Presenetation includes assessment of echocardiographic features of Mitral regurgitation

1. MITRAL REGURGITATION

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

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

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

6. 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)

7. MITRAL VALVE ANATOMY ON TTE

8. MITRAL VALVE ANATOMY ON TEE

11. 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%.

12. Mechanism of Mitral Regurgitation
Carpentier's Classification

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

14. Etiology Mitral valve prolapse

15. Cleft Mitral valveEtiology

16. Flail Mitral LeafletEtiology

17. Etiology Flail Mitral Leaflet

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

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

20. Assessment of severity
1. Settings: Adjust 2D and color gain, NL, ECG, B.P
2. 2D visual Assessment
3. 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

21. Is It Easy?
Mild
Moderate
Severe
Trace
Mild
Mild to
Moderate
Moderate
Moderately
Severe
Progressive
Severe
Severe
M
R
MS

22. 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

23. Why Severity Assesment?

28. Effect Of Blood Pressure

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

30. 2D visual Assesment:

33. 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.

34. Vena ContractaWidth
• 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.
• TheVC is the area of the jet as it leaves the
regurgitant orifice; it reflects thus the
regurgitant orifice area
Mild MRVC < 3 mm
Severe MRVC > 7 mm

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

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

39. Proximal isovelocity surface area (PISA)
Flow = Area x Velocity
EROA = Flow/Peak velocity
EROA = (2πr2 × Va)/Peak velocity
Reg Vol = EROA × TVI

40. Proximal isovelocity surface area (PISA)

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

42. 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

43. CW Doppler of MR jet

44. • 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

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

46. Consequences of mitral regurgitation
• Left ventricle size and function
• LA size andVolumes
• Pulmonary Artery Pressure

47. Lets Summarize

48. Probability of successful mitral valve repair in MR

50. 36 Years old Asymptomatic female with severe
MR and LVEDs 38mm and EF 65% presents for
routine clinic visit
A. Admit for surgery
B. Followup after 6 months with Echocardiogram
C. Followup after 1 year and echo after 2 years
D. Followup after 1 year and echo after 1 year

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

52. Thanks for your patience listening

53. 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