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