Titel Kardiologie-SG.ch hot topics in heart failure and mitral regurgitation

Transcription

1 Titel Kardiologie-SG.ch hot topics in heart failure and mitral regurgitation where and how to quantify mitral regurgitation: Echolab, Cathlab or MRI? Philipp K. Haager, St. Gallen

2 Measuring mitral regurgitation? There is no method to do this directly in clinical practice today. Cathlab Echolab Radiology department Echo!

3 What does Mitral regurgitation do with the heart? Primary volume overload: Dilatation of Left atrium (LA) and Left ventricle (LV; normal forward venous return + recirculated volume) Forward cardiac output limited VTI 30.4 cm/s VTI 17.0 cm/s diastolic, if prolonged, systolic dysfunction

4 Quantification of MR is also Quantification of the left ventricle Quantification of the left atrium Quantification of cardiac output finally Quantification of regurgitation volume

5 Cardiac catheterisation: LV Angio (40 ml/s)

6 Seller`s criteria for MR 1+ Contrast does not completely fill left atrium 2+ Contrast completely opacifies left atrium but does not reach the intensity of the contrast in the LV 3+ Contrast completely opacifies left atrium and reaches intensity of the contrast in the LV after 4 heart beats 4+ Contrast completely opacifies left atrium and reaches intensity of the contrast in the LV within 2 or 3 beats

7 Cardiac catheterisation: LV Angio (40 ml/s) Which Seller`s class is this?

8 Another case Which Seller`s class is this?

9 Pulmonary Pressure Important operative mortality predictor (euroscore II)

10 Right Heart Catherization v-wave neither sensitive nor specific for presence of severe MR v-wave height poor measure of MR severity related to LA systolic volume & compliance Large Reg. Vol + normal/low compl. LA: large v-wave! Large Reg. Vol + large/compliant LA: v-wave may be normal Freihage et al. Cath Cardiovasc Intervent 2007; Kern Cath Cardiovasc Diagn 1992

11 direct LA/ LV measurements, n=40 normal Relevant MR the sum of the area under the LV pressure time curve and the area under the LA pressure time curve reflects the total energy or force generated by the LV Freihage et al. Cath Cardiovasc Intervent 2007

12 V-Wave area/ LV Wave Area r = 0.6, p<0.01 Freihage et al. Cath Cardiovasc Intervent 2007 Seller MR 0-1+ MR 2-4+ Ratio of V wave area to LV systolic area: correlation with MR grade.

13 Echo?!

14 Established in 2D Vena contracta Parasternal LX TOE 120 3C Cave non circular EROA 3 mm 7 mm mild undetermined severe

15 vena contracta area: 3D! overcomes the assumption of a circular regurgitation orifice needs high volume rates and small volumes to improve spatial resolution

16 Vena contracta area using 3D color doppler Buck, Curr Cardiovasc Imaging Rep (2015) Proposed 3D VC Area cut-off 0.6 cm²

17 adjust cutplane as needed

18 add color doppler data to visualize MR

19 direct measurements within every user defined cutplane

20 VC area in DMR and FMR: tomographic cut planes

21 Case after Mitraclip

22 Calculating Reg. Volume PISA flow convergence method shift baseline in direction of Reg Jet

23 HE-PISA hemielliptic PISA Buck, Curr Cardiovasc Imaging Rep (2015) HE PISA = 2π( r P D1 2 P + r P D2 2 3 P + D1 2 P D2 2 P )1 1/P

24 3D PISA? adjust baseline to delineate proximal convergence zone

25 Brugger et al, Am J Cardiol D PISA vs MRI n=55; TTE, TOE, CMRI 42% mild, 48% moderate, 10% severe MR 75% DMR, 25% FMR All 3D PISA shapes during systole were measured to calculate the integrated RVol

26 3D PISA vs MRI TOE TTE Brugger et al, Am J Cardiol 2015

27 Systemic outflow stroke volume LVOT Area x VTI (pw) no valve regurgitation RVOT Area x VTI (pw) 2D geometric multiplanar determination of assumptions LVOT/RVOT area by 3D data

28 CMR B systolic phase contrast C-F diastolic phase contrast images with manually tracing G time volume curve mitral inflow I aorta during systole J outflow time-volume curve aortic stroke volume Thavendiranathan et al J A C C : C A R D I O V A S C U L A R I M A G I N G,

29 Discordance MRI vs Echo in MR Quantitative Comparison of regurgitant volume n=108 MRI: MR volume=lv stroke volume- forward flow Uretsky et al. J A C C V O L. 6 5, N O. 1 1,

30 Post surgical decrease in LV EDV (MRI) No Echo FU available Only 26 of 58 pts. Uretsky et al. J A C C V O L. 6 5, N O. 1 1,

31 CMR in valve Disease Mitral Regurgitation alternative if poor Echo quality (lower spatial and temporal resolution) Comprehensive assesment LV/RV dimension, mass, fibrosis and function Forward and regurgitant flow/fraction Mean/peak velocity Jet detection, direction and origin LV SV - SV from phase contrast VENC above aortic valve Alternatively LV SV RV SV Limitations: visual assessment from cine images alone is not recommended due to a signal void in turbulence flow Herzog et al, CMR guide

32 What to do in mitral intervention?

33 Baseline After 1. Mitraclip

34 After 2. Mitraclip After 3. Mitraclip

35 Final Result after 3 Mitralclip After 3. Mitraclip

36 Conclusion 1. VC -VC area 3DEcho or - VC 2D 2. Rvol- CMR or - 3DEcho LV SV and aortic SV 3. EROA - 3D Echo PISA - 2D Echo PISA 4. AROA - 3DEcho AROA or - MRI // CT Thavendiranathan et al J A C C : C A R D I O V A S C U L A R I M A G I N G,

37 In Summary LV Angio does not play a role Haemodynamics are important to stratify the patient Interventional procedures in mitral valve disease are not possible without 3D TOE Mitral regurgitation Quantification today is 3D Echo Haemodynamics have a big role in controlling this procedures CMR is a reasonable alternative if poor Echo quality exists

38 Merci beaucoup! Grazie mille! Vielen Dank!