How to assess ischaemic MR?
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1 ESC 2012 How to assess ischaemic MR? Luc A. Pierard, MD, PhD, FESC, FACC Professor of Medicine Head, Department of Cardiology University Hospital Sart Tilman, Liège
2 ESC 2012 No conflict of interest Luc A. Pierard, MD, PhD, FESC, FACC Professor of Medicine Head, Department of Cardiology University Hospital Sart Tilman, Liège
3 Ischaemic mitral regurgitation
4 Carpentier s functional classification TYPE I : NORMAL LEAFLET MOTION - Annular dilatation - Leaflet perforation TYPE II : EXCESSIVE LEAFLET MOTION - Prolapse - Flail TYPE III : REDUCED LEAFLET MOTION - SYSTOLE AND DIASTOLE: Chordae shortening, leaflet thickening - SYSTOLE: Incomplete coaptation
5 What should we assess? Mechanism(s) Quantified severity of MR Dynamic component Myocardial state Dyssynchrony Markers of MV repair failure
6 Secondary MR Tethering force PMs displacement Dilation/Sphericity Annular dilation Closing force Reduced contractility Asynchrony PMs dyssynchrony Reduced annular contraction Global and Local LV Remodeling LV Asynchrony Mitral valve deformation
7 If tethering is normal, MR develops only when mitral annulus area is 75% above baseline
8 Assessment of tethering forces Postero-lateral angle Systolic tenting area Coaptation distance
9
10 Assessment of closing force Reduced contractility LV dyssynchrony
11 Ao MR No MR Ao Baseline Normal Post-Infarct PM functioning Post-Infarct PM ischemic
12 Papillary muscle dysfunction and secondary MR Normal Post-Infarct PM functioning Post-Infarct PM ischemic LV PM contraction PM dysfunction LA Ao Messas E et al, Circulation 2001;104:
13 What should we assess? Mechanism(s) Quantified severity of MR Dynamic component Myocardial state Dyssynchrony Markers of MV repair failure
14 Physical examination Desjardins et al Am J Med 1996,100,149
15 Degree of regurgitation - Regurgitation area - Vena contracta width - Effective regurgitation orifice area - Regurgitant volume
16 Regurgitant area: should be abandoned Gain Scale
17 Vena contracta width The narrowest portion of the MR jet downstream from the orifice 2 orthogonal planes Zoom to optimize visualization Colour sector as narrow as possible Maximal lateral and temporal resolution # Mild MR : VC < 0.3 cm # Severe MR: VC 0.7 cm
18 Doppler volumetric method Not applicable if significant aortic regurgitation Calculate LVOT stroke volume LVOT SV = LVOT diameter² x x LVO TVI Calculate Mitral Inflow stroke volume MI SV = mitral annulus diameter² x x MI TVI Substract LVOT SV from MI SV = RV Measure MV TVI by continuous-wave Doppler ERO = MV Reg V / MR TVI
19 PISA Method 1. Optimize 2-D colour (AP-4CV) 2. Zoom or RES 3. Colour-flow baseline shift downwards to increase PISA (15-40 cm/s) 4. Measure PISA radius at mid systole using the first aliasing 5. Measure MR peak velocity and TVI ( CW Doppler ) 6. Calculate mitral flow rate, ERO and RV
20 Variance OFF
21 Effective regurgitant orifice and regurgitant volume Flow rate at PISA = Flow rate at regurgitant orifice 2 r² x Aliasing velocity = ERO x MR velocity ERO = 6.28 r² x Alia vel / MR vel Reg Vol = ERO x MR TVI
22 Limitations of the PISA method Isovelocity surface not always a hemisphere Contour flattening of the orifice Underestimation Va /Vmax > 10 % (if high Va) ----> ideal Va cm/s Phasic changes
23 3 D PISA and Vena contracta width
24 Echocardiographic criteria for the definition of severe valve regurgitation: an integrative approach Aortic regurgitation Mitral regurgitation Tricuspid regurgitation Semiquantitative Vena contracta width (mm) > 6 7 (> 8 for biplane) 7 Upstream vein flow Inflow Other Pressure half-time < 200 ms Systolic pulmonary vein flow reversal E-wave dominant 1.5 m/s TVI mitral/tvi aortic > 1.4 Quantitative Primary Secondary Systolic hepatic vein flow reversal E-wave dominant 1 m/s PISA radius > 9 mm EROA (mm²) R Vol (ml/beat) enlargement of cardiac chambers/ vessels LV LV, LA Adapted from Lancellotti, EAE recommendations. Eur J Echocardiogr. 2010;11: and RV, RA, inferior vena cava European Heart Journal doi: /eurheartj/ehs109 & European Journal of Cardio-Thoracic Surgery doi: /ejcts/ezs455).
25 Severe ischaemic MR: ERO 20 mm² MI > 16 days NYHA Class IV MI > 6 months No NYHA IV Grigioni et al Circulation 2001, 103; 1759 Lancellotti, Pierard et al Circulation 2003, 108:1713
26 What should we assess? Mechanism(s) Quantified severity of MR Dynamic component Myocardial state Dyssynchrony Markers of MV repair failure
27 Ischaemic MR is dynamic Rest Increase with exercise Rest Decrease with exercise
28 Which measurement of MR severity? Interobserver variability 1.0 PISA DOPPLER r 0.5 RJA VCW 0.0 Lebrun, Lancellotti, Piérard JACC 2001; 38:
29 REST : Ischaemic mitral regurgitation
30 VC width = 5 mm ERO = 6.28 x (0.78)²x ERO = 22 mm² RV = 22 x 1.85 = 40 ml TTPG = 36 mmhg
31 Doppler Echocardiography during exercise Exercise-induced dyspnea
32 EXERCISE: Dynamic ischaemic MR
33 VC width = 7 mm ERO = 6.28 x (1.1)²x ERO = 38 mm² (+ 16) RV = 38 x 1.81 = 69 ml (+ 29) TTPG = 77 mmhg (+ 41)
34 Exercise-induced dyspnea vs fatigue 103 fatigue 58 dyspnea Piérard, Lancellotti N Engl J Med 2006;354:871-2
35 ΔEx.-rest OR p Recent APE ERO 1.15 ( ) < TTPG 1.13 ( ) LVEF 0.86 ( ) 0.02
36 Long-term prognosis of dynamic ischaemic MR Survival Decompensated HF Lancellotti et al Circulation 2003;108: Lancellotti, Gérard, Piérard Eur Heart J 2005;26:
37 What should we assess? Mechanism(s) Quantified severity of MR Dynamic component Myocardial state Dyssynchrony Markers of MV repair failure
38 REST DOBUTAMINE preload afterload contractility Assessment of contractile reserve inducible ischaemia
39 No contractile reserve No evidence of inducible ischaemia REST EXERCISE
40 Biphasic response during exercise
41 What should we assess? Mechanism(s) Quantified severity of MR Dynamic component Myocardial state LV dyssynchrony Markers of MV repair failure
42 LV dysynchrony
43 Before CRT Early Late Mitral Regurgitation (%) OFF ON Breithardt et al JACC 2003; 41: Baseline 1wk 1mo 3mo offimmed off- 1wk off- 4wk
44 What should we assess? Mechanism(s) Quantified severity of MR Dynamic component Myocardial state Dyssynchrony Markers of MV repair failure
45 Markers of MV repair failure Postero-lateral angle Tenting area Coaptation distance - Posterolateral angle > 45 - Tenting area > cm² - Coaptation distance 1 cm
46 How to assess ischaemic MR? Mechanism(s) Quantified severity of MR Dynamic component Myocardial state Dyssynchrony Markers of MV repair failure
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