MR/MS Flashcards
Describe the key features of rheumatic MS?
-
Commisural Fusion
- leaflet: thick at tips
- Chordae: thick/retracted
- Short posterior leaflet
- Calcification: late
- MS > MR
Describe the key features of degenerative MS?
-
Annular calcification
- Leaflet: thick at base
- Associated with atherosclerosis, HTN, AS
- MR > MS
What are the methods for determining MVA in MS?
- Planimetry
- Continuity equation
- PHT
- PISA
What is the formula for calculating MVA using PHT?
MVA = 220 / PHT
Define PHT
time required for the gradient between the LA and the LV to fall to one half of its initial value
What PHT correlates with severe MS?
- 150 ms
- 220/150 = 1.46 cm2
- < 1.5 cm2 –> severe MS
Under what conditions is PHT assessment of MS inaccurate?
- AR (short PHT)
- will rapidly increase the LV diastolic pressure and shorten PHT –> underestimation of MS (overestimation of MVA)
- Sudden changes in LA-LV compliance
- immediately following BMVP
- Diastolic dysfunction
- increased LV filling pressure
- ASD
****less accurate in calcific MS
What group of patients should PHT assessment of MS be avoided?
Elderly patients with calcific, degnerative MS
How do you calculate MVA using the continuity equation?
MVA = LVOTVTI x LVOTarea / MVVTI
- MVA = LVOT D2 x 0.785 x ( LVOTVTI / MVVTI )
What situations make use of the continuity equation unreliable in assessment of MS?
- MR
- AR
- A-Fib
What is one change in the echo settings that is useful when calculating PISA?
shift baseline (aliasing velocity) in the direction of the flow
What is the formula for calculating MVA using PISA?
MVA = 6.28 x r2 x Vr / Peak Vmax x angle/180
- r = radius of convergence hemisphere
- Vr = aliasing velocity c/s
- Vmax = peak CWD velocity of mitral inflow c/s
- angle = opening angle of mitral leaflets relative to flow direction
What are the Class I ASE recommendations for MVA?
- Planimetry
- PHT
What are the Class 2 ASE recommendations for MVA?
- PISA
- Continuity equation
What is the best/most reproducible method for assessing MVA in rheumatic MS?
3D planimetry
What is the best/most reproducible method for assessing MVA in degenerative MS?
Continuity equation > 3D planimetry
What are the levels of severity for MS: MVA
- Progressive > 1.5 cm2
- Severe 1.0-1.5 cm2
- Very severe < 1.0 cm2
What are the levels of severity for MS: MG
- Progressive < 5 mmHg
- Severe 5-10 mmHg
- Very severe > 10 mmHg
What are the levels of severity for MS: PHT
- Severe > 150
- Very Severe > 220
What are the levels of severity for MS: PASP
- Severe > 30 (50) mmHg
- Very severe > 30 (70) mmHg
What factors should be considered in evaluation for balloon valvuloplasty of MS?
- Valve pliable:
- commissural calcification
- Wilkins/Abascal Score < 8
- Mobility (1-4)
- Thickening (1-4)
- Calcification (1-4)
- Sub-valvular thickening (1-4)
- MR < 2+
- No thrombus in LAA
What are the indications for PMBV?
- Symptoms
- Severe MS
- Feasibile valvuloplasty
- Asymptomatic + Pulmonary hypertension
What are unusual (acquired) etiologies of MS?
- Lupus
- Carcinoid
- Drugs
- Radiation
- Infiltrative (Maroteaux-Lamy)
- Mucopolysaccharidosis Type IV
- Iatrogenic
What are unusual (congenital) etiologies of MS?
- Luttembacher (ASD + MS)
- Shone (AS + MS + Coarctation)
- Supravalvular membrane
What is the formula to calculate PHT from deceleration time (DT)?
PHT = 0.29 x Deceleration Time (DT)
What is vena contracta?
- narrowest width of the regurgitant jet, measured using color doppler flow imaging
- both proximal acceleration region and the distal jet expansion should be seen to ensure the narrowest segment of the jet is measured
- < 0.3 cm = mild MR
- > 0.7 cm = severe MR
What are the four components of the mitral valve?
- mitral leaflets (anterior and posterior)
- mitral annulus
- subvalvular structure (including both chordae tendinae and papillary muscles)
- LV wall
What are the categories of MR?
- Primary (predominantly degenerative)
- lesions of the mitral leaflets and subvalvular apparatus
- Secondary (functional)
- annular or LV dilation
What are causes of primary MR?
- Myxomatous valve disease
- prolapse
- Barlow’s syndrome
- Elongated/Ruptured/Flail Chordae
- Degenerative diseases:
- Thickened/calcified MV apparatus with restricted mobility and poor coaptation
- Ruptured chordae/flail valve
- Infectious etiology/endocarditis
- Vegetations
- Perforation
- Leaflet aneurysm
- Abscess
- Inflammatory
- Rheumatic
- Collagen vascular diseases
- Radiation
- Drugs
- Congenital
- Cleft valve
- Parachute mitral valve
- Blood cysts
What is the most common cause of MR?
What is the pathophysiology that leads to MR?
- myxomatous degeneration
- localized, fibroelastic deficiency due to abnormalities in connective tissue –> results in chordal thinning and elongation and subsequent MV prolapse
What occurs in Barlows disease?
MR secondary to diffuse, myxoid degeneration of the MV –> excess tissue in multiple valve segments, including leaflets, chordae, and annular dilation
**myoxoid degneration: degenerative process in which the connective tissues are replaced by a gelatinous or mucoid substance.
What is the mechanism of MR in secondary or functional MR?
LV dilatation and/or dysfunction –> mitral annular dilation and impaired leaflet mobility or tethering
How does the Carepntier classificaiton system classify MR types?
- focus on differences in leaflet mobility as the cause of leaflet malcoaptation and MR
- 3 types
Define the Carpentier classification - Type I
- Dysfunction –> normal leaflet motion (poor leaflet coptation)
- Lesions –> isolated annular dilation + leaflet perforation / tear
-
Etiology
- Dilated cardiomyopathy
- Ischemic cardiomyopathy
- Congenital
- Endocarditis
Define the Carpentier classification - Type II
- Dysfunction –> excessive leaflet mobility (leaflet prolapse) above the mitral annulus plane
-
Lesions –>
- elongation / rupture chordae
- elongation / rupture of papillary muscle
-
Etiology
- Degenerative valve disease
- fibroelastic deficiency
- Barlow’s disease
- Marfan’s disease
- Ischemic Cardiomyopathy
- Endocarditis
- Ehler-Danlos syndrome
- Trauma
- Degenerative valve disease
Define the Carpentier classification - Type IIIa
- Dysfunction –> restricted leaflet motions (diastole and systole - opening)
-
Lesions –>
- leaflet calcification / thickening / retraction
- chordal fusion / thickening / retraction
- commisural fusion
-
Etiology –>
- Carcinoid heart disease
- Hypereosinophilic syndrome
- Radiation
- Rheumatic heart disease
- Mucopolysaccharidosis
- SLE
What are the best views for evaluating vena contracta (in MR) on TTE and TEE?
- TTE: parasternal long-axis view
- TEE: long-axis view at 120
In what other clinical situation is Sgarbossa criteria utilized for the diagnosis of MI?
RV pacing (also demonstrates LBBB on EKG)
What are the Doppler parameters used in the assessment of MR severity?
- Color flow jet area
- Mitral inflow - PW
- Jet density - CW
- Jet contour - CW
- Pulmonary vein flow
What does the image show?
What is the treatment of choice?
- SAM of the mitral valve - consistent with LVOTO
- Nondihydropyridine CCB’s (Verapamil) or BB’s
- Afterload reducing agents (Lisinopril and Amlodipine) and diuretics are likely to exacerbate the obstruction
What is the pathophysiology of hemoptysis in MS cases?
elevated postcapillary pulmonary pressure
Describe MV leaflet scallops visualized in A2C view?
Describe MV leaflet scallops visualized in A4C view?
What are causes of mitral regurgitation secondary to systolic anterior motion?
- hypertrophic cardiomyopathy
- hypertensive heart disease with prominent basal septum
- acute anterior infarcts with hyperdynamic compensatory function
- apical ballooning syndrome with a hyperdynamic base
What are the components of the Wilkins score for MS/PMBV?
- Leaflet/valvular
- thickening
- mobility
- calcificaiton
- Subvalvular thickening
What is the diagnosis?
- Flail P2 scallop
*
What is the formula for PHT in MS, utilizing deceleration time?
PHT = 0.29 x DT
MVA = 220/PHT
Describe MV leaflet scallops visualized in PLAX view?
What is the mechanism of successful mitral valuloplasty?
commisural separation
Describe scallop anatomy
Describe MV leaflet scallops visualized in parasternal SAX view?
What is one major contraindication to percutaneous MitraClip repair?
leaflet calcification at the device landing zone (in this case A2 and P2
Describe scallop anatomy
Describe MV leaflet scallops visualized in these views:
- PLAX
- PSAX
- AP4
- AP2