MR echo case N.Koutsogiannis Department of Cardiology University Hospital Of Patras
Case A 35 years old male came to the echo lab for a third opinion for his valvulopathy. He reports a long standing MR and fatigue during the last two years. He had already scheduled surgery for his valvulopathy based on the opinion of his physician and a second opinion from an experienced hospital doctor.
His Valve
His MR
Questions 1) What is wrong with his valve? 2) Is his MR severe? 3) Does he needs surgery to correct it?
A systematic approach is the key for every valvulopathy Look at the Valve first!! (Aetiology, lesions, mechanism) Define the severity Define the consequences on cardiac champers and pulmonary circulation Explain the symptoms of the patient
Prolapse Flail leaflet Rheumatic Look at the valve first!! (Aetiology,lesions, mechanism) Functional Annular calcification Endocarditis SAM Mitral Cleft
Carpentier s Functional Classification Type I Normal leaflet mobility Φυσιολογική κινητικότητα των γλωχίνων Annular dilatation (DCM, Ischemic CMR, Chronic AF) Leaflet perforation (endocarditis) Congenital abnormalities Type II Excessive leaflet mobility Αυξημένη κινητικότητα των γλωχίνων Leaflet prolapse (degenerative) Flail leaflet (degenerative, endocarditis,ruptured PM in MI) Type III Restricted leaflet mobility Περιορισμένη κίνηση των γλωχίνων Both in diastole and systole (Rheumatic, radiation) In systole (DCM, Ischemic CMP) ΙΙΙα IIIb
Is it the Valve or the Ventricle? Increased EF = Organic MR Reduced EF = Functional MR Treat the Valve! Treat the Ventricle!
Based on Carpentier s functional classification what is the mechanism and the aetiology of MR in the case? 1) Normal leaflet mobility-annular dilatation 2) Excessive leaflet mobility-degenerative mitral disease 3) Excessive leaflet mobility-endocarditis 4) Restricted leaflet mobility-functional MR
The case Excessive leaflet mobility with normal EF Degenerative Valve disease
Degenerative mitral valve disease 2% of the population - 60-70% of mitral valve surgery Age > 60 years short history of MR due to rupture of chordae ( typical of P2 segment) normal size of normal or thin leaflets normal annular size Age < 60 years long history of MR due to chordal elongation and leaflet prolapse large thick leaflets large annular size
Phenotype presentation of degenerative valve disease in the patient Barlow s disease Excessive leaflet tissue (floppy valve) Valve prolapse Annular dilatation Large posterior leaflet
Parasternal long axis Classical view Medium portion A2 P2 segments Tilting toward aorta Anterolateral portion A1 P1 segments Tilting toward tricuspid Posteromedial portion A3 P3 segments
TTE 4-Champer View Tilting upward Anterolateral portion A1 P1 segments Classical view Medium portion A2 P2 segments Tilting downward Posteromedial portion A3 P3 segments
Short axis view Systole: Localization of prolapse by localization of the origin of the regurgitant jet
Questions Degenerative Barlow s disease with most affected the anterolateral segment(s) 1) What is wrong with his valve? 2) Is his MR severe? 3) Does he needs surgery to correct it?
Moderate MR can be tolerated indefinitely Progression of organic MR is variable and determined by progression of lesions (most often a new flail leaflet) and/or annular dilatation
Severity of MR Is the valve flail? Case A flail valve If you see a flail segment the MR is SEVERE
Color Flow imaging Beware of the PISA Look upstream for PISA with normal settings.if you see it quantify the degree of MR
If the PISA dosen t seems HOLOSYTOLIC do a color M-mode Functional MR Degenerative MR Variation of ERO (and PISA) during systole in the different forms of MR Rheumatic MR
If we measure the end-systolic PISA in the case the ERO is 57mm² witch indicates SEVERE MR
Based on end-systolic PISA calculation for ERO,the MR in the case is: 1) Severe (because ERO > 40mm²) 2) Moderate (because the PISA is end-systolic) 3) We need also the time duration of end-systolic PISA to conclude about MR severity 4) We can not use PISA for the calculation of ERO
When PISA is not holosystolic:
A peak E velocity > 1,5 m/sec suggests severe MR (in the absense of MS) A dominant A wave basically excludes severe MR Case E wave 1,1 m/sec No systolic reversal in pulmonary veins PW Doppler Systolic reversal in pulmonary veins in severe MR
Mitral to aortic Time velocity integral (TVI) TVI ratio = Mitral TVI / Aortic TVI TVI ratio > 1,4 in severe MR TVI ratio < 1 in mild MR Case ratio = 1
Doppler Volumetric method (when pisa-method of vena contracta is not applicable ) Calculation of LVOT stroke volume LVOT SV = LVOT ² X 0,785 X LVOT TVI Case RegVolume = 56ml ERO=30mm² Calculation of mitral inflow stroke volume MV SV = Mitral annulus ² X 0,785 X MV TVI Regurgitant Volume = MV SV LVOT SV EROA = Reg Vol / MR TVI Time consuming multiple calculations (and possible errors)
CW Doppler In severe MR Dense MR signal Early peak Triangular contour LOW MAX VELOCITY High Max Velocity means LOW LEFT ATRIAL and WEDGE PRESSURES
Consequences LVEF = 68% ESD = 38mm LV dilatation and systolic dysfunction RVSP =40mmHg Pulmonary hypertension
Questions Degenerative Barlow s disease with most affected the anterolateral segment(s) 1) What is wrong with his valve? 2) Is his MR severe? No it is Moderate 3) Does he needs surgery to correct it?
50% of patients with SEVERE organic MR will need surgery in the next 8 years Moderate Severe How many years before the clock start clocking? But the patient is here Rosenhek Circulation 2006
The patient visited the surgery center and after a Transesophageal echo the Surgeon told him that his condition is severe and he should repair the valve
Don t ask the butcher these questions: Is it good to eat meat? Have you got good meat? Should I buy now?