Rheumatic Valvular Heart Disease Assessment of Severity

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


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


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


Doppler parameters

Jet width or jet cross – sectional area in LVOT – Color Flow Vena contracta Width

PISA method


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


Flow quantitation –PW

Jet density –CW

Jet deceleration rate (PHT) –CW

Diastolic flow reversal in

descending aorta-PW


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


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


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


? 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


• 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


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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Rheumatic Valvular Heart Disease Assessment of Severity

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