Theodora A Zaglavara, MD, PhD
BSCI/BSCCT Accredited for Cardiac CT
Advanced Cardiac Imaging
INTERBALKAN MEDICAL CENTER
THESSALONIKI, GREECE
Assessment of Mitral Regurgitation with Echocardiography
Mitral Valve: One of the Most Complex Structures in the Human Body
Role of Echo in Mitral Regurgitation
• Mechanism :
lesion/deformation resulting in valve dysfunction
• Severity of regurgitation
• Consequences of MR
• Possibility of repair /suitability for MC/percutaneous intervention
Mitral Valve Analysis: Transthoracic Echo
Transthoracic versus Transesophageal Echo
Challenges in Imaging a Structure with
Complex 3-D Geometry with 2-D Imaging
The Complex Structure of the Mitral Annulus
Cannot be Fully Imaged in 2D
Normal Saddle Shaped
Dilated and Flattened
Normal Mitral Valve 3D Anatomy
LA surgeon’s VIEW
LV VIEWAnatomic View
Anterior
Volumetric Quantification of the Mitral Valve
Carpentier Classification of MR
Degenerative Mitral Valve Disease
Affects 2% of population
Leaflet prolapse most common finding
A wide spectrum of degenerative disease resulting in MR
In contrast to functional MR, which is a disease of the LV, degenerative MR is a disease of the valve and therefore repair of the valve results in cure of the disease.
The annulus is always dilated
in Barlowsdisease
A case of P3 prolapse
BarlowsValve
EUROECHO 2009 - Madrid
Functional Mitral Valve Disease
Assessment of MR Severity
• Mitral Valve Morphology
• Colour-flow imaging
• Vena Contracta
• PISA
• EROA, Regurgitant Volume,
Regurgitant Fraction
• Doppler volumetric
quantitation (Non applicable
in case of significant AR)
Colour Flow Imaging• Optimize colour
gain/scale• Evaluate in multiple
views• Need blood pressure
evaluation• Good screening for mild
vs severe MR• Influenced by technical
and haemodynamicfactors
• Underestimates eccentric jets
Vena Contracta for MR Quantitation• Colour scale 40-70cm/s• VC reflects ROA• Relatively independent of
haemodynamic and instrument factors
• Good for extreme MR : mild vs severe
• Not affected by other regurgitation
• not valid for multiple jets
• Mild MR VC< 3 mm• Severe MR > 7 mm
Proximal Isovelocity Surface Area (PISA)
• Flow across any isovelocity surface = flow through orifice (Conservation of Mass principle)
• Can be used in eccentric jet• Quantitative : estimate lesion severity (EROA) and
volume overload (R vol)• Flow convergence at 50 cm/s alerts to significant MR
• Mild MR EROA< 20 mm²• Severe MR EROA >40 mm²
3-D Vena Contracta (VC) – PISA in MR
Mitral Inflow and Outflow Stroke Volume Measurement
Supportive Findings
2017
2017
Consequences of MR
LV size and function• LVESD > 4.5 cm • LV EF : load dependent• GLS < 18%• TDI E’medial <10.5 m/s
LA size• LA volume index > 40 ml/m²
(significant enlargement)
PASP> 50 mmHg at rest
Tricuspid Annular Dilatation ( > 40 mm or 21 mm/m²)
Probability of successful mitral valve repair in MR
Unfavourable characteristics for mitral valve repair in functional MR
Echocardiographic Evaluation of Mitral Valve for Patient Selection for Mitral Clip
The Anatomy Lesson of Dr. Nicolaes TulpRembrandt 1632, The Hague Netherlands