Ανεπάρκεια Μιτροειδούς : Σταυρόλεξο για δυνατούς λύτες Ποσοτικοποίηση με Ηχωκαρδιογράφημα και ο ρόλος των δοκιμασιών φόρτισης Μαρία Μπόνου Διευθύντρια, ΓΝΑ Λαϊκό

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Mitral Regurgitation MR results in significant morbidity and mortality. Severe primary MR warrants mitral valve surgery which improves prognosis. Yet, the timing of surgery in asymptomatic patients remains controversial.

Optimal timing for surgery - Severe MR the “Golden Moment” Very well Hyperdynamic, dilating LV Ventricular Reverse Time (yrs) Disease Progression T=0 T=5yrs (?+) Reliable assessment of MR severity is of crucial importance to guide clinical management “Normal EF”, dilated LV Very bad Reversible LV Dysfunction • Poor EF, dilated LV Irreversible LV Dysfunction Too Early Too Late

Mitral Regurgitation grading Mitral valve pathology LV/LA size Color Doppler Vena contracta, Jet area, Flow convergence Mitral E, Pulmonary vein pattern Regurgitant flow / fraction CW density and contour Anatomy Color Flow PW Doppler CW Doppler

Mitral Valve Pathology Primary Secondary

MR – Challenges in severity assessment m Emphasis on the 3 components of the jet Assessing Vena Contracta Flow Convergenge (PISA) Assumptions of hemispheric geometry Less accurate in eccentric jets Limitations in non-holosystolic MR Pulsed Doppler Volumetric Quantitation Quantification of multiple jets Quantifying MR after MitraClip

MR– Color Doppler 3 components of the jet

MR– Color Doppler

MR– Color Doppler

MR – Challenges in severity assessment Emphasis on the 3 components of the jet Assessing Vena Contracta Flow Convergenge (PISA) Assumptions of hemispheric geometry Less accurate in eccentric jets Limitations in non-holosystolic MR Pulsed Doppler Volumetric Quantitation Quantification of multiple jets Quantifying MR after MitraClip

MR - 2D Vena Contracta (VC) Proximal Jet Width (cm) VC FC Area

MR - 3D VC Area VC Area is often not circular in Secondary MR Severe MR: EROA > 0,4cm2

MR – Challenges in severity assessment Emphasis on the 3 components of the jet Assessing Vena Contracta Flow Convergenge (PISA) Assumptions of hemispheric geometry Less accurate in eccentric jets Limitations in non-holosystolic MR Pulsed Doppler Volumetric Quantitation Quantification of multiple jets Quantifying MR after MitraClip

Flow Convergence (PISA) PISA Method Flow Convergence (PISA) Little. Am J Cardiol,2007;1440-47

The application of the tool depends on the mechanism 3D PISA The application of the tool depends on the mechanism

less accurate in eccentric jets Flow convergence less accurate in eccentric jets

Duration of MR MV Prolapse Functional MR

Late systolic MR in MV Prolapse PISA, EROA, VC - are calculated from a single-frame image - Overestimate MR severity

Late systolic MR in MV Prolapse

Late systolic MR in MV Prolapse Is this severe MR?

MR – Challenges in severity assessment Emphasis on the 3 components of the jet Assessing Vena Contracta Flow Convergenge (PISA) Assumptions of hemispheric geometry Less accurate in eccentric jets Limitations in non-holosystolic MR Pulsed Doppler Volumetric Quantitation Quantification of multiple jets Quantifying MR after MitraClip

MR – Pulsed Doppler Volumetric Quantitation Advantages Quantitative, valid with multiple jets and eccentric jets. Pitfalls MV annulus diameter is less reliable in calcific MV Needs training

MR – Challenges in severity assessment Emphasis on the 3 components of the jet Assessing Vena Contracta Flow Convergenge (PISA) Assumptions of hemispheric geometry Less accurate in eccentric jets Limitations in non-holosystolic MR Pulsed Doppler Volumetric Quantitation Quantification of multiple jets Quantifying MR after MitraClip

MR - Quantification after MitraClip

Tissue gain setting can influence the size of the visible VC area MR - Quantification of multiple jets Tissue gain setting can influence the size of the visible VC area Little JACC imag 2012;5:677-680

MR – Stress echocardiography Primary MR Patients with asymptomatic severe MR Symptomatic patients with moderate MR Secondary MR Dyspnea on exertion disproportionate to LV systolic dysfunction or MR severity at rest Recurrent and unexplained acute pulmonary edema Patients with intermediate severity MR who are scheduled for CABG Persistent Pulmonary Hypertension after mitral valve repair

MR – Stress echocardiography Markers of poor prognosis Supine bicycle / treadmill exercise Assessment MR severity SPAP LV contractile reserve RV contractile reserve Markers of poor prognosis Increase ≥1 grade in MR (from moderate-to-severeMR) SPAP≥60 mmHg, Lack of contractile reserve (increase <5% in EF or <2% in GLS) m TAPSE <19mm MR quantification becomes more difficult at heart rate >115 bpm

MR – Stress echocardiography MV prolapse and asymptomatic severe MR Lancellotti et al. Eur Heart J – Cardiovascular Imaging (2016);1191–1229

Conclusions What is the mechanism of MR? What is the severity of MR What is the consequence of MR on LV/LA? Is it time for valve intervention?

Conclusions Use all echo parameters and correlate with clinical findings. Consider exercise echo if parameters are discordant. Optimize management of heart failure before labeling as severe MR.

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