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Mitral Regurgitation Francesca N. Delling, MD July 8, 2009.

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Presentation on theme: "Mitral Regurgitation Francesca N. Delling, MD July 8, 2009."— Presentation transcript:

1 Mitral Regurgitation Francesca N. Delling, MD July 8, 2009

2 Outline  Anatomy  Diagnosis - Two-dimensional echocardiography (etiology) - Doppler methods (assessment of severity) - Role of 2D and 3D-TEE - Role of CMR  Treatment

3 Anatomy: The mitral valve apparatus  Subvalvular apparatus (papillary muscles with their supporting left ventricular walls and chordae tendineae)  Mitral annulus  Mitral valve leaflets

4 Anatomy: The mitral valve  Reference view from the left ventricular apex  Surgical view from the left atrium with the heart rotated

5 Diagnosis

6 2D Echocardiography: Etiology of mitral regurgitation  Primary: - Myxomatous - Endocarditis - Rheumatic - Trauma - Congenital - Drugs ( ergotamines, methysergide, pergolide, fen fen)  Secondary: - Non-ischemic dilated CMP - Ischemic heart disease - HCM

7  Type I = normal leaflet motion but with annular dilatation or leaflet perforation  Type II = leaflet prolapse (eg myxomatous disease) or papillary muscle rupture  Type III = restricted leaflet motion. IIIa = rheumatic disease IIIb = ischemic or idiopathic cardiomyopathy. Carpentier classification

8 2D Echocardiography: additional information  Left ventricular size and function and left atrial size as clues to: - severity of MR - acuteness or chronicity - necessity and timing of surgery

9 Mitral valve prolapse  Occurs in 2.4% of the population (Freed at al. NEJM 1999)  Patients exhibit fibromyxomatous changes in the mitral leaflet tissue that cause superior displacement of the leaflets into the left atrium (by definition > 2 mm)  T he most common primary cause of isolated MR requiring surgical repair  Both familial (loci identified: chromosomes 11, 16, 13) and “sporadic” cases observed

10 Mitral valve prolapse


12 AO Septum A P AO Septum NormalMVP A Coaptation LV  Leaflet elongation can manifest itself not only by superior motion into the LA but also by anterior motion that shifts the coaptation point toward the aortic root and septum. Mitral valve prolapse SUPERIOR ANTERIOR

13 Nesta et al. Circulation 2005

14 Prodromal form  Anterior displacement of the coaptation point.  Mild bulging of the posterior leaflet relative to the anterior. NormalProdromal

15 Functional Mitral Regurgitation: Incomplete Mitral Leaflet Closure LV LA NORMAL IMI or global LVD AO Papillary Muscle Displacement Mitral Valve Tethering IMLC MR Courtesy of Judy Hung, MD

16 Functional Mitral regurgitation


18 Leaflet concavity (PS view) in functional MR



21 MR related to HOCM LV ejection through an LVOT narrowed by both septal hypertrophy and anterior displacement of MV apparatus (PM + MV) causes the Venturi effect or “drag forces” which drag the MV leaflets and chordae towards the septum MR is related to SAM of the anterior mitral leaflet AND failure of post leaflet to move anteriorly with consequent gap between the two leaflets

22 Yu et al. Mitral regurgitation in hypertrophic cardiomyopathy: relationship to obstruction and relief with myectomy. J Am Coll Cardiol 2000;36;

23 Doppler Methods for assessment of severity  Color flow Doppler - Regurgitant jet area - Vena contracta - Flow convergence (PISA)  Continuous wave Doppler  Pulsed Doppler - Mitral inflow pattern - Quantitative parameters (regurgitant volume, fraction, EROA)

24 Regurgitant jet area  Pros: - Simple, quick screen for mild or severe central MR - Evaluates spatial orientation of jet  Cons: - Subject to technical, hemodynamic variation - Underestimates severity in eccentric jets  Mild: < 4 cm2 or < 20% of LA area Moderate: variable Severe: > 10 cm2 or > 40% of LA area

25 Vena contracta width LAX SAX Mild: < 0.3 cm Severe  0.7 with large central jet or with wall impinging jet of any size

26 Proximal isovelocity surface area (PISA)  Based on the hydrodynamic principle that the flow profile of blood approaching a circular orifice forms concentric, hemispheric shells of increasing velocity and decreasing surface area.  Color flow mapping able to image one of these hemispheres that corresponds to the aliasing velocity or Nyquist limit of the instrument.  The aliasing velocity should be adjusted to identify a flow convergence region with a hemispheric shape.

27  PkVreg = the peak velocity of the regurgitant jet by continuous wave Doppler  Reg volume = EROA x VTIreg jet

28  Mild: EROA <0.2cm2 Severe: EROA >/=0.4cm2  Pros: - Presence of flow convergence at Nyquist limit of cm/s alerts to significant MR - Provides both lesion severity (EROA) and volume overload (R Vol)  Cons: - Less accurate in eccentric jets - Not valid in multiple jets - Any error is determining the location/radius of the orifice is squared Proximal isovelocity surface area (PISA)

29 EROA = [6.28 x (.8)(.8) ml/s x 36] / [480 cm/s] = 0.3cm2 Example of PISA calculation r = 0.8 cm

30 Supportive signs of MR severity

31 Other supportive signs of MR severity  Mild MR: - A-wave dominant mitral inflow ** - Normal LV size  Severe MR: - E-wave dominant mitral inflow (E > 1.2 m/s) ** - Enlarged LV and LA size ** Usually above 50 years or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA pressure

32 Quantitative pulsed Doppler parameters  In the absence of regurgitation, stroke volume should be equal at different sites, e.g. the mitral and aortic annulus.  In the presence of regurgitation (assuming the absence of an intracardiac shunt), the flow through the affected valve is larger than through other competent valves. ann

33 Supportive signs of severity Quantitative pulsed Doppler parameters

34 JASE 2003;16:777 Summary

35 2D-TEE localization of MR defects Foster et al. Ann Thorac Surg 1998;65:1025 Probe in Standard mid esophageal position

36 2D-TEE localization of MR defects Foster et al. Ann Thorac Surg 1998;65:1025 Probe at 0 degrees, effects of flexion or withdrawal and retroflexion or advancement

37 2D-TEE localization of MR defects Foster et al. Ann Thorac Surg 1998;65: to 90 degrees, effect of clockwise and counterclockise probe rotation

38 3D-TEE  To simulate a surgeon’s view of the valve, the 3D TEE image is positioned with the aortic valve the 11- o’clock position.

39 Intra-Operative 2D and 3D TEE Depiction of MV Prolapse and Leaflet Flail


41 3D-TEE quantitative analysis of the mitral apparatus

42 CMR  Etiology of mitral regurgitation  Quantitation of mitral regurgitation  Better determination of volumes and LVEF (facilitating surgical decision making in asymptomatic patients)

43 LVOT stack


45 Therapy

46  The distinction between primary and secondary MR is key  Correction of primary MR in a timely fashion reverses LV remodeling, PHTN, and heart failure  It is less obvious that correcting secondary MR will be curative or beneficial

47 Primary MR  No conclusive data showing that medical therapy (vasodilators or beta-blockers) is effective in primary MR without heart failure (however recommended for heart failure)  Surgical therapy - Mitral valve repair instead of replacement is the preferred method in non-rheumatic valves

48 Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Carabello, B. A. J Am Coll Cardiol 2008;52: Survival MV repair vs replacement

49 ACC/AHA 2006 guidelines

50 Secondary MR  Should be treated with standard heart failure therapy  In selected patients, CRT reduces amount of MR  No evidence of improved survival with annuloplasty  Also divergence of opinion about whether MR should be corrected during revascularization

51 Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply. Carabello, B. A. J Am Coll Cardiol 2008;52: Results of Mitral Surgery in CHF

52 Limitations of ring annuloplasty AOLA LV Papillary Muscle Tethering Forces Ring Annuloplasty Ischemic LV Doesn’t address tethering Further ventricular remodeling after ring

53 Percutaneous therapies Alfieri procedure Percutaneous mitral annuloplasty

54 Noninvasive assessment for percutaneous MVR Role of TEE

55 Take home points  Need to use multiple criteria for more accurate assessment of MR  Importance of distinguishing primary from secondary MR  In secondary MR, indications for mitral valve intervention are less certain and more data are needed

56 References  Recommendations for evaluation of the severity of native valvular regurgitation with 2D and Doppler echocardiography. J Am Soc Echocardiogr 2003;16  O’Gara et al. The role of imaging in chronic degenerative mitral regurgitation. JACC Cardiovascular Imaging 2008;1  Carabello. The current therapy for mitral regurgitation. JACC 2008;52

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