Mitral Valve Disorders

Transcription

1 Mitral Valve Disorders Echocardiography Findings and Assessment NEHOUA October 2013 Leominster, MA Adela de Loizaga, M.D.

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3 Mitral Valve Disorders Overview Anatomy of the Heart Anatomy of the Mitral Valve Mitral Valve Disorders and Causes Mitral Valve Prolapse Mitral Valve Regurgitation Mitral Valve Stenosis Mitral Regurgitation and Echocardiography Mitral Stenosis and Echocardiography h New Gold Standards on the Horizon 3

4 Anatomy of the Heart 4

5 Anatomy and Blood Flow of the Heart Heart Chambers, Valves, Blood Flow Through the Heart Source: Wikipedia 5

6 Anatomy of the Heart Valves of the Heart Source: Wikipedia 6

7 Anatomy of the Heart Valve Function Vl Valves act as one-way inlets of blood into the ventricles And one-way outlets of blood out of the ventricles They prevent backward flow of blood passing through the heart MV opens for forward flow into LV and closes to prevent backward flow out of LV. 7

8 Anatomy of the Heart Valve Function As the heart muscle contracts and relaxes, the valves open and shut, letting blood into the atria and ventricles at alternate times As LA fills pressure increases above ventricular pressure : the MV opens and blood flows into the LV (Early diastole) Late diastolic atrial contraction completes flow of LA blood into the left ventricle. (E/A) LV contraction (systole) moves blood out of the ventricle into the aorta Mitral valve is closed Aortic valve is open The ventricles fill during ventricular diastole The atria fill during ventricular systole 8

9 Anatomy of the Mitral Valve 9

10 Mitral valve Mitral Valve Open Bicuspid id structure t Anchored by chordae tendineae Chordae tendineae attach to papillary muscles Functioning i MV apparatus contributes a small portion of LV EF Source: Wikipedia 10

11 Anatomy of the Mitral Valve Mitral Valve Closed Anteromedial papillary muscle Left atrial appendage Left atrium Posterior leaflet Anterior leaflet Chordae tendineae Posterolateral papillary muscle Source: Wikipedia 11

12 Anatomy of the Mitral Valve Normal Mitral Valve View from the Left Ventricle Source: Wikipedia 12

13 Anatomy of the Mitral Valve Normal Mitral Valve Surgical View 3-D View Source: Wikipedia 13

14 Mitral Valve Disorders and Causes 14

15 Mitral Valve Disorders and Causes Various Mitral Valve Disorders Mitral Valve Prolapse (primarily myxomatous degeneration) Mitral Valve Insufficiency / Regurgitation Primary insufficiency Secondary insufficiency Mitral Valve Stenosis 15

16 Mitral Valve Prolapse Mitral valve prolapse is the ballooning of one or both leaflets backwards into the left atrium The leaflets are usually thickened due to myxomatous degeneration Prevalence 2% to 4% US population 5% to 10% worldwide 16

17 Mitral Valve Prolapse Mitral Valve Leaflets Protrude Into Left Atrium Leaflet displacement of 2 mm above the mitral annulus Source: Wikipedia 17

18 Mitral Valve Prolapse The mitral valve doesn t close normally. One or both flaps don t close in the correct way. When this happens, blood can leak backward in the wrong direction. Displacement of an Abnormally Thickened Mitral Valve Leaflet Into the Left Atrium During Systole Source: UpToDate 18

19 Mitral Valve Prolapse Identification of mitral valve prolapse The current accepted echocardiographic definition of MVP is billowing of any portion of the mitral leaflets at least 2 mm above the annular plane in the long axis views. On this parasternal long axis there is pronounced prolapse of the posterior leaflet (arrows) above the annular plane (red line). LV: left ventricle; LA: left atrium; Ao: aorta. Source: UpToDate 19

20 Mitral Valve Prolapse Mitral Valve Prolapse (Left Ventricular View) Source: Wikipedia 20

21 Mitral Valve Prolapse Mitral Valve Prolapse (LA View) Source: Wikipedia 21

22 Mitral Valve Prolapse Leaflet displacement and complications Mitral valve prolapse with displacement > 5mm carries higher h risk of complications, e.g., Leaflet asymmetry Flail leaflet Mitral regurgitation Infective endocarditis 22

23 Mitral Valve Prolapse Partial Mitral Valve Prolapse Source: Wikipedia 23

24 Mitral Valve Prolapse Signs or Symptoms? Auscultation Auscultation ti of mitral valve prolapse Crisp mid-systolic click from the prolapse Subvalve apparatus tightens abruptly Heard best at the left apex Patient in left lateral decubitus position Pure MVP only does not cause symptoms 24

25 Mitral Valve Insufficiency Mitral Valve Insufficiency and Regurgitation Mitral valve insufficiency is caused by inadequate closure of the mitral leaflets Insufficient closure of the leaflets allows backward flow of blood into the left atrium during systole = regurgitation Mitral regurgitation is the most common valve disorder in the U.S - the reported prevalence varies widely Framingham Offspring study ( ca. 3,000 individuals) showed that prevalance depends on the definition of MR Any detectable t trace MR 90% mild MR 19% moderately severe MR 0.4%-2.0% 25

26 Mitral Valve Regurgitation Causes of Primary Mitral Regurgitation Any abnormalities of the mitral valve apparatus: Mitral annulus (e.g., calcification) Mitral leaflets (e.g., 50% of MVP, endocarditis, rheumatic heart disease, flail leaflet) Chordae tendineae (e.g., elongation, rupture) Papillary muscles (e.g., fibrosis, calcification, rupture) 26

27 Mitral Valve Regurgitation Causes of Secondary Mitral Regurgitation Ventricular myocardium (e.g., ischemia, infarction) Dilated cardiomyopathy Dilated annulus Hypertrophic cardiomyopathy Deformed leaflets Chordal slack Displaced apparatus 27

28 Primary MR Due to Endocarditis Verrucous endocarditis in SLE Verrucous endocarditis with valvular vegetations (arrows) cardiac murmur had been heard by auscultation. Courtesy of Peter H Schur, MD. Source: UpToDate 28

29 Primary Mitral Valve Insufficiency Mitral Valve Vegetation in Bacterial Endocarditis 29

30 Mitral Valve Regurgitation Mitral Valve Prolapse Source: Wikipedia 30

31 Mitral Valve Regurgitation Ruptured Chordae Tendineae of the Mitral Valve Source: Wikipedia 31

32 Mitral Valve Regurgitation Mitral Valve Regurgitation From Ruptured Chordae Tendineae Source: Wikipedia 32

33 Mitral Valve Regurgitation Symptoms Exercise intolerance with dyspnea upon exertion Orthopnea Palpitations, tachycardia Symptoms increase with decreasing LV function 33

34 Mitral Valve Regurgitation Clinical Phases of Mitral Regurgitation Compensation phase Gradual development of volume overload Asymptomatic for years or decades Transitional phase Onset of symptoms Decompensation phase Increased symptoms, decreasing LV function Symptoms of congestive heart failure 34

35 Mitral Valve Regurgitation Auscultation of Chronic MR Findings depend d on the severity and duration of mitral regurgitation High-pitched holosystolic murmur at the apex, radiating to the back or clavicular area Loudness of the murmur does not correlate well with the severity of regurgitation A third heart sound is commonly heard 35

36 Mitral Valve Prolapse with Regurgitation Auscultation Click murmur Syndrome Mid-systolic click from the prolapse, a late systolic MR murmur heard best at the apex In contrast to most other heart murmurs, murmur of MV Is accentuated by standing and valsalva maneuver, and Diminished with squatting The only other heart murmur that follows this pattern is the murmur of hypertrophic cardiomyopathy 36

37 Mitral Valve Prolapse with Regurgitation Patient Standing Patient Squatting EKG and phonocardiogram of MVP heard at the apex. S1 (mitral and tricuspid valve closure) followed by a mid systolic click from the prolapse of the MV. After the prolapse occurs, there is the mid systolic murmur of MR. Standing there is a decrease in venous return, a decrease in LV volume d/t decr pulm ven return and the mitral valve prolapses earlier in systole. Consequently, the MR murmur is lengthened. EKG and phonocardiogram of MVP at the apex. S1 (mitral and tricuspid valve closure)followed by a mid systolic click from the prolapsing MV which there is a systolic murmur of MR. With squatting there is an increase in systemic vascular resistance or afterload and an increase in LV pressure and volume. As a result, there is a delay in MV closure and the prolapse (and click) are delayed, occurring late in systole. Consequently, the MR murmur is late and shortened. Provided by John M Criley, MD, The Physiological Origins of Heart Sounds and Murmurs, Little, Brown, Boston, 1996, This program contains a complete interactive ti tutorial t integrating ti over 200 heart sounds and murmurs with cineangiographic, i echo-doppler, and hemodynamic motion picture sequences. Source: UpToDate 37

38 Mitral Valve Regurgitation Symptoms of Acute MR Acute mitral regurgitation will have sudden onset of symptoms Suggestive of a low cardiac output state Decreased exercise tolerance Of decompensated congestive heart failure Shortness of breath, pulmonary congestion, orthopnea, paroxysmal nocturnal dyspnea Palpitations Atrial fibrillation Cardiogenic shock In individuals with acute mitral regurgitation due to papillary muscle rupture or rupture of a chorda tendinea 38

39 Acute Mitral Regurgitation Post MI Papillary Muscle Rupture After MI Complete transection of papillary muscle (arrow) after an acute myocardial infarction The patient died with severe mitral regurgitation. Photograph courtesy of Dr. William D Edwards. From Reeder, GS, Gersh, BJ, Acute myocardial infarction. In: Internal Medicine, 4th ed, Stein, JH, Hutton, JJ, Kohler, PO, et al (Eds), Mosby-Year Book, St Louis, 1994, pp By permission. Source: UpToDate 39

40 EKG Changes in Mitral Valve Regurgitation P Mitrale is a Broad Notched PWave Source: Wikipedia 40

41 EKG Changes in Mitral Valve Regurgitation Prominent Late Negative Component of P Wave in Lead V 1 Source: Wikipedia 41

42 Mitral Valve Regurgitation Electrocardiogram in Mitral Regurgitation P mitrale is broad notched P waves in several or many leads with a prominent late negative component to the P wave in lead V 1 May be seen in mitral regurgitation Butalsoinmitralstenosis stenosis Potentially seen with any left atrial enlargement (LAE) 42

43 Mitral Regurgitation and Echocardiography 43

44 Mitral Valve Regurgitation and Echocardiography Some Echocardiography Basics What is an echocardiogram? What can an echocardiogram tell us? What is a Doppler study and what does it add to the echocardiogram? 44

45 Some Echocardiography Basics High frequency sound waves (> 1MHz) Reflections from solid-fluid interfaces Fluid density appears black on US (no echos) The heart is a fluid filled structure» allows excellent imaging of structures Courtesy: UpToDate 45

46 Some Echocardiography Basics Doppler Echocardiography Doppler effect Sound waves bouncing off moving blood elements causes shift in wave length of the echo Can be used to indicate direction, speed, and magnitude of flow Revolutionized understanding of valve disorders Echocardiography and Doppler studies continue to evolve 46

47 Some Echocardiography Basics Doppler Echocardiography Flow direction and quantitation Gradients Pressure calculations Courtesy: UpToDate 47

48 Mitral Valve Regurgitation and Echocardiography 2 D and Anatomic basis for the presence of mitral M Mode Anatomic basis for the presence of mitral regurgitation (e.g., mitral annular calcification) Left atrial enlargement with systolic bowing of the interatrial septum Increased LA / RA ratio (normal is 1:1) Left ventricular volume overload pattern Hyperkinesia of the left ventricular walls with left ventricular dilatation Evidence of pulmonary hypertension 48

49 Mitral Valve Regurgitation and Echocardiography Pulse Wave Doppler Measurements Regurgitant t jet Regurgitant t fraction Pulmonary venous inflow Diminished or reversed with significant mitral regurgitation 49

50 Mitral Regurgitation and Echo Measurements Color Flow Doppler A small jet occupying <20% of the left atrial area is considered d mild regurgitation. A large jet occupying > 40% of the LA area and extending into the pulmonary veins is considered severe mitral regurgitation. These jets are very sensitive to instrument settings, may be misleading. They should be used in conjunction with other findings, not alone. 50

51 Mitral Valve Regurgitation and Echocardiography Color Flow Doppler Regurgitant jet width is measured at the regurgitant orifice: it can be calculated using the Proximal Isovelocity Surface Area (PISA). PISA is based on the hemodynamic principles of flow through a small circular orifice. There is flow acceleration of the regurgitant blood on the ventricular side as it moves towards and through the mitral valve opening into the LA. There are different layers of equal velocity in this regurgitant blood flow as it converges proximal to the valve opening. 51

52 Mitral Regurgitation Echocardiography Proximal Isovelocity Surface Area Limitation of PISA Measures the flow at one moment in time in the cardiac cycle May not reflect the average performance of the regurgitant jet 52

53 Mitral Valve Regurgitation and Echocardiography Color Flow Doppler These velocity areas are visualized as concentric hemispheric h i rings above the mitral valve opening on color flow Doppler. The smaller the opening, the higher the velocity. The larger the opening, the slower the velocity. Using the size of the velocity areas and the velocity the orifice can be calculated. The diameter of the ring closest to the regurgitant orifice is used as the assumed jet width. 1cm jet width is consistent with severe mitral regurgitation. 53

54 PISA and JET Width (Severe Mitral Regurgitation) Color Flow Doppler Severe MR Four chamber view with typical features of severe mitral regurgitation; a large proximal isovelocity surface area (PISA) and a broad crossing jet from left ventricle (LV) into the left atrium (LA). Source: UpToDate 54

55 Mitral Regurgitation and Echo Measurements Quantification of Mitral Valve Regurgitation Effective Regurgitant t Orifice area = ERO is the area of the regurgitant flow at the level of the valve ERO correlates with the size of the defect in the mitral valve MR severity is quantifiable with Regurgitant Fraction Regurgitant Fraction = RF is the percentage of the left ventricular stroke volume that regurgitates into the left atrium 55

56 Mitral Regurgitation and Echo Measurements Mitral Regurgitation Measured by Vena Contracta and Central Jet Width Left Ventricle MV Jet Width Vena Contracta Left Atrium Vena contracta is the point in a fluid stream where the diameter of the stream is the least. The maximum contraction takes place slightly downstream of an orifice where the jet is more or less horizontal. This phenomenon is because fluid streamlines cannot abruptly change direction. Source: Wikipedia 56

57 Mitral Regurgitation and Echo Measurements Vena Contracta in Mitral Regurgitation FIGURE Measurement of the vena contracta (VC between arrows) in two different patients: A a central mitral regurgitation jet; B an eccentric mitral regurgitation jet (note change in color flow baseline). LA = left atrium; LV = left ventricle. (Modified from Oh JK, Seward JB, Tajik AJ: The Echo Manual. 3rd ed. Philadelphia, Lippincott Williams & Wilkins, Used with permission of Mayo Foundation for Medical Education and Research.) Vena contracta Braunwald 57

58 Mitral Regurgitation and Echo Measurements MR Severity and Vena Contracta vs. Regurgitant Fraction (RF) Mitral Regurgitation Vena Contracta Width Regurgitant Fraction (RF) Grade 1 < 4 mm < 20% Grade mm 20% 30% Grade mm 30% 49% Grade 4 > 8 mm > 50% 58

59 Mitral Regurgitation and Echo Measurements Regurgitant Jet in Mitral Insufficiency Panel A. apical four chamber view of mild MR and mild TR also present. Regurgitant jets have a mosaic of color; they begin with a very narrow point of origin at the valve, remain narrow and penetrate only partially into LA cavity. Source: Braunwald Panel B. The size of the MR jet at the site of origin is wider, the jet reaches the posterior LA wall characteristics of moderate to severe MR. Panel C. The jet is even wider, almost filling the LA, and it reaches the posterior LA wall and enters the pulmonary veins. 59

60 Flow Reversal in Pulmonary Veins Reversed ersed Pulmonary Venous Flow Source: Wikipedia 60

61 Guide for Quantitating Severity of Mitral Regurgitation Mild MR (Grade 1+) Normal history, possible murmur Normal left atrial and left ventricular dimensions by Echocardiography h Regurgitant fraction <20% Normal EF >55% May never progress 61

62 Guide for Quantitating Severity of Mitral Regurgitation Moderate MR (Grade 2+) Likely asymptomatic, ti possible murmur Mild left atrial and left ventricular enlargement by echocardiography h Regurgitant fraction 20% to 30% High EF >60%, compensation 62

63 Guide for Quantitating Severity of Mitral Regurgitation Moderately Severe MR (Grade 3+) Onset of symptoms, murmur, EKG and /or chest x-ray Moderate left atrial and left ventricular enlargement Left atrial dimension > right atrial dimension Significant coaptation defect of the mitral valve leaflets, with large ERO Wide mitral regurgitation jet Regurgitant fraction 30% to 49% EF 50%-59%, transitional phase 63

64 Guide for Quantitating Severity of Mitral Regurgitation Severe MR (Grade 4+) Symptomatic, murmur, r EKG and / or chest x-ray No systolic coaptation of the mitral valve Very large ERO and PISA 1 cm or more Moderate to severe left atrial and left ventricular enlargement (cardiomegaly) Regurgitant fraction > 50% Regurgitant g jet area / left atrial area ratio > 40% EF <50%, decompensation 64

65 Chest X-Ray Findings in Chronic Severe MR Normal Chest Film PA CXR Chronic MR Posteroanterior view of a normal Female with known mitral regurgitation ti chest radiograph. cardiomegaly with left atrial (black arrow) left ventricular enlargement (red arrow), as well as mild pulmonary venous redistribution, features characteristic of mitral regurgitation. Photos courtesy of Jonathan Kruskal, M.D. Source: UpToDate 65

66 Mitral Valve Regurgitation Findings Look for: LA dilatation ti LV dilatation Symptoms: Red Flag! Palpitations (tachycardia, atrial fibrillation) Exercise intolerance Dyspnea with mild exertion or at rest LH Failure SOB Pulmonary edema Cardiogenic shock 66

67 Assessment of Mitral Valve Regurgitation Echo Measurements for Mitral Regurgitation Parameters Grade 1 Grade 2 Grade 3 Severe Structural Left Ventricular Size Normal Normal or dilated Dilated, except acute MR Doppler Quantitative Color Doppler regurgitant jet <20% <20% LA area >40% of LA area Doppler vena contracta width <3-3.9mm 4-6mm 6-8 mm >8mm Regurgitant volume <30 ml/beat 30-44mL/beat 45 to 59 ml/beat 60 ml/beat Regurgitant fraction <20% 20 to 30% 30 to 49% 50% Regurgitant orifice area < 20 mm mm 2 25 to 39 mm 2 40 mm2 American College of Cardiology/American Heart Association, Guidelines 2006 Source: UpToDate Left Atrial Enlargement Normal Mild Moderate Severe Diameter in cm Men < >5.2 Diameter in cm Women < >4.7 Source: American Society of Echocardiography 67

68 Mitral Stenosis 68

69 Mitral Valve Disorder with Inflow Obstruction Obstructed Flow from LA to LV Some conditions cause a limiting iti orifice that obstructs diastolic transit of blood from atrium to ventricle Hemodynamic consequence: a holo-diastolic pressure gradient between the left atrium and left ventricle 69

70 Mitral Valve Disorder with Inflow Obstruction Mitral Valve Stenosis The most common lesion of the mitral valve that causes inflow obstruction is: Mitral stenosis Usually acquired as the result of rheumatic heart disease Estimated prevalence 0.1% (range 0.02% to 0.2%) Lancet study 2006 on burden of valve disorders; also based on 1500 reviewed valvotomies as indicators of severe MS Other causes include: Left atrial myxoma and other tumors Severe mitral annular calcification Left-sided carcinoid heart disease Congenital disordersd 70

71 Mitral Valve Stenosis Signs and Symptoms Slow decline of exercise tolerance Decreased stroke volume Reduced arterial pulses Left atrial hypertrophy EKG with P-mitrale Atrial fibrillation Stroke 71

72 Mitral Valve Stenosis Signs and Symptoms Pulmonary hypertension Dyspnea, hemoptysis Pulmonary edema Right heart enlargement Leg and sacral edema Hepatomegaly, ascites 72

73 Mitral Valve Stenosis Marked thickening of the leaflets and LA hypertrophy 73

74 Mitral Valve Stenosis and Echo Findings ICE Mitral Stenosis Hockey Stick Intracardiac ultrasound examination shows a stenotic mitral valve with some leaflet thickening and a hockey-stick appearance of the anterior mitral valve leaflet. Source: UpToDate 74

75 Mitral Stenosis Echocardiographic Findings TTE Mitral Stenosis Alters Appearance and Motion of the Valve on Two-Dimensional Echocardiography Normal is a rapid, biphasic motion of the valve MS from partially fused leaflets causes the valve to open only partly and as a single unit Persistent gradient develops between the left atrium and left ventricle This gradient keeps the stenotic valve opened and causes the entire valve to bulge like a dome into the ventricle throughout diastole The elevated gradient initiates iti t the opening motion abruptly, generating an opening snap and a characteristic hockey stick / knee bend appearance on the precordial long axis view 75

76 Mitral Stenosis and Echo Measurements Doppler can measure velocity of mitral inflow In mitral stenosis the velocity increases from < 1m/sec to > 1.5m/sec. Continuous Wave Doppler MS Peak velocity of 1.7 m/s in this patient with rheumatic mitral stenosis (MS). Apply simplified Bernoulli formula: the initial diastolic gradient across the mitral valve is 12 mmhg. Source: UpToDate 76

77 Mitral Valve Stenosis and Echo Findings Peak Velocity, Peak Gradient and Pressure Half Time Peak gradient, in mmhg = 4 x peak velocity 2 Peak velocity of 1 m/sec indicates a peak gradient of 4 mmhg Peak velocity of 2 m/sec indicates a peak gradient of 4 x (2x2) = 16 mmhg Peak velocity of 3 m/sec indicates a peak gradient of 4x (3x3) = 36 mmhg Transmitral gradient during diastole can be measured in the pressure half-time (PHT) PHT = the time required for the gradient between the left atrium and the left ventricle to fall to one-half of its initial value 77

78 Mitral Valve Stenosis and Echo Findings Transmitral Gradient During Diastole can be Measured in the Pressure Half-time (PHT) The mitral valve area can be obtained from the continuous wave Doppler by calculating the time required for the opening pressure to reach one half of its value (P 1/2); this is called P 1/2 time and is calculated as shown. By regression analysis, a critically stenotic valve measuring 1 cm 2 has a PHT of 220 ms; the valve area can be calculated as shown above. Source: UpToDate 78

79 Mitral Valve Stenosis and Echo Findings Velocity and Pressure Gradient Empirically i pressure half-time of 220 msec = MVA of 1.0 cm 2 Thus MVA = 220 / PHT With PHT 300 msec MVA = 220 / 300 = 0.7cm 2 79

80 Mitral Valve Stenosis and Echo Findings Mitral Valve Stenosis Pressure half-time Normal: 30 to 60 milliseconds (ms) (MVA 220/60 =3.66 cm 2 ) Mild MS: 90 to 150 ms (MVA 220/150 =1.46 cm 2 ) Moderate MS: 150 to 219 ms (MVA 220/219 =1 cm 2 ) Severe MS: > 220 ms (MVA 220/300 = 0.73 cm 2 ) 80

81 Mitral Valve Stenosis Indirect Findings Look for: Left atrial hypertrophy Symptoms of low cardiac output Pulmonary hypertension Symptoms: Red Flag! Atrial fibrillation, PAF Right heart failure SOB, pulmonary edema Leg edema 10 year survival at time of presentation In asymptomatic individuals 80% or more With severe ere symptoms 0%- 15% 81

82 Mitral Stenosis Assessment of Severity Echo Measurements for Mitral Stenosis Severity Mitral Stenosis (ACC/AHA 2006) Normal Mild Moderate Severe Valve Area (cm 2 ) <1.0 Mitral Jet Velocity (m/sec) 2.0 < >4.0 Mean Gradient (mmhg) < >12 Pulmonary Artery Systolic Pressure (mmhg) >50 Source: UpToDate 82

83 New Gold Standards on the Horizon 83

84 New Gold Standards on the Horizon Two more advanced d technologies are making their way into routine echocardiography 1. 3-D Echocardiography 2. Tissue Doppler Echocardiography (TDE) 84

85 New Gold Standards on the Horizon Advantages of 3-D echocardiography Real-time 3-D allows immediate evaluation without calculations and geometric modeling of two-dimentional measurements Direct evaluation of cardiac valves Volumetric quantification of regurgitant t valve lesions, shunts, and cardiac output 85

86 New Gold Standards on the Horizon Advantages of 3-D echocardiography Improved the accuracy and quantification of Mitral Regurgitation and Mitral Stenosis More accurate direct measurements of mitral valve area Improved reproducibility 86

87 New Gold Standards on the Horizon 3-D echocardiography Baseline image before mitral balloon valvuloplasty (A) shows a restricted mitral valve opening with bicommissural fusion. Postvalvuloplasty, splitting of the medial commissure and posterior leaflet tear can be seen (B). Source: UpToDate 87

88 New Gold Standards on the Horizon Advantages of Tissue Doppler TDE has become an established component of the diagnostic ultrasound examination It permits an assessment of myocardial motion, using Doppler ultrasound imaging, often with color coding This is similar to routine Doppler ultrasound used to assess blood flow 88

89 New Gold Standards on the Horizon Advantages of Tissue Doppler The technique calculates l myocardial velocity TDE offers an objective measure to quantify regional and global l LV function It can be used to assess RV systolic function as in chronic pulmonary hypertension, and chronic heart failure. 89

90 New Gold Standards on the Horizon TDE This TDE shows normal left ventricular systolic function. Panel A : color-coded 2-D tissue Doppler image; panel B : the corresponding color- M-mode tissue Doppler image for a single cardiac cycle panel C: the time-velocity plot of the posterior wall of the color-m-mode tissue Doppler image. S: peak systolic velocity; E: peak early diastolic velocity; A: peak atrial velocity. Source: UpToDate 90

91 New Gold Standards on the Horizon 3-D Decho These two technologies are not yet and TDE the Gold Standard. Scientific evidence seems strong enough to endorse 3-D echo and TDE as a new standard. They offer improved clinical assessment of fthe heart anatomy and dfunction. 91

92 Mitral Valve Disorders Echocardiography Findings and Assessment Webinar 2013 Adela de Loizaga, M.D.