mitral regurgitation francesca n. delling, md july 8, 2009
TRANSCRIPT
Mitral Regurgitation
Francesca N. Delling, MDJuly 8, 2009
Outline
Anatomy
Diagnosis
- Two-dimensional echocardiography (etiology)
- Doppler methods (assessment of severity)
- Role of 2D and 3D-TEE
- Role of CMR
Treatment
Anatomy: The mitral valve apparatus
Subvalvular apparatus (papillary muscles with their supporting left ventricular walls and chordae tendineae)
Mitral annulus Mitral valve leaflets
Anatomy: The mitral valve
Reference view from the left ventricular apex
Surgical view from the left atrium with the heart rotated
Diagnosis
2D Echocardiography: Etiology of mitral regurgitation
Primary:
- Myxomatous
- Endocarditis
- Rheumatic
- Trauma
- Congenital
- Drugs (ergotamines,
methysergide, pergolide, fen fen)
Secondary:
- Non-ischemic dilated CMP
- Ischemic heart disease
- HCM
Type I = normal leaflet motion but with annular dilatation or leaflet perforation
Type II = leaflet prolapse (eg myxomatous disease) or papillary muscle rupture
Type III = restricted leaflet motion.
IIIa = rheumatic disease
IIIb = ischemic or idiopathic cardiomyopathy.
Carpentier classification
2D Echocardiography: additional information
Left ventricular size and function and left atrial size as clues to:
- severity of MR
- acuteness or chronicity
- necessity and timing of surgery
Mitral valve prolapse
Occurs in 2.4% of the population (Freed at al. NEJM 1999)
Patients exhibit fibromyxomatous changes in the mitral leaflet tissue that cause superior displacement of the leaflets into the left atrium (by definition > 2 mm) The most common primary cause of isolated MR requiring surgical repair
Both familial (loci identified: chromosomes 11, 16, 13) and “sporadic” cases observed
Mitral valve prolapse
Mitral valve prolapse
AOSeptum
A
P
AOSeptum
Normal MVP
ACoaptationLV
Leaflet elongation can manifest itself not only by superior motion into the LA but also by anterior motion that shifts the coaptation point toward the aortic root and septum.
Mitral valve prolapse
SUPERIOR
ANTERIOR
LV
AO
LA
AL
PL
Coaptation
RV
I
Coaptation
RV
AOLV AL
PL
II
Prodromal form:
III
LV
AO
LA
AL
PL
Coaptation
RV
I
LV
AO
LA
AL
PL
Coaptation
RV
LV
AO
LA
AL
PL
Coaptation
RV
I
Coaptation
RV
AOLV AL
PL
II
Coaptation
RV
AOLV AL
PL
Coaptation
RV
AOLV AL
PL
II
Prodromal form:
III
Prodromal form:Prodromal form:
III
Nesta et al. Circulation 2005
Prodromal form
Anterior displacement of the coaptation point.
Mild bulging of the posterior leaflet relative to the anterior.
Normal Prodromal
Functional Mitral Regurgitation:Incomplete Mitral Leaflet Closure
LV
LA
NORMAL IMI or global LVD
AO
Papillary Muscle
Displacement
Mitral ValveTethering
IMLC
MRCourtesy of Judy Hung, MD
Functional Mitral regurgitation
Leaflet concavity (PS view) in functional MR
MR related to HOCM
• LV ejection through an LVOT narrowed by both septal hypertrophy and anterior displacement of MV apparatus (PM + MV) causes the Venturi effect or “drag forces” which drag the MV leaflets and chordae towards the septum
• MR is related to SAM of the anterior mitral leaflet AND failure of post leaflet to move anteriorly with consequent gap between the two leaflets
Yu et al. Mitral regurgitation in hypertrophic cardiomyopathy: relationship to obstruction and relief with myectomy. J Am Coll Cardiol 2000;36;2219-2225
Doppler Methods for assessment of severity
Color flow Doppler
- Regurgitant jet area
- Vena contracta
- Flow convergence (PISA)
Continuous wave Doppler
Pulsed Doppler
- Mitral inflow pattern
- Quantitative parameters (regurgitant volume, fraction, EROA)
Regurgitant jet area
Pros:
- Simple, quick screen for mild or severe central MR
- Evaluates spatial orientation of jet
Cons:
- Subject to technical, hemodynamic variation
- Underestimates severity in eccentric jets
Mild: < 4 cm2 or < 20% of LA area
Moderate: variable
Severe: > 10 cm2 or > 40% of LA area
Vena contracta width
LAX SAX
Mild: < 0.3 cm Severe 0.7 with large central jet or with wall impinging jet of any size
Proximal isovelocity surface area (PISA)
Based on the hydrodynamic principle that the flow profile of blood approaching a circular orifice forms concentric, hemispheric shells of increasing velocity and decreasing surface area.
Color flow mapping able to image one of these hemispheres that corresponds to the aliasing velocity or Nyquist limit of the instrument.
The aliasing velocity should be adjusted to identify a flow convergence region with a hemispheric shape.
PkVreg = the peak velocity of the regurgitant jet by continuous wave Doppler Reg volume = EROA x VTIreg jet
Mild: EROA <0.2cm2
Severe: EROA >/=0.4cm2
Pros:
- Presence of flow convergence at Nyquist limit of 50-60 cm/s alerts to significant MR
- Provides both lesion severity (EROA) and volume overload (R Vol)
Cons:
- Less accurate in eccentric jets
- Not valid in multiple jets
- Any error is determining the location/radius of the orifice is squared
Proximal isovelocity surface area (PISA)
EROA = [6.28 x (.8)(.8) ml/s x 36] / [480 cm/s] = 0.3cm2
Example of PISA calculation
r = 0.8 cm
Supportive signs of MR severity
Other supportive signs of MR severity
Mild MR:
- A-wave dominant mitral inflow **
- Normal LV size
Severe MR:
- E-wave dominant mitral inflow (E > 1.2 m/s) **
- Enlarged LV and LA size
** Usually above 50 years or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA pressure
Quantitative pulsed Doppler parameters
In the absence of regurgitation, stroke volume should be equal at different sites, e.g. the mitral and aortic annulus.
In the presence of regurgitation (assuming the absence of an intracardiac shunt), the flow through the affected valve is larger than through other competent valves.
ann
Supportive signs of severityQuantitative pulsed Doppler parameters
JASE 2003;16:777
Summary
2D-TEE localization of MR defects
Foster et al. Ann Thorac Surg 1998;65:1025
Probe inStandard midesophageal position
2D-TEE localization of MR defects
Foster et al. Ann Thorac Surg 1998;65:1025
Probe at 0 degrees, effects of flexion or withdrawal and retroflexion or advancement
2D-TEE localization of MR defects
Foster et al. Ann Thorac Surg 1998;65:1025
40 to 90 degrees, effect of clockwise and counterclockise probe rotation
3D-TEE
To simulate a surgeon’s view of the valve, the 3D TEE image is positioned with the aortic valve the 11-o’clock position.
Intra-Operative 2D and 3D TEE Depiction of MV Prolapse and Leaflet Flail
3D-TEE quantitative analysis of the mitral apparatus
CMR
Etiology of mitral regurgitation
Quantitation of mitral regurgitation
Better determination of volumes and LVEF (facilitating surgical decision making in asymptomatic patients)
LVOT stack
LVOT
Therapy
Therapy
The distinction between primary and secondary MR is key
Correction of primary MR in a timely fashion reverses LV remodeling, PHTN, and heart failure
It is less obvious that correcting secondary MR will be curative or beneficial
Primary MR
No conclusive data showing that medical therapy (vasodilators or beta-blockers) is effective in primary MR without heart failure (however recommended for heart failure)
Surgical therapy- Mitral valve repair instead of replacement is the preferred method in non-rheumatic valves
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Carabello, B. A. J Am Coll Cardiol 2008;52:319-326
Survival MV repair vs replacement
ACC/AHA 2006 guidelines
Secondary MR
Should be treated with standard heart failure therapy
In selected patients, CRT reduces amount of MR
No evidence of improved survival with annuloplasty
Also divergence of opinion about whether MR should be corrected during revascularization
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Carabello, B. A. J Am Coll Cardiol 2008;52:319-326
Results of Mitral Surgery in CHF
Limitations of ring annuloplasty
AOLA
LV
Papillary
MuscleTethering
Forces
Ring Annuloplasty
IschemicLV
• Doesn’t address tethering
• Further ventricular remodeling after ring
Percutaneous therapies
Alfieri procedure
Percutaneous mitralannuloplasty
Noninvasive assessment for percutaneous MVR
Role of TEE
Take home points
Need to use multiple criteria for more accurate assessment of MR
Importance of distinguishing primary from secondary MR
In secondary MR, indications for mitral valve intervention are less certain and more data are needed
References
Recommendations for evaluation of the severity of native valvular regurgitation with 2D and Doppler echocardiography. J Am Soc Echocardiogr 2003;16
O’Gara et al. The role of imaging in chronic degenerative mitral regurgitation. JACC Cardiovascular Imaging 2008;1
Carabello. The current therapy for mitral regurgitation. JACC 2008;52