Echo Assessment Flashcards
What is the “seagull” sign in ischaemic MR?
- Asymmetric tethering of amvl due to secondary chords
- Creates kink in amvl => poor coaptation
- Concave appearance of amvl
Hypertrophic CM: Aetiology of MR and Mechanism of MR
- Aetiology: dynamic – hypertrophic obstructive cardiomyopathy
- Mechanism: abnormal – systolic anterior motion of amvl (Type IV)
- Note: the mechanism is important – MV repair is NOT indicated as the valve is not causing the MR
What is the definition of mitral valve prolapse (MVP)?
- Primary cause of MR; Carpentier Type II (excessive leaflet motion)
- Abnormal systolic displacement of one or both leaflets into LA due to a disruption or elongation of leaflets, chordae or papillary muscles
Label the MV scallops seen in PSAX?
- Top leaflet = A (anterior)
- Bottom leaflet = P (posterior)
- Left to right = lateral, middle, medial
- A3, A2, A1
- P3, P2, P1
Which MV scallops are seen in PLAX?
A2 and P2
Which MV scallops are seen in PSAX?
All scallops seen
Which MV scallops are seen in AP4?
A3, A2 and P1
Which MV scallops are seen in AP2?
P3, A2 and P1
What is the echo criteria for MVP?
- Billowing of MV leaflets ≥ 2mm above annular plane in long-axis views
- “Hammocking” of the MV
(PLAX or AP3; diagnosis should be made on long axis views unless severe)
What are the common causes of MVP?
- Barlow’s disease
- Fibroelastic deficiency (FED)
- Mitral annular disjunction (MAD)
Barlow’s MVP: Leaflets
- Bulky and billowing
- Cul-de-sac at base of posterior leaflet
- Floppy redundant valve, excessive leaflet tissue
- Fused and matted chords
Barlow’s MVP: Prolapse segments
- Multi-segment prolapse
- Bileaflet MVP common
Barlow’s MVP: Non-prolapse segments
- Billowing of body of both leaflets including non-prolapsing segments
Barlow’s MVP: Annulus
- Always dilated
- Calcification common
Barlow’s MVP: Chordal rupture
Uncommon
Barlow’s MVP: Patient age
Younger (<60 yrs)
FED: Leaflets
- Thin, prolapsing segment may appear bulky
- Thin, almost transparent leaflets
- Chordal thinning, elongation and rupture
FED: Prolapse segments
Single segment prolapse (P2 most common)
FED: Non-prolapse segments
No billowing of non-prolapsing segments
FED: Annulus
Variably dilated (less than Barlow’s)
FED: Chordal rupture
Common
FED: Patient age
Older (> 60yrs)
Barlow’s MVP: Aetiology and Mechanism of MR
Aetiology: primary degenerative MV
Mechanism: abnormal leaflet motion - excessive motion/prolapse (Type II)
FED: Aetiology and Mechanism of MR
Aetiology: primary degenerative MV
Mechanism: abnormal leaflet motion - excessive motion/prolapse (Type II)
MR Jet Direction in Anterior MVP?
- Posterior MR jet
MR Jet Direction in Posterior MVP?
- Anterior MR jet
MR Jet Direction in Bileaflet MVP?
- Central MR jet
What is mitral annular disjunction (MAD)?
Atrial displacement of hingepoint of MV from ventricular myocardium
MAD: Leaflets
- Hypermobility of MV apparatus with systolic curling
- Separation between LA-MV junction and LV attachment
- Paradoxical systolic ↑ in annulus diameter (systolic diameter > diastolic diameter)
MAD: DTI Lateral Annulus
“Pickelhaube” (spike) sign (s’ > 16cm/s)
MAD: Patient Age/Symptoms
- 30-40yrs
- Present with palpitations
MAD: Importance
- Linked with ventricular arrhythmias and sudden cardiac death
What is the “Pickelhaube” Sign?
- Seen in MAD
- Tugging of PM pap. muscle in mid-systole by prolapsing leaflets
- Causes adjacent LV wall to be pulled sharply toward LV apex (s’ spike)
- Optimal location of highest velocity is from APLAX/AP3 at posterolateral annulus
LA Size in Severe (usually primary) Chronic MR
- LA dilatation due to chronic LA volume overload
- Normal LA size virtually excludes severe chronic MR
- LA dilatation occurs in other disease states therefore LA dilatation does not imply severe MR
LV Size in Primary MR
LV dilatation occurs due to chronic LV volume overload
LV Size in Secondary/Functional MR
- MR due to LV dysfunction
- MR further contributes to ↑ LV size
- Progressive LV systolic dysfunction and adverse remodelling => ↑ MR severity
- Degree of LV dilatation not reflective of MR severity
Pathophysiology of PHTN in MR
- Post-capillary PHTN
- Chronic severe MR => compensatory (LV and) LA dilatation => (LV systolic and diastolic dysfunction) => reduced LA compliance and ↑ LAP
- Backward transmission of ↑ LAP can cause secondary PHTN
Surgical Indications for Severe Primary MR
Surgery should be considered in:
- Asymptomatic patients with preserved LV function (LVESD <40mm and LVEF >60%) and AF secondary to MR or PHTN (systolic pulmonary pressure at rest > 50mmHg)
