Structural and Functional Mitral Regurgitation:

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Presentation transcript:

Structural and Functional Mitral Regurgitation: Echo Subleties and Hallmarks Steven A. Goldstein, MD Director, Noninvasive Cardiology Washington Hospital Center Sunday, February 21, 2010

The Mitral Apparatus Mitral leaflets Chordae tendinae Papillary muscles Mitral annulus Left ventricle Left atrium

Mitral Valve Anatomy Dilatation Left atrium Annulus Leaflets Chordae tendinae Papillary muscles LV free wall Dilatation Calcification Prolapse Redundancy Thickening Perforation Cleft Commissural fusion Abnormal insertion Elongation Rupture Thickening/fusion Ischemia Fibrosis Rupture Lateral displacement (ischemia, fibrosis, dilatation)

Mechanisms of Mitral Regurgitation Prolapse Normal Apical Tethering Dilated anulus Restricted PML Ruptured pap muscle

Mitral Valve Repair Mechanisms to be Discussed Ruptured chordae tendinae Mitral valve prolapse (MVP) Ischemic/functional MR

Ruptured cords

Case 1 Ruptured cords P2

Gastric short-axis view 1.6 cm + . . . + Gastric short-axis view (PSR view)

Systolic flow reversal  severe MR L-upper pulm vein Systolic flow reversal  severe MR

Roadmap for the surgeon

Mitral Valve Repair Information Required by Surgeon Exact lesion(s) - affected segment(s) Extent Degree of calcification (leaflet/annulus) Dilatation/size of annulus

Case 2 Ruptured cord P2

Case 3 Ruptured cords A2 and A3

Surgeon’s roadmap  A2 and A3

MVP

Case 4 Mitral Valve Prolapse

AML

S/P repair

Functional MR

Morphologic Changes in Heart Failure Papillary muscles displaced apically and laterally Bolling J Heart Valve Dis 11:S28(2002)

Functional Mitral Regurgitation Global LV dysfunction Regional LV dysfunction Sphericity of LV Excessive pap muscle displacement Decreased overlap of leaflets LA enlargement Loss of systolic mital anular contraction Increased “tenting” area Delayed activation of P-M pap muscle (dyssynchrony)

Ischemic Mitral Regurgitation B C A D Mitral leaflets are tented apically Mitral annulus is enlarged (A-B = 45mm) Mitral coaptation depth is increased (C-D = 13 mm)

Effect of Annular Dilatation on Tethering Area MROP340

Apical Tethering of Mitral Leaflets Basal cord tents anterior leaflet (“seagull sign”)

Increased tenting area Basal cord tents anterior leaflet (“seagull sign”) Increased tenting area

Distance from Mitral Annulus to Mitral Leaflet Coaptation Point Normal Ventricle Spherical Ventricle

Ischemic MR

Ischemic Mitral Regurgitation "Ischemic MR" is a commonly used term, but its definition is not clearcut; Most articles discussing ischemic MR do not even define it !

Ischemic Mitral Regurgitation Definition Moderate to severe MR due to CAD (MI, myocardial ischemia, or resulting LV remodeling) in the absence of primary, preexisting leaflet or chordal pathology

Ischemic Mitral Regurgitation Mechanisms Dislocation of papillary muscles Increased tenting length and area Antero-posterior dilatation of the MV annulus Kinetics of MV annulus during cardiac cycle Intraventricular synchrony/dyssynchrony Atrio-ventricular synchrony

Ischemic Mitral Regurgitation Single Papillary Muscle Involved Local malfunction of LV wall adjacent to a single pap muscle Calafiore Eur Assoc Cardio-Thorac Surg 2005

Abnormal Mitral Valve Coaptation Normal coaptation Abnormal coaptation

Ischemic MR  restricted PML Case 7 Ischemic MR  restricted PML

Dilated LV; posterior wall thinner than septum LVIDd = 6.4 cm Dilated LV; posterior wall thinner than septum

Bent anterior mitral leaflet

Increased tenting area

The End

Mitral Annular Calcification (MAC)

Mitral Annulus Calcification Ventricular and Leaflet Extension

Ischemic Mitral Regurgitation Mechanisms Dislocation of papillary muscles Increased tenting length and area Antero-posterior dilatation of the MV annulus Kinetics of MV annulus during cardiac cycle Intraventricular synchrony/dyssynchrony Atrio-ventricular synchrony - Papillary muscles dislocated toward apex Apply traction to chorade Chordae tendinae lack elasticity

Ischemic Mitral Regurgitation Mechanisms Dislocation of papillary muscles Increased tenting length and area Antero-posterior dilatation of the MV annulus Kinetics of MV annulus during cardiac cycle Intraventricular synchrony/dyssynchrony Atrio-ventricular synchrony Anterior MI  displacement of the 2 pap muscles Posterior MI  displacement of the postero-medial in the global LV enlargement pap muscle responsible for an asymmetric tethering

Ischemic Mitral Regurgitation Mechanisms Dislocation of papillary muscles Increased tenting length and area Antero-posterior dilatation of the MV annulus Kinetics of MV annulus during cardiac cycle Intraventricular synchrony/dyssynchrony Atrio-ventricular synchrony A-P dilatation of the mitral annulus can determine the degree of MR, even if no anomaly of the mitral leaflets exists

Ischemic Mitral Regurgitation Mechanisms Dislocation of papillary muscles Increased tenting length and area Antero-posterior dilatation of the MV annulus Kinetics of MV annulus during cardiac cycle Intraventricular synchrony/dyssynchrony Atrio-ventricular synchrony Progress in echo imaging, particularly including 3D-echo have demonstrated the importance of motion and specific features of kinetics of the annulus

Ischemic Mitral Regurgitation Mechanisms Dislocation of papillary muscles Increased tenting length and area Antero-posterior dilatation of the MV annulus Kinetics of MV annulus during cardiac cycle Intraventricular synchrony/dyssynchrony Atrio-ventricular synchrony - Several investigators have demonstrated correlation b/w width of QRS and degree of “functional” MR - Observational data on resynchronization by pacing can improve functional ischemic MR