ECHO- Mitral Regurgitation

Question 1

Differentiate Primary vs Secondary Mitral Valve disease

Answer 1

see pic

Question 2

Carpentier Classification for Mitral Regurgitation

Answer 2

Type I - normal leaflet motion and position
- Primary: Leaflet perforation, cleft
- Secondary: Atrial MR, Nonischemic Cardiomyopathy

Type II - excessive leaflet motion - MVP

Type IIIa - restricted leaflet motion in systole and diastole - RHD, mitral annular calcification,, Drug induced MR

Type IIIb - Restricted leaflet motion in systole - Ischemic Cardiomyopathy

Question 2

Examples of type I MR

Answer 2

• annular dilatation, perforation and cleft/indentation of a leaflet.
• endocarditis and iatrogenic MR

Question 2

two classic subtypes of Type II MR?

Answer 2

MVP and leaflet flail with ruptured chordae.

Question 3

example of Carpentier type I MR

Answer 3

Primary: leaflet perforation

Secondary: function- annular dilatation

Question 4

Example of Carpentier type II MR

Answer 4

Prolapse /flail
- Barlow’s Syndrome - multi scallop prolapse

• fibroelastic deficiency - posterior MV leaflet prolapse

Question 5

What is SAM-mediated MR

Answer 5

• mid to late-systolic timing (matches obstruction
• typically posteriorly directed
• Dynamic: varies with outflow obstruction

Question 6

Valve hemodynamics for severe MR

Answer 6

• Central jet MR >40% LA or holosystolic eccentric jet MR
• vena contracta ≥ 0.7cm
• Regurgitant volume ≥60ml
• Regurgitant fraction ≥50%
• effective regurgitant orifice ≥ 0.4cm2
  angiographic grade 3-4+

Question 7

in Staging of MR, stage is asymptomatic severe MR. what is the difference between C1 and C2 (in PRIMARY MR)

Answer 7

C1 - LVEF >60% and LVESD <40
C2 - LVEF ≤ 60% and LVSED ≥40

Question 8

Why classifying MR (Carpentier) is important?

Answer 8

guide for management

Question 9

Class I Indication for surgery for PRIMARY MR? (AHA and ESC)

Answer 9

• symptomatic severe MR regardless of LV systolic function
• mitral valve repair is preferred over replacement when the anatomic cause of MR is degenerative, if a successful and durable repair is possible
• for asymptomatic severe MR with LV systolic dysfunction (LVEF ≤60%, LVSED ≥40mm - Stage C2)

***for stage C1 - Class 2a

***repair of MV for RHD with severe MR - class 2b only

Question 10

Specific Criteria for CHRONIC severe MR

Answer 10

• Flail leaflet
• Vena contracta of 0.7cm
• PISA radius ≥ 1.0cm at nyquist 30-40 cm/s
• Central large jet > 50% of LA area
• Pulmonary Vein Systolic flow reversal
• Enlarged LV with normal function

***≥4 criteria definitely severe

Question 11

Specific Criteria for CHRONIC Mild MR

Answer 11

• Small, narrow central jet
• Vena contracta ≤0.3cm
  -PISA radius ≤0.3 cm at nyquist 30-40 cm/s
• Mitral A wave dominant inflow
• soft or incomplete jet by CWD
• Normal LV and LA size

***≥4 criteria definitely mild

Question 12

for chronic severe MR, what is the expected mitral inflow pattern?

Answer 12

E wave >1.2 m/s (high E/A ratio) suggests severe MR or restrictive filling

*** A dominant pattern is suggestive of MILD MR

Question 12

Echo integrative approach for assessment for MR

Answer 12

see pic

Question 12

for chronic severe MR, what is the expected pulmonary vein doppler findings?

Answer 12

PV systolic reversal

Question 13

for chronic severe MR, what is the expected CWD?

Answer 13

see pic

*** mid to late systolic MR in MVP or early systolic in secondary MR are considered as non-severe
(in short, NON-HOLOSYSTOLIC JET suggests less severe MR)

Question 13

Formula for Effective regurgitant orifice

Answer 13

see pic

***use peak velocity

***measure PISA in mid-late systole, close to the peak of T wave

Question 14

Quantitative doppler in MR: regurgitant volume

Answer 14

see pic

mitral flow/stroke volume
= mitral VTI x mitral annulus area

Aortic flow/stroke volume
= LVOT VTI x aortic annulus area

Question 15

Quantitative doppler in MR: regurgitant volume

Answer 15

see pic

mitral flow/stroke volume
= mitral VTI x mitral annulus area

Aortic flow/stroke volume
= LVOT VTI x aortic annulus area

Question 16

Quantitative doppler in MR: Effective orifice orifice

Answer 16

see pic

Question 17

Class 2a indication for Chronic Secondary MR

Answer 17

• severe MR ( C and D) undergoing CABG
• chronic severe secondary MR related to LVEF <50% who have persistent symptoms while on optimal GDMT for HF (stage D), TEER is reasonable with favorable anatomy (LVEF 20-50%, LVESD ≤70mm and PASP ≤70mmHg)

***if with unfavorable mitral anatomy, MV surgery is Class 2b

Question 18

hemodynamics with ACUTE severe MR

Answer 18

• reduction of forward SV
• slight reduction in ESV
• increase in EDV
• normal or reduced LA compliance