Functional mitral regurgitation revisited CMR and CT...
Transcript of Functional mitral regurgitation revisited CMR and CT...
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FunctionalmitralregurgitationrevisitedCMRandCT:addedvalue?
AnaG.Almeida
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Functionalmitralregurgitation
Ischemic- InferiorMI- Papillarymusclerupture–
LCX/RCA- AnteriorMIandLVremodeling
Non-ischemic- DilatedCMP- HCM
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Ischemicmitralregurgitation
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AsymmetricversusSymmetricTethering
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LocalizedremodellingPMdisplacementMildannulusdilatationAsymmetrictetheringModeratetenting
GlobalremodellingAnnulus dilatationSymmetrictetheringSeveretenting
PosteriorMI Ischemiccardiomyopathy
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Ø CMRandCT
Ø Addedvaluetoechoassessment?
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• Mitralregurgitationseverity
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CMR:Qualitative assessment
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Quantitative assessment
• Accurateandreproducibleassessment,independentofjetnumberandeccentricity
• Reliablewhenthereare2associatedlesions
• LVstroke volume-RVstroke volume=Rvol and RF
• LVstroke volume-aortic forward flow=Rvol/RF
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• Anatomiccharacterization,etiologyandpredictionoffMR
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CMR:Mitralvalveanatomy
Speaker
5mmstackcoveringallMVscallops
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CMRandCT
Ø Tentingarea,coaptation depth,annulusdimension,leafletlength……..
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Fernandez-Golfin etal.Int JCvim 2011
EDinterPMdistance ESinterPMdistance
CMRbetterthanCT(temporalresolution)
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Fernandez-Golfin etal.Int JCvim 2011
Mitralregurgitation– ischemicversusnon-ischemic
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380pts withMI,20%withpartialPMinfarctionBouam etal.Clin ResCardiol 2016
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PredictorsofFunctionalMitralRegurgitation
Bouam etal.Clin ResCardiol 2016
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Chinitz etal.JACCCardiov Im 2013
- 153firstMI,PMI30%- PMIwasnotindependentlyassociatedtofMR- Inmultivariableanalysis,lateralwallinfarctsizewasindependentlyassociatedwith≥moderatefMR
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Totalmitralleafletarea Beaudoin etal.Circ Cardiovasc Imaging.2013
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Mitralclosurearea
Beaudoin etal.Circ Cardiovasc Imaging.2013
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Nl versusDCM(withoutMRversuswithfMR)
Beaudoin etal.Circ Cardiovasc Imaging.2013
MitralvalveenlargementforadaptingtopreventMRinpatientswithabnormalLVfunction
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Mitralleafletssize- CTreproducibility
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• Prognosis
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Pts withIMRandannuloplasty
ExtentoffibrosiswasrelatedtopostopLVEF
Takedaetal.Circ j2011
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• Basalsegmentswithfibrosis- lackofimprovementafterannuloplasty(lackofreverseremodelingandgeometricrecovery)
• ThebasalportionoftheLVisconnectedwithlongitudinalsubendocardialmusclefibers sensitivetopathologicalconditionsincludingischemiaandinfarctionascomparedwiththeapicalportion
Takedaetal.Circ j2011
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Fig2
The Annals of Thoracic Surgery 2014 98, 1557-1563DOI: (10.1016/j.athoracsur.2014.06.049)
FibrosisbyLGECMRwasanindependentpredictorofMACEaftersurgicalrepairamongclinicalvariables,riskfactorsandpre-operativecharacteristicsofMV
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FibrosisandpredictionofMACEafterMitraclip
33pts Mitraclip forfunctionalmitralregurgitation;fibrosisofinferolateral segmentswerethemostprevalent
Velu etal.CatheterCardiovasc Interv.2018;1–4.
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• Assessmentbeforeintervention
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Blanke etal.JACCCVIm 2015
TranscatheterMitralValveReplacement
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Mak Getal.Circ CVImag 2016
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Transcatheter mitralvalveinterventions/CT
• Cross-sectionalarea,perimeter,anddiametersoftheannulus
• Annuluscalcification• Papillarymuscleanatomy• Landingzoneand
myocardialshelf• Distance
annulus/coronarysinus• Distance
annulus/circunflex• Aorto-mitralangle
Mak Getal.Circ CVImag 2016
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- Characterizationofapost-procedural"neo-LVOT.”- Factorsthatpredictneo-LVOTobstruction- acuteaortomitral angle,smallLVcavitysize,andbasalseptalhypertrophy
Transcatheter mitralvalveinterventions/CTPredictingLVobstruction– Virtualplacement
Blanke etal,JACCCVImag 2016
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Conclusions
• CMRandCTareusefulandpromisingtoolsforpreciseandaccurateassessmentoffunctionalmitralregurgitation
• Thesemodalitiesprovideinformationonanatomy,etiology,functionalseverity,tissuecharacterization,prognosisandprocedure’splanning,yetawaitingfuturedevelopments