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

2. ¨Δεν υπάρχει σύγκρουση συμφερόντων¨

3. 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.

4. 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

5. 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

6. Mitral Valve Pathology
Primary
Secondary

7. 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

8. MR– Color Doppler
3 components of the jet

9. MR– Color Doppler

10. MR– Color Doppler

11. 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

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

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

14. 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

15. Flow Convergence (PISA)
PISA Method
Flow Convergence (PISA)
Little. Am J Cardiol,2007;

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

17. less accurate in eccentric jets
Flow convergence
less accurate in eccentric jets

18. Duration of MR
MV Prolapse
Functional MR

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

20. Late systolic MR in MV Prolapse

21. Late systolic MR in MV Prolapse
Is this severe MR?

22. 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

23. 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

24. 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

25. MR - Quantification after MitraClip

26. 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:

27. 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

28. 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

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

30. 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?

31. 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.

32. Thank you