Imaging MV. Jeroen J. Bax Leiden University Medical Center The Netherlands Davos, feb 2015
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1 Imaging MV Jeroen J. Bax Leiden University Medical Center The Netherlands Davos, feb 2015
2 MV/MR: information needed on.. 1. MV anatomy 2. MR etiology - primary vs secondary 3. MR severity quantification 4. Annulus and subvalvular apparatus 5. LV function, size and shape 6. LCX (percut MVR)?
3 Mitral valve anatomy Leaflets Annulus Chordae tendinae Papillary muscles Left ventricle
4 Mitral valve anatomy
5 Segmental analysis with MSCT RV RA PC A3 A2 A1 AC P3 P2 P1
6 Segmental analysis with MRI
7 MV/MR: information needed on.. 1. MV anatomy 2. MR etiology - primary vs secondary 3. MR severity quantification 4. Annulus and subvalvular apparatus 5. LV function, size and shape 6. LCX (percut MVR)?
8 MR etiology - excessive motion of the leaflets (P2) primary MR
9 MR etiology - LV remodeling (functional, secondary MR)
10 MV/MR: information needed on.. 1. MV anatomy 2. MR etiology - primary vs secondary 3. MR severity quantification 4. Annulus and subvalvular apparatus 5. LV function, size and shape 6. LCX (percut MVR)?
11 MR quantification semiquantitative parameters Vena contracta (jet areas as leaves ERO) 7mm Systolic pulmonary flow reversal
12 MR Quantification-PISA proximal isovelocity surface area r Va VTI V max EROA = 2πr 2 x Va / V max Rvol = EROA x VTI
13 MR Quantification-PISA R= 1.1 cm Va V max =501 cm/s EROA = 2π(1.1) 2 x 21 / 501=0.3 cm 2
14 MR Quantification-PISA VTI=123.8 cm Rvol = 0.3 x = 37 ml/beat
15 MR Quantification
16 3D Flow Quantification in All Valves MV & TV AV 3D volume scan /w 3-dir velocity encoded MRI PV Westenberg, LKEB
17 Flow (ml/s) MRI: 3D Flow Quantification MV MV flow time (ms) V forward = 116 ml V back = 32 ml V eff = 84 ml Regurg. Fraction = 27% Westenberg, LKEB
18 MV/MR: information needed on.. 1. MV anatomy 2. MR etiology - primary vs secondary 3. MR severity quantification 4. Annulus, subvalvular apparatus 5. LV function, size and shape 6. LCX (percut MVR)?
19 Mitral annulus - calcifications
20 MV subvalvular apparatus Anterior septum IIB Posterior Posterior Anterior septum IIB
21 MV/MR: information needed on.. 1. MV anatomy 2. MR etiology - primary vs secondary 3. MR severity quantification 4. Annulus and subvalvular apparatus 5. LV function, size and shape 6. LCX (percut MVR)?
22 LV size and shape assessment of MSCT FMR related to: 1. Remodeling of left ventricle 2. Displacement of papillary muscles 3. Annular dilatation 4. Leaflet tethering
23 LV function, size and shape Echo, MRI / MSCT
24 MV/MR: information needed on.. 1. MV anatomy 2. MR etiology - primary vs secondary 3. MR severity quantification 4. Annulus and subvalvular apparatus 5. LV function, size and shape 6. LCX (percut MVR)?
25 Tops et al. Circ 2007
26 Percutaneous approach feasible? CS Cx 68% LCX between CS and MVA could create problems
27 Imaging to select for MitraClip Ideal valve morphology Unsuitable valve morphology Mitral regurgitation originating from the mid Perforated mitral leaflets or clefts, lack of primary and portion of the valve (degenerative or functional secondary chordal support etiology) Lack of calcification in the grasping area Severe calcification in the grasping area Mitral valve area >4cm 2 Hemodynamically relevant mitral stenosis Length of posterior leaflet 10 mm Length of posterior leaflet <7mm Non-rheumatic or endocarditic valve disease Rheumatic valve disease (restriction in systole and diastole) or endocarditic valve disease Flail width <15 mm, flail gap <10 mm Sufficient leaflet tissue for mechanical coaptation: coaptation depth <11 mm, coaptation length >2mm Wunderlich et al. EHJCVI 2013
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