Marti McCulloch, BS, MBA, RDCS, FASE Houston, Texas
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1 Marti McCulloch, BS, MBA, RDCS, FASE Houston, Texas Mitral Regurgitation
2 What to Expect Review Specific Signs of Severity Supportive Signs of Severity Qualitative Parameters Structural Doppler Quantitative Parameters Vena Contracta Width Regurgitant Volume (ml/beat) Regurgitant Fraction (%) Effective Regurgitant Orifice Area (EROA cm 2 ) Cases implement what you learned!
3 Specific Signs Mild Small central jet <4 cm 2 or <20% of LA Vena contracta width <0.3cm No or minimal flow convergence Moderate Signs of MR > Mild but no criteria for severe MR Severe Vena contracta width >0.7cm Large flow convergence Systolic reversal in pulmonary veins Prominent flail MV leaflet of ruptured papillary muscle Zoghbi, et. al. JASE 2003
4 Supportive Signs Mild Systolic dominant flow in pulmonary veins A-wave dominant mitral inflow Soft density, parabolic CW Doppler MR signal Normal LV size Moderate Intermediate signs/findings Severe Dense, triangular CW Doppler MR jet (early peaking) E-wave dominant mitral inflow (E > 1.2 m/s) Enlarged LV Enlarged LA Zoghbi, et. al. JASE 2003
5 Quantitative Parameters EROA (cm 2 ) Mild <0.20 Mild-Mod Mod-Sev Severe >0.40 R Vol (ml/beat) Mild: <30 Mild-Mod Mod-Sev Severe >60 Regurgitant Fraction % (RF) Mild <30 Mild-Mod Mod-Sev Severe >50 Zoghbi, et. al. JASE 2003
6 Grading MR Qualitative/Supportive Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitative Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
7 7
8 Mitral Regurgitation
9 Vena Contracta Measurement at the narrowest portion of neck during mitral regurgitation. VC = 0.9 Optimize jet in PLAX Zoom or RES Look for flow across the valve with a neck Measurement of the vena contracta is a quick and accurate quantitative technique when properly applied. It works best on single central MR jets, but is also valuable in assessing an eccentric jet. Roberts, B and Grayburn, P. Vena Contracta: Practical Approach. J Am Soc Echocardiogr 2003;16: )
10 PISA Method Volume Flow Rate (VFR) = 2 x x r 2 x V r Effective Reg Orifice Area = VFR/V MAX Regurgitant Volume (rvol) = ERO x VTI r=0.7 Adjust baseline Scroll to midsystole Locate vena contracta Measure from vena contracta to 1 st color shift change
11 PISA Method Volume Flow Rate (VFR) = 2 x x r 2 x V r Effective Reg Orifice (ERO) = VFR/V MAX Regurgitant Volume (RVol) = ERO x VTI VFR = 6.28 x.49 x 34 VFR = 105cc/s r=0.7 ERO = VFR/V MAX ERO = 105/417.4 ERO = 0.25cm 2 RVol = ERO x VTI RVol = 0.25 x 130 Rvol = 32mL
12 Grading MR Qualitative Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitive Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
13 Easy PISA? If aliasing velocity cm/sec and the velocity is around 500 cm/sec ERO = ERO = 0.38 X r X r 2 X 30 cm/sec 500 cm/sec r=0.7 ERO = 0.38 x (0.7) 2 ERO = 0.38 x 0.49 ERO = 0.19 cm 2
14 Left Atrial Pressure LAP = SBP 4 X MRV 2 SBP = 140 MRV = 5 m/s LAP= X 25 LAP= LAP= 40 LAP = SBP 4 X MRV 2 SBP = 140 MRV = 4 m/s LAP = X 16 LAP = LAP = 76
15 Regurgitant Fraction % RF% = SV (Valve) SV (Systemic) / SV (Valve) VTI 25.9 cm MA ann 2.2 cm MA SV = D 2 x.785 x VTI MA SV = 2.2 x.785 x 25.9 MA SV = 98.4 ml LVOT SV = D 2 x.785 x VTI
16 Regurgitant Fraction % RF% = SV (Valve) SV (Systemic) / SV (Valve) VTI 15.8 cm LVOT 1.8 cm MA SV = D 2 x.785 x VTI MA SV = 2.2 x.785 x 25.9 MA SV = 98.4 ml LVOT SV = D 2 x.785 x VTI LVOT SV = 3.24 x.785 x 15.8 LVOT SV = 40.2 ml RF% = MA SV LV SV / MA SV RF% = / 98.4 RF% = 59%
17 Grading MR Qualitative Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitive Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
18 Case 175,425,421cn 32 y/o Vietnamese Female lb B/P 105/51 HR 68 Prior MV Repair 18
19 Case 175,425,421cn 19
20 Case 175,425,421cn 20
21 Case 175,425,421cn What kind of MV surgery? a) No surgery b) Ring repair c) Mitral Clip d) Replacement 21
22 Case 175,425,421cn What kind of MV surgery? a) No surgery b) Ring repair c) Mitral Clip d) Replacement 22
23 Case 175,425,421cn 23
24 Case 175,425,421cn Based on info so far, what is severity? a) Mild b) Moderate c) Severe d) Low Nyquist 24
25 Case 175,425,421cn Based on info so far, what is severity? a) Mild b) Moderate c) Severe d) Low Nyquist 25
26 Case 175,425,421cn What is the estimated vena contracta? a) <0.30 b) c) >0.70 d) Poor image 26
27 Case 175,425,421cn What is the estimated vena contracta? a) < cm b) c) >0.70 d) Poor image 27
28 Case 175,425,421cn When do you measure? a) Early sys 0.5 b) Mid sys 0.9 c) Late sys
29 Case 175,425,421cn a) When do you measure? b) a) Early sys 0.5 b) Mid sys 0.9 c) c) Late sys
30 Case 175,425,421cn 30
31 Case 175,425,421cn What size is the LA? 130.7ml What about density and shape of Doppler? 31
32 Case 175,425,421cn 32
33 Case 175,425,421cn What supportive sign is noted in pulmonary vein flow for significant MR? S D A a) Dominant D wave b) Dominant S wave c) Dominant A wave d) All of the above 33
34 Case 175,425,421cn What supportive sign is noted in pulmonary vein flow for significant MR? S D A a) Dominant D wave b) Dominant S wave c) Dominant A wave d) All of the above 34
35 Case 175,425,421cn What is the LA pressure? 32 y/o Vietnamese Female lb B/P 105/51 HR 68 Prior MV Repair MV pk Vel 417.4cm/s 35
36 Left Atrial Pressure LAP = SBP 4 X MRV 2 SBP = 105 MRV = 4.2 m/s LAP= X LAP= LAP= MV pk Vel 417.4cm/s SBP = 105
37 Case 175,425,421cn Tips for measuring flow convergence (PISA) 1. Leaflet to 1 st color shift 2. Mid systole 3. Baseline shift 4. Zoom 5. Do often 37
38 PISA Method - 4 Numbers r = 0.9 MR pk Vel = 417 cm/s V r = 38 cm/s MR TVI = 130 cm r=0.9 ERO and RVol
39 PISA Method - 4 Numbers r=0.9 VFR = 2 x x r 2 x V r VFR = 6.28 x.81 x 38 VFR = 193cc/s V MAX 4.17m/s VTI 130 ERO = VFR/V MAX ERO = 193/417.4 ERO = 0.46cm 2 RVol = ERO x VTI RVol = 0.46 x 130 Rvol = 59.8 ml
40 Case 175,425,421cn iase app Severe 54 Severe 40
41 Grading MR Qualitative Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitive Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
42 Case 175,425,421cn MA Stroke Volume & CO 42
43 Regurgitant Fraction % RF% = SV (Valve) SV (Systemic) / SV (Valve) VTI 15.8 cm LVOT 1.8 cm MA SV = D 2 x.785 x VTI MA SV = 2.2 x.785 x 25.9 MA SV = 98.4 ml LVOT SV = D 2 x.785 x VTI LVOT SV = 3.24 x.785 x 15.8 LVOT SV = 40.2 ml RF% = MA SV LV SV / MA SV RF% = / 98.4 RF% = 59%
44 Grading MR Qualitative Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal Quantitive Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
45 Case 175,425,421cn Findings for the 32 y/o Vietnamese Female LV function normal RV normal LA Severely enlarged RA normal AV trace AI MV thickened leaflets, surgical ring, severe regurgitation with RF of 59% and estimated Rvol of 58 ml. 45
46 46
47 Case 176,298,521JH 68 y/o Female lb BSA 1.79 m 2 Primary indication Atrial Fibrillation 47
48 Case 176,298,521JH 48
49 Case 176,298,521JH 49
50 Case 176,298,521JH 50
51 Case 176,298,521JH Based on information so far, what degree is the MR? a) Mild b) Mild to Moderate c) Moderate d) Severe 51
52 Case 176,298,521JH Based on information so far, what degree is the MR? a) Mild b) Mild to Moderate c) Moderate d) Severe 52
53 Case 176,298,521JH Based on vena contracta what is the VC = 0.2 degree of MR? VC = 0.4 a) Mild b) Mild to Moderate c) Moderate d) Severe 53
54 Case 176,298,521JH Based on vena contracta what is the VC = 0.2 degree of MR? VC = 0.4 a) Mild b) Mild to Moderate c) Moderate d) Severe 54
55 Grading MR Qualitative Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitive Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
56 Case 176,298,521JH What size is the LA? 56
57 Case 176,298,521JH What size is the LA? 71.7 ml a) Normal b) Mildly enlarged c) Moderately big d) Severely enlarged 57
58 Case 176,298,521JH What size is the LA? 71.7 ml a) Normal b) Mildly enlarged c) Moderately big d) Severely enlarged 58
59 Case 176,298,521JH 59
60 Case 176,298,521JH 60
61 Case 176,298,521JH How many MR jets are there?? a) one b) two c) three d) What MR? 61
62 Case 176,298,521JH How many MR jets are there?? a) one b) two c) three d) What MR? 62
63 Case 176,298,521JH 63
64 Case 176,298,521JH 64
65 Case 176,298,521JH 65
66 Case 176,298,521JH 66
67 Case 176,298,521JH MIn Supportive signs include MR PVein S D D S a) Dominant E b) Dense parabolic Doppler c) None of the above d) A & B A 67
68 Case 176,298,521JH MIn Supportive signs include MR PVein S D D S a) Dominant E b) Dense parabolic Doppler c) None of the above d) A & B A 68
69 Grading MR Qualitative/Supportive Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitative Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
70 Case 176,298,521JH 70
71 Case 176,298,521JH 71
72 PISA Method - 4 Numbers r=0.4 VFR = 2 x x r 2 x V r VFR = 6.28 x.16 x 34 VFR = 34 cc/s V MAX 5 m/s ERO = VFR/V MAX ERO = 34/500 ERO = 0.068cm 2 Easy PISA = 0.38 x r 2 ERO = 0.38 X 0.16 ERO = 0.06cm 2
73 Grading MR Qualitative Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitive Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
74 Case 176,298,521JH Findings for the 68 y/o female LV size normal, mild/mod LVH, fx lower limits of normal RV size normal and mildly depressed LA mod to severely enlarged RA mildly enlarged Small PE AV mild calcification with trace AI MV no structural abnormalities with mild to moderate regurgitation 74
75 Case 185,425,421cj 59 y/o female Primary diagnosis CHF lb BSA 1.92 B/P 70/00 75
76 Case 185,425,421cj 76
77 Case 185,425,421cj 77
78 Case 185,425,421cj What do you think about the valves? 78
79 Case 185,425,421 79
80 Case 185,425,421 80
81 Case 185,425,421cj 59 y/o female Primary diagnosis CHF lb BSA 1.92 B/P 70/00 Heartmate II LVAD insertion 9/28/2010 LVAD misalignment 81
82 Case 185,425,421 After LVAD adjustment 82
83 Case 185,425,421 Heartmate II 83
84 Case 546,222,333RR 57 y/o female Primary diagnosis mitral regurgitation 65 in 113 lb BSA 1.55 B/P 110/77 84
85 Case 546,222,333RR 85
86 Case 546,222,333RR 86
87 Case 546,222,333RR What is the estimated vena contracta? a) <0.30 b) c) >0.70 d) Too eccentric to estimate 87
88 Case 546,222,333RR What is the estimated vena contracta? VC 1.4cm a) <0.30 b) c) >0.70 d) Too eccentric to estimate 88
89 Grading MR Qualitative/Supportive Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitative Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
90 Case 546,222,333RR 90
91 Case 546,222,333RR 91
92 Case 546,222,333RR What size is the LA? a) Normal b) Mildly enlarged c) Moderately big d) Severely enlarged 92
93 Case 546,222,333RR What size is the LA? LA Vol = 89.6 ml a) Normal b) Mildly enlarged c) Moderately big d) Severely enlarged 93
94 Case 546,222,333RR What size is the LA? LA Vol = 89.6 ml a) Normal b) Mildly enlarged c) Moderately big d) Severely enlarged 94
95 Case 546,222,333RR 95
96 Case 546,222,333RR 96
97 Case 546,222,333RR What do you think about these Doppler tracings? 97
98 Case 546,222,333RR What do you think about these Doppler tracings? 98
99 Grading MR Qualitative/Supportive Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitative Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
100 Specific Signs Mild Small central jet <4 cm 2 or <20% of LA Vena contracta width <0.3cm No or minimal flow convergence Moderate Signs of MR > Mild but no criteria for severe MR Severe Vena contracta width >0.7cm Large flow convergence Systolic reversal in pulmonary veins Prominent flail MV leaflet of ruptured papillary muscle Zoghbi, et. al. JASE 2003
101 Supportive Signs Mild Systolic dominant flow in pulmonary veins A-wave dominant mitral inflow Soft density, parabolic CW Doppler MR signal Normal LV size Moderate Intermediate signs/findings Severe Dense, triangular CW Doppler MR jet (early peaking) E-wave dominant mitral inflow (E > 1.2 m/s) Enlarged LV Enlarged LA Zoghbi, et. al. JASE 2003
102 Regurgitant Fraction % RF% = SV (Valve) SV (Systemic) / SV (Valve) MA ann 3 cm VTI 18.5 cm MA SV = D 2 x.785 x VTI MA SV = 9 x.785 x 18.5 MA SV = ml LVOT SV = D 2 x.785 x VTI
103 Regurgitant Fraction % RF% = SV (Valve) SV (Systemic) / SV (Valve) VTI 13.1 cm LVOT 2.3 cm MA SV = D 2 x.785 x VTI MA SV = 9 x.785 x 18.5 MA SV = 130 ml LVOT SV = D 2 x.785 x VTI LVOT SV = 5.3 x.785 x 13.1 LVOT SV = 54.5 ml RF% = MA SV LV SV / MA SV RF% = / 130 RF% = 58% RVol = = 76 ml
104 Grading MR Qualitative/Supportive Methods Parameters Mild Moderate Severe Color jet area 4cm 2 or 10% LA Variable >10cm 2 or 40% LA CW Faint/parabolic Dense/para Dense/early peak Pvein flow Sys. dominance Sys. Blunting Systolic reversal MV Inflow Dominant A wave Dominant E >1.2 Quantitative Methods Parameters Mild Moderate Severe Vena Contracta < >0.7 Reg. Volume < >60 Reg. Fraction < >50 EROA (cm 2 ) < >0.40 Zoghbi, et. al. JASE 2003
105 Case 546,222,333RR Findings LV size is enlarged, overall fx normal RV size is normal with normal fx LA severely enlarged RA normal MV barlows and prolapsed. Severe regurgitation with an estimated RF of 58% and a Rvol of 76ml. 105
106 Test Time What are the 2 views/images needed for PISA? a) Subcostal and parasternal b) Zoom color 4 chamber and MR cw Doppler c) Parasternal and color M-Mode d) Zoom color 4 chamber and MR cw Doppler
107 Test Time What are the 2 views/images needed for PISA? a) Subcostal and parasternal b) Zoom color 4 chamber and MR cw Doppler c) Parasternal and color M-Mode d) Zoom color 4 chamber and MR cw Doppler
108 Test Time What 4 #/measurements do you need for PISA? a) Baseline shift, lvot vel, lvot TVI, prox flow convergence b) Baseline shift, pulm vein flow, lvot TVI, prox flow convergence c) Baseline shift, MR vel, MR TVI, prox flow convergence d) Lvot diam, lvot vel, lvot TVI, prox flow convergence
109 Test Time What 4 #/measurements do you need for PISA? a) Baseline shift, lvot vel, lvot TVI, prox flow convergence b) Baseline shift, pulm vein flow, lvot TVI, prox flow convergence c) Baseline shift, MR vel, MR TVI, prox flow convergence d) Lvot diam, lvot vel, lvot TVI, prox flow convergence
110 Test Time Which of the following best describes the vena contracta? a) The vena contracta is too hard to do on a daily basis to accurately define MR b) The vena contracta is relatively simple and accurate for identifying mild and severe MR c) The vena contracta is a vasospasm in the descending vein of marshal and not related to MR d) The vena contracta is only used for PISA
111 Test Time Which of the following best describes the vena contracta? a) The vena contracta is too hard to do on a daily basis to accurately define MR b) The vena contracta is relatively simple and accurate for identifying mild and severe MR c) The vena contracta is a vasospasm in the descending vein of marshal and not related to MR d) The vena contracta is only used for PISA
112 Pearls and Pitfalls Practice, Practice, Practice Are you really good at something you only do every now and then? Specific signs in conjunction with the supportive signs renders a > 90% specificity Nyquist limit must be greater than 54cm/s The process of grading MR should be comprehensive, using clues and and measurements by Doppler echocardiography
113 Thank you!
114 Texas Medical Center 5 million pt s Pre-stress test 114
115 115
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