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