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Echo 2 > Module 7 : Mitral Regurgitation > Flashcards

Module 7 : Mitral Regurgitation Flashcards

1
Q

mitral regurgitation defintion

A
  • a backward flow of blood from the LV to the LA during systole
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2
Q

what time does MR occur

A
  • occurs during systole through both isovolumic periods
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3
Q

annulus pathology causes of MR

A
  • MAC

- dilation og LV from any cause

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4
Q

valve pathology causes of MR

A
  • rheumatic heart disease
  • MVP
  • infective endocarditis
  • trauma
  • cleft MC
  • connective tissue disorders
  • left side myxoma
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5
Q

chordae tendinea pathology causes of MR

A
  • rupture
  • trauma
  • infective endocarditis
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6
Q

papillary muscles pathology causes of MR

A
  • trauma

- CAD

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7
Q

left ventricle (myocardium) pathology causes of MR

A
  • CAD

- cardiomyopathy

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8
Q

prosthetic valve pathology causes of MR

A
  • prosthetic malfunction
  • thrombosis
  • ## paravalvular leak
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9
Q

etiology of MR - leaflet abnormalities

A
  • the leaflets need to be in perfect apposition to each other in order to stop any regurge
  • leaflets may be malformed , term or regraded which would not allow for perfect apposition
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10
Q

etiology of MR - chordae tendinae abnormalities

A
  • the chords may become elongated
  • misdeveloped
  • or ruptured
  • then can become thickened and matted with inflammation
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11
Q

etiology of MR - mitral valve prolapse

A
  • includes similar diseases as Barlows disease, fibroelastic deficiency and marfans syndrome
  • in MVP the fibroma layer is thinner and spongiosa layer is thicker
  • makes the leaflet bend with much more pressure when faced with a high pressure gradient during systole
  • it leads to one or both leaflets to buckle/ prolapse into LA during systole
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12
Q

mitral valve prolapse characteristics

A
  • has a genetic determinism
  • systolic bowing of the belly of the mV leaflets in systole into the LA > 2mm
  • prone to choral rupture, bacterial endocarditis and arrhythmias
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13
Q

prevalence of MVP

A
  • 2-5% of pop
  • tall slender build
  • sometimes with pectus excavatum
  • marfans or Euler danlos
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14
Q

etiology of MR - papillary muscle

A
  • contraction of the LV contracts the pap muscle
  • contraction pulls down on the valve during systole to prevent prolapse
  • misalignment may occur when the LV is dilated or overly muscled as in hypertrophic cardiomyopathy
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15
Q

what is IPMD

A
  • inter-papillary muscle distance

+ increase distance = MR

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16
Q

etiology of MR - ischemic MR

A
  • abnormality at the LV myocardium level
  • when artery leading to pap muscle becomes blocked the wall is also affected
  • pap muscle moves away from valve plane as the LV dilates
  • this tethers the chordae and leads to ischemic MR
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17
Q

4 symptoms of significant MR

A
  • DYSPNEA = SOBOE no associated with mild or moderate unless LV dysfunction or arrhythmias are involved
  • palpitations = extra blood moving through the heart can increase stroke volume in normal sinus rhythm
  • arrhythmias
  • CHF = due to back up into lungs
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18
Q

signs and symptoms of MR

A 
- symptoms similar to CHF
  \+ dyspnea 
  \+ fatigue
  \+ low exercise 
- signs
  \+ xray = cardio megaly, palm venous congestion
  \+ LVH on echo and ECG
  \+ murmur 
  \+ arrhythmia like AFIB
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19
Q

pathophysiology of acute MR

A
  • as a result of large acute MI, trauma, torn leaflet or chordae or pap
  • the MR fills a normal sized LA because it has not had time to compensate by dilation
  • leads to markedly increased in LA pressure, acute pulmonary edema and y hypertension ensue
  • the EF is usually increased, the EDV increases due to MR and arterial BP crops because more blood goes back to the LA than AO
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20
Q

what heart rate is usually seen with acute MR

A
  • tachycardia
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21
Q

what does MR lead to in regards to volume

A
  • significant MR causes volume overload
  • MS causes pressure overload to the LA
  • both LV and LA have to try to overcome volume overload from MR
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22
Q

what adaptations occur in the LV when volume overload occurs

A
  • eccentric hypertrophy/ remodelling of the muscle fibres (dilatation with little change in LV thickness
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23
Q

what adaptations occur in the LA when volume overload occurs

A
  • dilation&raquo_space; PV congestion&raquo_space; afib&raquo_space; CHF
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24
Q

pathophysiology of chronic MR

A
  • the heart has had time to develop compensatory mechanism
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25
Q

chronic compensated MR

A
  • increased LAP pleads to the LA dilating
  • the dilated LA can accommodate the extra volume at a lower pressure
  • this will also increase total forward stroke volume
  • LVEF remains increased until many years later when it fails and decreases
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26
Q

chronic decompensated MR

A
  • prolonged increased LV volume damages the muscle fibres in the LV when it fails and ef starts to drop
  • LVESV increases in the case
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27
Q

chronic decompensated MR leads to what 2 thing s

A
  • decreased forward stroke volume

- increased LVEDP and LAP

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28
Q

is EF a good marker of systolic function with chronic MR

A
  • not a good marker of systolic function because 30-50% of the stoke volume is actually going back into the LA
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29
Q

5 roles of echo in MR assessment

A
  • determine etiology of the lesion
  • assess LA size
  • assess LV size and systolic function
  • estimate severity of regurgitation
  • estimate RVSP or other pulmonary pressures
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30
Q

5 things to look for when assessing MV morphology

A
  • thickened, flail or perforated leaflets
  • annulus = MAC ( mitral annulus calcification)
  • chordal structures = thickened, tethered
  • pap structures stretched (post MI?)
  • LV dilates = prohibiting computation
    + tenting
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31
Q

how far does the leaflet have to buckle for MVP

A

> /= 2mm toward the LA said of annular plane

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32
Q

M mode MVP

A
  • posterior displacement o the prolapsing leaflets will occur in systole
33
Q

LA myxoma with MR/ MS

A
  • mass does physical damage by smashing into LV many times a day
34
Q

tented MV with dilated LV&raquo_space; ischemic MR

A
  • occurs when the LV has dilated for whatever reason (ischemic heart disease)
  • the MV has an increased coaptation depth
  • can be measured
  • caused by pap muscles being pulled away from the MV as the LV expands
35
Q

what is coaptiaton depth

A
  • depth form the MV leaflet tips to the MV annulus
36
Q

how is the amount of regurge put into context

A
  • by relating the jet area to the LA size
37
Q

what are two ways to indirectly account for acuity

A
  • small LA + large MR = more sever and acute

- large LA + larger MR = less severe and chronic

38
Q

what type of assessment does color doppler give us

A
  • qualitative assessment

- indirect measure of MR severity

39
Q

why is color doppler considered an indirect assessment

A
  • many variables act on the color doppler jet

- preload afterload, jet direction, number of jets affect assessment

40
Q

3 methods of indirect grading of MR

A
  • color Doppler MR jet area to LA area %
  • vena contracta
  • PISA radius
41
Q

what is entrainment

A
  • blood already sitting in the LA gets displaced by the incoming jet
42
Q

with what kind of jet does entrainment usually occur

A
  • central more than eccentric jets
43
Q

what does the doppler color look like with entrainment

A
  • represented by non aliased colours like darker blue
44
Q

what does entrainment lead to

A
  • overestimation of MR severity
45
Q

how do you calculate MR area % of LA area

A
  • trace normal LA area and MR jet area

- MR jet / LA area x 100

46
Q

vena contracta defintion

A
  • the narrowest part of the jet downstream form the narrowed orifice
47
Q

what does the oven contracta provide info on

A
  • estimated effective orifice size (size of the hole)
48
Q

where must the vena contracta be measured

A
  • must be measured parallel to the US bema to maximize axial resolution
  • which is best in PLAX
49
Q

PISA radius (flow convergence zone)

A
  • as flow converges roars a narrowed orific e it asccelreates in a laminar manner forming a flow convergence zone
  • this zone is comprimased by a series os concentric hemispheric shells of the same velocity
  • as the flow advances toward the orifice the diameter of each shell decreases was the velocity within each shell increases
  • measuring the radius of the convergence zone can provide an indirect sign as to the severity of the leak
50
Q

is a larger or small convergence zone more indicative of a severe regurge

A
  • a large flow convergence zone
51
Q

what should the color baseline be shifted to and why

A
  • should be shifter downward to 30-40cm/s to enhance the hemispheric shells
52
Q

how to measure PISA radius

A
  • measure the vertical distance from the leaflets to the top of the convergence zone or red blue interface
53
Q

jet width ratio with mild MR

A
  • small central jet

- < 4cm^2 or <20% of LA area

54
Q

jet width ratio with severe MR

A
  • large central jet
  • > 8-10 cm^2 or > 40% of LA area
  • variable size wall impinging on jet swirling into LA
55
Q

vena contracta width (cm) with mild MR

A
  • < 0.3
56
Q

vena contract width with moderate MR

A
  • 0.3-0.69
57
Q

vena cocntracta width with severe MR

A
  • > /= 0.7
58
Q

PISA radius with mild MR

A
  • very small or no convergence sone

- < 0.4 cm central jet

59
Q

PISA radius with severe MR

A

large flow convergence

- >/= 0.9

60
Q

4 main methods to indirectly assess MR with spectral

A
  • transmitral flow
  • pulmonary venous flow
  • intensity of MR signal
  • colour of MR jet
61
Q

transmitral flow velocity - principle

A
  • the higher the more MR exists due to increased preload

- e wave velocity of > 1.2m/s is supportive sign of MR

62
Q

pulmonary venous systolic flow - principle

A
  • systolic flow reversal in one or more pulmonary veins is specific for severe MR
63
Q

CW signal intensity - principle

A
  • the brighter the CW signal of MR the more significant the leak
64
Q

CW of MR jet from MVP - timing principle

A
  • MR jet seen in mid to late systole only

- regular MR jet is holosystolic

65
Q

CW MR jet contour - principle

A
  • the CW MR jet reflects the pressure difference between the LV and LA during systole
  • in mild MR = the pressure gradient between LV and LA remains fairly high throughout systole
  • in severe MR the volume of blood leaking back into the LA raises the LA pressure dramatically thus lowering the pressure gradient between the 2 chambers
  • this is why severe MR takes on a more triangular parabolic shape
66
Q

3 main quantitative ways of assessing MR

A
  • regurgitant volume
  • regurgitant fraction
  • effective regurgitant orifice area (PISA)
67
Q

is regurgitant volume encouraged for use in MR

A
  • not recommended
68
Q

total stroke volume definition

A
  • the amount of blood the left ventricle pumps out on a single beat
  • includes blood ejected into the aorta and backward in to the MV
69
Q

forward stoke volume definition

A
  • the amount of blood that actually passes the AV and enters systemic circulation
70
Q

regurgitant stoke volume

A
  • the amount of blood that back flows across the abnormal valve
71
Q

what 4 things do you need for stroke volume method for MR

A
  • LVOT diamteter
  • LVOT VTI
  • MV diameter
  • MV VTI
72
Q

Pisa method to assess MR - principle

A
  • flow proximal to a narrowed orifice must be equal to flow through it
73
Q

what 3 things are needed to asses MR Pisa method

A
  • pisa radius
  • velocity at radius (which is number that color baseline is lowered too)
  • peak velocity of the MR jet
74
Q

regurgitant volume from Pisa method

A
  • RV = ERO x VTI
75
Q

when should you not use Pisa radius methods

A
  • with eccentric MR jets
76
Q

regurgitant volume with mild MR

A
  • < 30
77
Q

regurgitant volume with severe MR

A
  • > /= 60
78
Q

regurgitant fraction with mild MR

A
  • < 30
79
Q

regurgitant fraction with severe MR

A

> /= 50

Echo 2 (18 decks)

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