to base of Pap Muscle • AML – PML Ratio (For Ring Annuloplasty) • MV Coaptation point to septal distance.
Isch.MR MV Tenting Angle - AML, PML
MV Tenting Area
Mitral Valve Repair Measurements
Percutaneous Coro Sinus Devices
• Coro Sinus to Post. Mitral Annulus Distance.• Lay of Coro sinus • CS relation to post mitral annulus • LCX relation to CS / MV annulus
Assessment to Preoperative Risk for Assessment to Preoperative Risk for SAM/LVOTOSAM/LVOTO
• Pre-repair TEEPre-repair TEE– AL /PL ratio AL /PL ratio
• Greater in patient with AL/PL <1 Greater in patient with AL/PL <1 than in patients with AL/PL >3than in patients with AL/PL >3
– C-septC-sept• Greater in patients with C-sept < 2.5cm Greater in patients with C-sept < 2.5cm than in patients with C-sept > 3.0 cmthan in patients with C-sept > 3.0 cm
STRESS ECHO Mitral Regurgitation
? Who needs
• Asymptomatic + Severe organic MR ERO > 40 mm2
Unmasking latent LV dysfunction
Predicting post op EF
Assess EX tolerance
Effects on PA pressure / MR severity
class 2 a /level of evidence c
STRESS ECHO Mitral Regurgitation
? WHICH PARAMETERS
• EXERTIONAL SYMPTOMS• LV LVEDV TVI dp/dt
LVESV SRI Contractile Reserve LVEF SR RW thickening
• RV RVEF TVI RVSP SRI
• MR JA Tenting Area VC PISA - RV / RF/ ERO ERO
• Pulm Vein Doppler flow parameters / PWD profiles MV / PV• TDI E/E’• TR Severity RVSP = PASP
STRESS ECHO Mitral Regurgitation
• VHD considered static • Most valve diseases have DYNAMIC component (Every day life)• Loading conditions, contractility change – Life activities. • Contractility reserve, compliance, vent-art coupling- change • Reveal
_ Symptoms – Valve dynamics – Ventricle dynamics – Change in forward output – Retrograde flow – Pulmonary pressures – Objective assessment of functional disability
• Euro Heart Surgery - stress testing under used- Inappropriate use
Findings Indicative of Hemodynamically Significant Tricuspid Stenosis
* Stroke volume derived from left or right ventricular outflow. In the presence of more than mild tricuspid regurgitation, the derived valve area will be underestimated. Nevertheless a value 1 cm2 implies a significant hemodynamic burden imposed by the combined lesion.
Specific Findings
Mean pressure gradient ≥ 5 mm Hg
Inflow time velocity integral > 60 cm
T ½ ≥ 190 ms
Valve area by continuity equation* 1 cm2
Supportive Findings
Enlarge right atrium ≥ moderate
Dilated inferior vena cava
Grading of Tricuspid Regurgitation Severity
Parameter Mild Moderate Severe
Tricuspid Valve Usually normal Normal or abnormal
Abnormal / flail leaflet / poor coaptation
RV / RA / IVC size Normal 1 Normal or dilated Usually dilated 2
Jet area - Central jets (cm2) 3
< 5 5 – 10 > 10
PISA radius (cm) 4 < 0.5 0.6 – 0.9 > 0.9
Jet density and contour – CW
Soft and parabolic
Dense, variable contour
Dense, triangular with early peaking
Hepatic vein flow 5 Systolic dominance
Systolic blunting Systolic reversal
1. Unless there are other reasons for RA or RV dilationt. 2 . Exception: acute TR. 3. At a Nyquist limit of 50-60 cm/s. 4. Baseline shift with Nyquist limit of 28 cm/s. 5. Other conditions may cause systolic blunting (e.g atrial fibrillation, elevated RA pressure). CW = continuous wave Doppler, IVC = inferior vena cava; RA = right atrium; RV = right ventricle; VC = Vena contracta width.
Grading of Pulmonary Stenosis
Mild Moderate Severe
Peak Velocity (m/s) < 3 3 – 4 > 4
Peak gradient (mmHg) < 36 36 to 64 > 64
Grading of Pulmonary Regurgitation Severity Parameter Mild Moderate Severe
Pulmonic valve Normal Normal or abnormal
Abnormal
RV size Normal 1 Normal or dilated
Dilated 2
Jet size by color Doppler
Thin (usually < 10 mm in length) with a narrow origin
Intermediate Usually large, with a wide origin; may be brief in duration
Jet density and deceleration rate- CW3
Soft; slow deceleration
Dense; variable deceleration
Dense; steep deceleration, early termination of diastolic flow
Pulmonic systolic flow compared to systemic flow –PW
Slightly increased
Intermediate Greatly increased
1. Unless there are other reasons for RV enlargement. 2 . Exception: acute PR. 3. Steep deceleration is not specific for severe PR. CW= continuous wave Doppler; PR = pulmonic regurgitation; PW= pulsed wave Doppler; RV = right ventricle.
GENDER DIFFERENCES
Mitral Valve disease Asymptomatic (Severe MR)
Timing of Surgery• LV dysfunction • LV volume ACC guidelines • Pulmonary Hypertension Univariate Predictors • Atrial fibrillation
• ESD / BSA > 22 mm / m2 Multi variate predictors• EROA > 55 mm2
• BNP > 105 pg / ul
• BNP annual increase > 25 pg/ml (over 1 year)
• New flail leaflet Univariate Predictors• EDD• LA
JACC 2009; 54 Hamzel et al 1107-1108,Pizamo et al 1099-1106
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