Mitral Valve Disorders Mitral Valve Disorders...Mitral Valve Disorders — Echoc ardiography...
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Mitral Valve DisordersEchocardiography Findings and AssessmentMitral Valve DisordersNEHOUA October 2013Leominster MALeominster, MAAdela de Loizaga, M.D.
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Mitral Valve Disorders
Anatomy of the HeartOverviewAnatomy of the Mitral Valve
Mitral Valve Disorders and CausesMitral Valve Disorders and Causes– Mitral Valve Prolapse– Mitral Valve Regurgitation– Mitral Valve StenosisMitral Valve Stenosis
Mitral Regurgitation and Echocardiography
Mit l St i d E h di hMitral Stenosis and Echocardiography
New Gold Standards on the Horizon
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Anatomy of the Heart
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Anatomy and Blood Flow of the Heart
HeartHeart Chambers, ValvesValves, Blood Flow Through the gHeart
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Source: Wikipedia
Anatomy of the Heart
Val es ofValves of the Heart
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Anatomy of the Heart
V l t i l t f bl d i t th t i lValve Valves act as one-way inlets of blood into the ventricles
And one-way outlets of blood out of the ventricles
Valve Function
They prevent backward flow of blood passing through the heart
MV opens for forward flow into LV and closes to prevent backward flow out of LV.
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Anatomy of the Heart
As the heart muscle contracts and relaxes, the valves open and shut, letting blood into the atria and ventricles at alternate timesValve and ventricles at alternate times
– As LA fills pressure increases above ventricular pressure : the MV opens and blood flows into the LV (Early diastole)
Valve Function
– Late diastolic atrial contraction completes flow of LA blood into the left ventricle. (E/A)
LV contraction (systole) moves blood out of the ventricle into– LV contraction (systole) moves blood out of the ventricle into the aorta• Mitral valve is closed
A ti l i• Aortic valve is open
– The ventricles fill during ventricular diastole
The atria fill during ventricular systole
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– The atria fill during ventricular systole
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Anatomy of the Mitral Valve
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Mitral valve
Bi id t t
Mitral Valve Open
Bicuspid structure
Anchored by h d t dichordae tendineae
Chordae tendineaett h t illattach to papillary
muscles
F ti i MV tFunctioning MV apparatus contributes a small portion of LV EF
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Source: Wikipedia
Anatomy of the Mitral Valve
Mitral Val eLeft atrial
appendageMitral ValveClosed
pp g
Posterior leaflet
Left atrium
Chordaetendineae
Anteromedialpapillary muscle
Anterior leaflet
Posterolateralpapillary muscle
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Anatomy of the Mitral Valve
Normal Mitral Valve – View from the Left Ventricle
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Anatomy of the Mitral Valve
Normal Mitral Valve
Surgical View 3-D ViewSurgical View 3 D View
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Source: Wikipedia
Mitral Valve Disorders and Causes
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Mitral Valve Disorders and Causes
Mit l V l P lVario s Mitral Valve Prolapse(primarily myxomatous degeneration)
Various Mitral Valve Disorders
Mitral Valve Insufficiency / Regurgitation
– Primary insufficiency
Disorders
– Secondary insufficiency
Mitral Valve StenosisMitral Valve Stenosis
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Mitral Valve Prolapse
Mit l l l i th b ll i f b th l fl tMitral valve prolapse is the ballooning of one or both leaflets backwards into the left atrium
Th l fl t ll thi k d d t tThe leaflets are usually thickened due to myxomatousdegeneration
P lPrevalence• 2% to 4% US population• 5% to 10% worldwide
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Mitral Valve Prolapse
Mitral Valve Leaflet displacement of ≥ 2 mmMitral Valve Leaflets Protrude Into
Leaflet displacement of ≥ 2 mm above the mitral annulus
Left Atrium
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Source: Wikipedia
Mitral Valve Prolapse
The mitral valve doesn’tThe mitral valve doesn t close normally. One or both flaps don’t close in the correct way. yWhen this happens, blood can leak backward in the wrong direction.
Displacement of an Abnormally Thickened Mitral Valve Leaflet Into the Left Atrium During Systole
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Source: UpToDate
Mitral Valve Prolapse
Identification of mitral valve prolapse
The current accepted echocardiographic definition of MVP is billowing of any portion of the
valve prolapse
is billowing of any portion of the mitral leaflets at least 2 mm above the annular plane in the long axis views. On this parasternal long axis there is pronounced prolapse of the posterior leaflet (arrows) above the annular plane (red line).
LV: left ventricle; LA: left atrium; Ao: aorta.
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Mitral Valve Prolapse
MitralMitral Valve Prolapse(Left Ventricular View)
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Source: Wikipedia
Mitral Valve Prolapse
MitralMitral Valve Prolapse(LA View)
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Source: Wikipedia
Mitral Valve Prolapse
Mit l l l ith di l t > 5 i hi h
Leaflet displacement and complications
Mitral valve prolapse with displacement > 5mm carries higher risk of complications, e.g. ,
– Leaflet asymmetry– Flail leaflet – Mitral regurgitation– Infective endocarditis
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Mitral Valve Prolapse
PartialPartial Mitral Valve ProlapseProlapse
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Mitral Valve Prolapse Signs or Symptoms?
A lt ti f it l l l
Auscultation
Auscultation of mitral valve prolapse– Crisp mid-systolic click from the prolapse– Subvalve apparatus tightens abruptly
Heard best at the left apex– Patient in left lateral decubitus positionp
Pure MVP only does not cause symptomsy y p
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Mitral Valve Insufficiency
Mitral valve insufficiency is caused by inadequate closure of the
Mitral Valve Insufficiency and Regurgitation
Mitral valve insufficiency is caused by inadequate closure of the mitral leaflets
Insufficient closure of the leaflets allows backward flow of blood into the left atrium during systole = regurgitation
Mitral regurgitation is the most common valve disorder in the U.S -th t d l i id lthe reported prevalence varies widely– Framingham Offspring study (1991-1995 ca. 3,000 individuals)
showed that prevalance depends on the definition of MRA d t t bl t MR 90%• Any detectable trace MR 90%
• ≥ mild MR 19%• ≥ moderately severe MR 0.4%-2.0%
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Mitral Valve Regurgitation
A b liti f th it l l t
Causes of Primary Mitral Regurgitation
Any abnormalities of the mitral valve apparatus:
– Mitral annulus (e.g., calcification)
– Mitral leaflets (e.g., 50% of MVP, endocarditis, rheumatic heart disease, flail leaflet)
– Chordae tendineae (e.g., elongation, rupture)
– Papillary muscles (e.g., fibrosis, calcification, rupture)
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Mitral Valve Regurgitation
V t i l di
Causes of Secondary Mitral Regurgitation
Ventricular myocardium – (e.g., ischemia, infarction)
Dilated cardiomyopathy– Dilated annulus
Hypertrophic cardiomyopathy– Deformed leaflets
Chordal slack– Chordal slack
– Displaced apparatus
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Primary MR Due to Endocarditis
Verrucous endocarditisin SLE
Verrucous endocarditis with valvular vegetations (arrows) cardiac murmur had been heardcardiac murmur had been heard by auscultation.
Courtesy of Peter H Schur, MD.
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Primary Mitral Valve Insufficiency
Mitral Valve Vegetation in Bacterial Endocarditis
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Mitral Valve Regurgitation
Mitral Val eMitral Valve Prolapse
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Source: Wikipedia
Mitral Valve Regurgitation
R pt redRuptured ChordaeTendineae of theTendineae of the Mitral Valve
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Mitral Valve Regurgitation
Mitral Val eMitral Valve Regurgitation From RupturedFrom Ruptured ChordaeTendineae
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Mitral Valve Regurgitation
E i i t l ith dS mptoms Exercise intolerance with dyspneaupon exertion
Symptoms
Orthopnea
Palpitations, tachycardia
Symptoms increase with decreasing LV function
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Mitral Valve Regurgitation
C ti h
Clinical Phases of Mitral Regurgitation
Compensation phase
• Gradual development of volume overload
• Asymptomatic for years or decades• Asymptomatic for years or decades
Transitional phase
• Onset of symptomsOnset of symptoms
Decompensation phase
• Increased symptoms, decreasing LV function
• Symptoms of congestive heart failure
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Mitral Valve Regurgitation
Fi di d d th it d d ti f
Auscultation of Chronic MR
Findings depend on the severity and duration of mitral regurgitation
– High-pitched holosystolic murmur at the apex, radiating to the back or clavicular area
Loudness of the murmur does not correlate well with the– Loudness of the murmur does not correlate well with the severity of regurgitation
– A third heart sound is commonly heard– A third heart sound is commonly heard
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Mitral Valve Prolapse with Regurgitation
Cli k S d
Auscultation
Click – murmur Syndrome– Mid-systolic click from the prolapse, a late systolic MR murmur
heard best at the apex
In contrast to most other heart murmurs, murmur of MV – Is accentuated by standing and valsalva maneuver, and – Diminished with squatting
The only other heart murmur that follows this pattern is the y pmurmur of hypertrophic cardiomyopathy
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Mitral Valve Prolapse with Regurgitation
Patient Standing Patient Squatting
EKG and phonocardiogram of MVP heard at the apex. S1 (mitral and tricuspid valve closure) followed by a mid systolic click from the prolapse of the MV. After the prolapse occurs, there is the mid systolic murmur of MR Standing there is a decrease in venous
EKG and phonocardiogram of MVP at the apex. S1 (mitral and tricuspid valve closure)followed by a mid systolic click from the prolapsing MV which there is a systolic murmur of MR. With squatting there is an increase in systemic vascular resistance or
Provided by John M Criley, MD, The Physiological Origins of Heart Sounds and Murmurs, Little, Brown, Boston, 1996, 1-800-527-0145. This program contains a l t i t ti t t i l i t ti 200 h t d d ith i i hi h D l d h d i ti i t
systolic murmur of MR. Standing there is a decrease in venous return, a decrease in LV volume d/t decr pulm ven return and the mitral valve prolapses earlier in systole. Consequently, the MR murmur is lengthened.
afterload and an increase in LV pressure and volume. As a result, there is a delay in MV closure and the prolapse (and click) are delayed, occurring late in systole. Consequently, the MR murmur is late and shortened.
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Source: UpToDate
complete interactive tutorial integrating over 200 heart sounds and murmurs with cineangiographic, echo-Doppler, and hemodynamic motion picture sequences.
Mitral Valve Regurgitation
Acute mitral regurgitation will have sudden onset of symptoms
Symptoms of Acute MR
Acute mitral regurgitation will have sudden onset of symptoms
– Suggestive of a low cardiac output state • Decreased exercise tolerance
– Of decompensated congestive heart failure• Shortness of breath, pulmonary congestion, orthopnea, paroxysmal
nocturnal dyspneanocturnal dyspnea
– Palpitations• Atrial fibrillation
– Cardiogenic shock• In individuals with acute mitral regurgitation due to papillary muscle
rupture or rupture of a chorda tendinea
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p p
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Acute Mitral Regurgitation Post MI
Papillary Muscle Rupture After MI
Complete transection of papillary muscle (arrow) after
After MI
an acute myocardial infarction
The patient died with severe mitral regurgitationmitral regurgitation.
Photograph courtesy of Dr. William D Edwards. From Reeder, GS, Gersh, BJ, Acute myocardial infarction. In: Internal Medicine, 4th ed, Stein, JH, Hutton, JJ, Kohler, PO, et al (Eds) Mosby Year Book St Louis 1994 pp 169 189
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et al (Eds), Mosby-Year Book, St Louis, 1994, pp. 169-189. By permission.
EKG Changes in Mitral Valve Regurgitation
P Mitrale is aP Mitrale is a Broad Notched P WaveP Wave
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Source: Wikipedia
EKG Changes in Mitral Valve Regurgitation
ProminentProminent Late Negative ComponentComponent of P Wave in Lead V11
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Source: Wikipedia
Mitral Valve Regurgitation
P it l i b d t h d P i l l d
Electrocardiogram in Mitral Regurgitation
P mitrale is broad notched P waves in several or many leads with a prominent late negative component to the P wave in lead V1
May be seen in mitral regurgitation
But also in mitral stenosisBut also in mitral stenosis
Potentially seen with any left atrial enlargement (LAE)
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Mitral Regurgitation and Echocardiography
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Mitral Valve Regurgitation and Echocardiography
Wh t i h di ?
Some Echocardiography Basics
What is an echocardiogram?
What can an echocardiogram tell us?
What is a Doppler study and what does it add to the echocardiogram?
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Some Echocardiography Basics
Hi h f d ( 1MH )High frequency sound waves (> 1MHz)
Reflections from solid-fluid interfaces
Fluid density appears black on US (no echos)
The heart is a fluid filled structure » allows excellent imaging of structures
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Courtesy: UpToDate
Some Echocardiography Basics
D l ff t
Doppler Echocardiography
Doppler effect
Sound waves bouncing off moving blood elements causes shift in wave length of the echoin wave length of the echo
Can be used to indicate direction, speed, and magnitude of flow
Revolutionized understanding of valve disorders
Echocardiography and Doppler studies continue to evolve
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Some Echocardiography Basics
Fl di ti d tit ti
Doppler Echocardiography
Flow – direction and quantitation
Gradients
Pressure calculations
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Courtesy: UpToDate
Mitral Valve Regurgitation and Echocardiography
Anatomic basis for the presence of mitral2 D and Anatomic basis for the presence of mitral regurgitation (e.g., mitral annular calcification)
Left atrial enlargement with systolic bowing of the
2 D andM–Mode
Left atrial enlargement with systolic bowing of the interatrial septum
Increased LA / RA ratio (normal is 1:1)Increased LA / RA ratio (normal is 1:1)
Left ventricular volume overload pattern– Hyperkinesia of the left ventricular walls with left
ventricular dilatation– Evidence of pulmonary hypertension
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Mitral Valve Regurgitation and Echocardiography
R it t j tPulse Wave Regurgitant jet
R it t f ti
Pulse WaveDopplerMeasurements Regurgitant fraction
P l i fl
Measurements
Pulmonary venous inflow• Diminished or reversed with significant
mitral regurgitationmitral regurgitation
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Mitral Regurgitation and Echo Measurements
A ll j t i <20% f th l ft t i l i id d
Color Flow Doppler
A small jet occupying <20% of the left atrial area is considered mild regurgitation.
A large jet occupying > 40% of the LA area and extending intoA large jet occupying > 40% of the LA area and extending into the pulmonary veins is considered severe mitral regurgitation.
These jets are very sensitive to instrument settings,These jets are very sensitive to instrument settings, may be misleading.
They should be used in conjunction with other findings, not alone.
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Mitral Valve Regurgitation and Echocardiography
Regurgitant jet width is measured at the regurgitant orifice: it
Color Flow Doppler
Regurgitant jet width is measured at the regurgitant orifice: it can be calculated using the Proximal Isovelocity Surface Area (PISA).
–PISA is based on the hemodynamic principles of flow through a small circular orifice.
–There is flow acceleration of the regurgitant blood on the ventricular side as it moves towards and through the mitral valve opening into the LA.
–There are different layers of equal velocity in this regurgitantblood flow as it converges proximal to the valve opening.
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Mitral Regurgitation Echocardiography
Proximal Isovelocity Surface Area
Limitation of PISA
Measures the flow at one moment in time in the cardiac cycle
May not reflect the average
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y gperformance of the regurgitant jet
Mitral Valve Regurgitation and Echocardiography
Th l it i li d t i h i h i
Color Flow Doppler
These velocity areas are visualized as concentric hemispheric rings above the mitral valve opening on color flow Doppler.
The smaller the opening the higher the velocity The larger theThe smaller the opening, the higher the velocity. The larger the opening, the slower the velocity.
Using the size of the “velocity areas” and the velocity the orificeUsing the size of the velocity areas and the velocity the orifice can be calculated.
The diameter of the ring closest to the regurgitant orifice is used g g gas the assumed jet width.
1cm jet width is consistent with severe mitral regurgitation.
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PISA and JET Width (Severe Mitral Regurgitation)
Color Flow Doppler
Four chamber view with typical
Color Flow Doppler Severe MR
Four chamber view with typical features of severe mitral regurgitation; a large proximal isovelocity surface area (PISA) y ( )and a broad crossing jet from left ventricle (LV) into the left atrium (LA).
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Mitral Regurgitation and Echo Measurements
Eff ti R it t O ifi ERO i th f th
Quantification of Mitral Valve Regurgitation
Effective Regurgitant Orifice area = ERO is the area of the regurgitant flow at the level of the valve
ERO l t ith th i f th d f t i th it l lERO correlates with the size of the defect in the mitral valve
MR severity is quantifiable with Regurgitant Fraction
Regurgitant Fraction = RF is the percentage of the left ventricular stroke volume that regurgitates into the left atrium
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Mitral Regurgitation and Echo Measurements
MitralMitral Regurgitation Measured by Left
Atrium
Jet Width
Left Ventricle
MV
Vena Contractaand Central Jet Width
Vena Contracta
Ventricle
Jet WidthVena contracta is the point in a fluid stream where the diameter of the stream is the least. The maximum contraction takes place slightly downstream of an orifice p g ywhere the jet is more or less horizontal. This phenomenon is because fluid streamlines cannot abruptly change direction.
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Source: Wikipedia
Mitral Regurgitation and Echo Measurements
Vena Contracta in Mitral RegurgitationFIGURE 15-50 Measurement of the vena contracta (VC between arrows) in twocontracta (VC between arrows) in two different patients: A – a central mitral regurgitation jet; B – an eccentric mitral regurgitation jet (note change in color flow baseline).
LA = left atrium; LV = left ventricle.
(Modified from Oh JK, Seward JB, Tajik AJ: The Echo Manual. 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 2006. Used with permission of Mayo Foundation for Medical Ed cation and Research ) Vena contractaEducation and Research.) Vena contractaBraunwald
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Mitral Regurgitation and Echo Measurements
MR Severity and Vena Contracta vs. Regurgitant Fraction (RF)
Mitral Regurgitation
Vena ContractaWidth
Regurgitant Fraction(RF)
G d 1 4 20%Grade 1 < 4 mm < 20%Grade 2 4–5.9 mm 20%–30%Grade 3 6–8 mm 30%–49%Grade 4 > 8 mm > 50%
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Mitral Regurgitation and Echo Measurements
Regurgitant Jet in Mitral Insufficiency
Panel A. apical four chamber view of mild MR and mild TR also present. Regurgitant jets have a mosaic of color; they begin
Panel B. The size of the MR jet at the site of origin is wider, the jet reaches the posterior LA wall characteristics of
Panel C. The jet is even wider, almost filling the LA, and it reaches the posterior LA wall and enters the pulmonary veinsmosaic of color; they begin
with a very narrow point of origin at the valve, remain narrow and penetrate only partially into LA cavity.
characteristics of moderate to severe MR.
pulmonary veins.
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Source: Braunwald
Flow Reversal in Pulmonary Veins
Re ersedReversed Pulmonary Venous FlowVenous Flow
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Guide for Quantitating Severity of Mitral Regurgitation
N l hi t iblMild MR Normal history, possible murmur
Normal left atrial and left ventricular dimensions b E h di h
Mild MR(Grade 1+)
by Echocardiography
Regurgitant fraction <20%
Normal EF >55%
May never progress
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Guide for Quantitating Severity of Mitral Regurgitation
Lik l t ti iblModerate MR Likely asymptomatic, possible murmur
Mild left atrial and left ventricular enlargement b h di h
Moderate MR (Grade 2+)
by echocardiography
Regurgitant fraction 20% to 30%
High EF >60%, compensation
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Guide for Quantitating Severity of Mitral Regurgitation
Onset of symptoms murmur EKG and /or chest x rayModerately Onset of symptoms, murmur, EKG and /or chest x-ray
Moderate left atrial and left ventricular enlargement
Moderately Severe MR(Grade 3+)
Left atrial dimension > right atrial dimension
Significant coaptation defect of the mitral valve leaflets, with large EROwith large ERO
Wide mitral regurgitation jet
Regurgitant fraction 30% to 49%Regurgitant fraction 30% to 49%
EF 50%-59%, transitional phase
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Guide for Quantitating Severity of Mitral Regurgitation
S mptomatic m rm r EKG and / or chest raSevere MR Symptomatic, murmur, EKG and / or chest x-ray
No systolic coaptation of the mitral valve
V l ERO d PISA 1
Severe MR(Grade 4+)
Very large ERO and PISA 1 cm or more
Moderate to severe left atrial and left ventricular enlargement (cardiomegaly)
Regurgitant fraction > 50%
Regurgitant jet area / left atrial area ratio > 40%g g j
EF <50%, decompensation
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Chest X-Ray Findings in Chronic Severe MR
Normal Chest Film PA CXR Chronic MR
Posteroanterior view of a normal F l ith k it l it tiPosteroanterior view of a normal chest radiograph.
Female with known mitral regurgitation cardiomegaly with left atrial (black arrow) left ventricular enlargement (red arrow), as well as mild pulmonary venous redistribution,
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Source: UpToDatePhotos courtesy of Jonathan Kruskal, M.D. features characteristic of mitral regurgitation.
Mitral Valve Regurgitation
Look for:LA dil t ti
Findings– LA dilatation– LV dilatation
Symptoms: Red Flag!Symptoms: Red Flag!– Palpitations (tachycardia, atrial fibrillation)– Exercise intolerance– Dyspnea with mild exertion or at rest– Dyspnea with mild exertion or at rest– LH Failure
• SOB• Pulmonary edema• Cardiogenic shock
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Assessment of Mitral Valve Regurgitation
Echo Measurements for Mitral Regurgitation
Parameters Grade 1 Grade 2 Grade 3 SevereParameters Grade 1 Grade 2 Grade 3 SevereStructural Left Ventricular Size Normal Normal or dilated Dilated, except acute MR
DopplerColor Doppler regurgitant jet <20% <20% LA area >40% of LA area
Doppler vena contracta width <3-3.9mm 4-6mm 6-8 mm >8mm pp
QuantitativeRegurgitant volume <30 mL/beat 30-44mL/beat 45 to 59 mL/beat ≥60 mL/beat
Regurgitant fraction <20% 20 to 30% 30 to 49% ≥50%
Regurgitant orifice area < 20 mm2 20-24 mm2 25 to 39 mm2 ≥ 40 mm2
American College of Cardiology/American Heart Association, Guidelines 2006Source: UpToDate
Mild M d t SLeft Atrial Enlargement Normal Mild Moderate SevereDiameter in cm Men <4.1 4.1–4.6 4.7–5.1 >5.2
Diameter in cm Women <3.9 3.9–4.2 4.3–4.6 >4.7
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Source: American Society of Echocardiography
Mitral Stenosis
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Mitral Valve Disorder with Inflow Obstruction
S diti li iti ifiObstr cted Flo Some conditions cause a limiting orifice that obstructs diastolic transit of blood from atrium to ventricle
Obstructed Flow from LA to LV
Hemodynamic consequence: a holo-diastolic pressure gradient between the left atrium andbetween the left atrium and left ventricle
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Mitral Valve Disorder with Inflow Obstruction
The most common lesion of the mitral valve Mitral Val e that causes inflow obstruction is:
– Mitral stenosis– Usually acquired as the result of rheumatic
Mitral Valve Stenosis
heart disease– Estimated prevalence 0.1% (range 0.02% to 0.2%)
Lancet study 2006 on burden of valve disorders; also based on 1500 reviewed valvotomies as indicators of severe MSon 1500 reviewed valvotomies as indicators of severe MS
Other causes include:Left atrial myxoma and other tumors– Left atrial myxoma and other tumors
– Severe mitral annular calcification – Left-sided carcinoid heart disease
C it l di d
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– Congenital disorders
Mitral Valve Disorders — Echocardiography Findings and Assessment | Adela de Loizaga, M.D.70
Mitral Valve Stenosis
Sl d li f i t lSigns and Slow decline of exercise tolerance
Decreased stroke volume
Signs and Symptoms
Reduced arterial pulses
Left atrial hypertrophy
EKG with P-mitrale
Atrial fibrillation– Stroke
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Stroke
Mitral Valve Disorders — Echocardiography Findings and Assessment | Adela de Loizaga, M.D.71
Mitral Valve Stenosis
P l h t iSigns and Pulmonary hypertension
Dyspnea, hemoptysis
Signs and Symptoms
Pulmonary edema
Right heart enlargement
Leg and sacral edema
Hepatomegaly, ascites
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Mitral Valve Stenosis
Marked thickening of the leaflets and LA hypertrophy
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Mitral Valve Stenosis and Echo Findings
ICE Mitral Stenosis — Hockey Stick
Intracardiac ultrasound examination shows a stenotic mitral valve with some leaflet thickening and a hockey-stick appearance of the anterior mitral valve leaflet.
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Mitral Stenosis Echocardiographic Findings
TTE — Mitral Stenosis Alters Appearance and Motion of the Valve on Two-Dimensional Echocardiography
Normal is a rapid, biphasic motion of the valve
MS from partially fused leaflets causes the valve to open only partly and as a single unitand as a single unit
Persistent gradient develops between the left atrium and left ventricle
This gradient keeps the stenotic valve opened and causes the entire valve to bulge like a dome into the ventricle throughout diastole
Th l t d di t i iti t th i ti b tl tiThe elevated gradient initiates the opening motion abruptly, generating an opening snap and a characteristic “hockey stick / knee bend” appearance on the precordial long axis view
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Mitral Stenosis and Echo Measurements
Doppler can measure velocity of mitral inflowy– In mitral stenosis the velocity
increases from < 1m/sec to > 1.5m/sec.
Continuous Wave Doppler MS– Peak velocity of 1.7 m/s in this
patient with rheumatic mitral stenosis (MS).
– Apply simplified BernoulliApply simplified Bernoulli formula: the initial diastolic gradient across the mitral valve is 12 mmHg.
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Mitral Valve Stenosis and Echo Findings
P k di t i H 4 k l it 2
Peak Velocity, Peak Gradient and Pressure Half Time
Peak gradient, in mmHg = 4 x peak velocity2
– Peak velocity of 1 m/sec indicates a peak gradient of 4 mmHg
– Peak velocity of 2 m/sec indicates a peak gradient of 4 x (2x2) = 16 mmHgy p g ( ) g
– Peak velocity of 3 m/sec indicates a peak gradient of 4x (3x3) = 36 mmHg
Transmitral gradient during diastole can be measured in the pressure half-time (PHT) – PHT = the time required for the gradient between the left atrium and the
left ventricle to fall to one-half of its initial value
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Mitral Valve Stenosis and Echo Findings
Transmitral Gradient During Diastole can be Measured in the Pressure Half-time (PHT)
The mitral valve area can be obtained from the continuous wave Doppler by calculating the time y grequired for the opening pressure to reach one half of its value (P 1/2); this is called P 1/2 time and is calculated as shown. By regression analysis, a critically stenotic valve measuring 1 cm2 has a gPHT of 220 ms; the valve area can be calculated as shown above.
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Mitral Valve Stenosis and Echo Findings
E i i ll h lf ti f 220Velocit Empirically – pressure half-time of 220 msec= MVA of 1.0 cm2
Thus
Velocity and Pressure Thus
– MVA = 220 / PHT– With PHT 300 msec
MVA 220 / 300 0 7 2
Pressure Gradient
– MVA = 220 / 300 = 0.7cm2
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Mitral Valve Stenosis and Echo Findings
Pressure half timeMitral Val e Pressure half-time
– Normal: 30 to 60 milliseconds (ms)• (MVA 220/60 =3 66 cm2)
Mitral Valve Stenosis
• (MVA 220/60 =3.66 cm2)
– Mild MS: 90 to 150 ms • (MVA 220/150 =1.46 cm2)( )
– Moderate MS: 150 to 219 ms• (MVA 220/219 =1 cm2)
– Severe MS: > 220 ms• (MVA 220/300 = 0.73 cm2)
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Mitral Valve Stenosis
Look for:Indirect – Left atrial hypertrophy– Symptoms of low cardiac output– Pulmonary hypertension
Findings
Symptoms: Red Flag!– Atrial fibrillation, PAF– Right heart failure
• SOB, pulmonary edema• Leg edema
10 year survival at time of presentation– In asymptomatic individuals 80% or more
With se ere s mptoms 0% 15%
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– With severe symptoms 0%- 15%
Mitral Valve Disorders — Echocardiography Findings and Assessment | Adela de Loizaga, M.D.81
Mitral Stenosis Assessment of Severity
Echo Measurements for Mitral Stenosis
S it Mit l St iSeverity Mitral Stenosis (ACC/AHA 2006)
Normal Mild Moderate SevereValve Area (cm2) 4-6 1.5-2.5 1.0-1.5 <1.0
Mitral Jet Velocity (m/sec) ≤2.0 <3.0 3.0–4.0 >4.0
Mean Gradient (mmHg) <5 6-12 >12
Pulmonary Artery Systolic Pressure >50(mmHg) >50
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New Gold Standards on the Horizon
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New Gold Standards on the Horizon
T d d t h l i kiTwo more advanced technologies are making their way into routine echocardiography
1. 3-D Echocardiography
2 Tissue Doppler Echocardiography (TDE)2. Tissue Doppler Echocardiography (TDE)
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New Gold Standards on the Horizon
R l ti 3 D ll i di t l tiAdvantages of Real-time 3-D allows immediate evaluation without calculations and geometric modeling of two-dimentional measurements
Advantages of 3-D
echocardiography
Direct evaluation of cardiac valves
V l t i tifi ti f it t lVolumetric quantification of regurgitant valve lesions, shunts, and cardiac output
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New Gold Standards on the Horizon
I d th d tifi tiAdvantages of Improved the accuracy and quantification of Mitral Regurgitation and Mitral Stenosis
More accurate direct measurements of mitral
Advantages of 3-D
echocardiographyMore accurate direct measurements of mitral valve area
Improved reproducibilityImproved reproducibility
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New Gold Standards on the Horizon
3 D3-D echocardiography
Baseline image before mitral balloon valvuloplasty (A) shows a g p y ( )restricted mitral valve opening with bicommissural fusion. Post-valvuloplasty, splitting of the medial commissure and posterior leaflet tear can be seen (B).
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New Gold Standards on the Horizon
TDE h b t bli h d tAd antages TDE has become an established component of the diagnostic ultrasound examination
It it t f di l
Advantages of Tissue Doppler It permits an assessment of myocardial
motion, using Doppler ultrasound imaging, often with color coding
Doppler
This is similar to routine Doppler ultrasound used to assess blood flow
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New Gold Standards on the Horizon
Th t h i l l t di l l itAd antages The technique calculates myocardial velocity
TDE offers an objective measure to quantify i l d l b l LV f ti
Advantages of Tissue Doppler regional and global LV function
It can be used to assess RV systolic function i h i l h t i d
Doppler
as in chronic pulmonary hypertension, and chronic heart failure.
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New Gold Standards on the Horizon
TDETDE
This TDE shows normal left ventricular systolic functionThis TDE shows normal left ventricular systolic function. Panel A : color-coded 2-D tissue Doppler image; panel B : the corresponding color- M-mode tissue Doppler image for a single cardiac cycle panel C: the time-velocity plot of the posterior wall of the color-M-mode tissue Doppler image.
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90
pp gS: peak systolic velocity; E: peak early diastolic velocity; A: peak atrial velocity.
New Gold Standards on the Horizon
Th t t h l i t t3 D echo These two technologies are not yet the Gold Standard.
3-D echo and TDE
Scientific evidence seems strong enough to endorse 3-D echo and TDE as a new standardas a new standard.
They offer improved clinical assessment f th h t t d f tiof the heart anatomy and function.
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Mitral Valve DisordersEchocardiography Findings and AssessmentMitral Valve DisordersWebinar 2013Adela de Loizaga M DAdela de Loizaga, M.D.
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