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6. Echocardiographic principles > MV/MR assessment > Flashcards

MV/MR assessment Flashcards

1
Q

Components of MV apparatus

A

LA wall, mitral annulus, anterior/posterior leaflets, chordae, pap muscle, LV myocardium

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2
Q

Normal shape of MV

A

o Normally saddle shaped ellipse
 Normal area of overlap/apposition = zona coapta
 Some degree of annular dilation tolerated

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3
Q

Cause of MR

A
  • Dysfct/altered anatomy of any component → MR
    o Leaflet flexibility

o Leaflet coaptation/apposition
 Chordae disruption/elongation → inadequate support of closed leaflet in systole → MR
* Severe bowing of leaflet with tip TOWARD LV apex
 Chordae rupture: flail leaflet segment into LA in systole → tip of leaflet AWAY from LV apex

o Annular dilation
 Normally smaller in systole vs diastole
 Annular calcification → ↑ rigidity → impaired systolic contraction → MR

o Papillary muscle orientation
 Ischemia → regional LV dysfct w abnormal contraction of pap muscles → restricted leaflet motion (tenting of valve in systole) → MR
 Papillary muscle rupture → acute severe MR
* Partial disconnection possible

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4
Q

Diseases affecting leaflets

A

CVD
Rheumatic MR
Endocarditis
Marfan syndrome
Infiltrative dz

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5
Q

CVD histo

A

↑ mucopolysaccharides, thickening/disarray of MV leaflets

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6
Q

CVD gross anatomy

A

thick leaflets and chordaes, chordae have ↓ tensile strength and are elongated

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7
Q

Rheumatic MR

A

commissural fusion, chordal fusion shortening of chordae

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8
Q

Endocarditis

A

leaflet destruction, perforation, deformity

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9
Q

Marfan syndrome

A

long, redundant anterior leaflet sagging into LA

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10
Q

Infiltrative dz

A

irregular leaflet thickening, inadequate coaptation

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11
Q

Functional MR

A

2nd to LV dilation and systolic dysfct → normal leaflets/chordae
o Papillary muscle orientation
o Leaflet coaptation

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12
Q

Echo characteristics of degenerative lesions

A

o LV and LA dilation
o Wall and septal hypertrophy and hyperdynamic motion
o ↑ thickness of MV
o Nodularity, prolapse of one of both MV leaflets
 Smooth and small lesions w club-shaped appearance in early states
* Shaggy/irregular on M-mode
* Systolic fluttering of MV on M-mode can happen
 Large and irregular as dz progress
o ↑ systolic function parameters

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13
Q

Mechanism of MR in degenerative dz

A
  • Lesions to valve prevent proper leaflet coaptation and closure
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14
Q

CVD in large breed dogs

A

o Large breed dogs: fewer changes to valve leaflets despite significant regurgitation
 Prolapse can be observed w/o abnormal thickness

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15
Q

Echo characteristics of degenerative lesions: less common

A

o Pericardial effusion → LA rupture
o Lack of hypertrophy
o ↓ systolic function → myocardial failure
o Ruptured chordae tendineae

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16
Q

Anatomy of chordae tendinae

A

o Primary/1st order chordae: attach to tip of leaflets → pap muscles
 Responsible for most of structural integrity
o Secondary, tertiary chordae: attach to midventricular portion of valve leaflets → pap muscles and ventricular wall

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17
Q

Chord rupture most common cause

A

CVD

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18
Q

Features of ruptured chordae tendinae

A

o Severe MR on color flow evaluation of regurgitant jet size
 Usually eccentric jet
 If present w/o LV or LA dilation → suggest acute change
o Most commonly septal leaflet, parietal leaflet less common
o Chaotic MV leaflet motion in systole + diastole
 May bend in LVOT during diastole
 Minor chordal rupture: may be seen in only 1 echo plane
 Major chordal rupture: usually in several echo planes

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19
Q

Pap muscle rupture

A

o Abnormal mass moving in LV → portion of pap muscle attached to chordae tendinae
o Severe mitral prolapse/flail leaflets
o Visualize tip of torn muscle: abnormal appearance

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20
Q

Causes of MV prolapse

A
  • Primary: from intrinsic abnormalities of MV leaflets → CVD
    o Chordal rupture: body of leaflet back in LA
  • Secondary: w/o inherent pathologic valvular abnormalities
    o Hemodynamic causes:
     Volume contraction + ↓LV size
     Myocardial dz → akinetic muscle and abnormal pap muscle fct
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21
Q

When do we see prolapse?

A
  • Can be seen w/o insufficiency.
    o Genetically influenced in CKCS, Spaniels, Dachshunds
    o Prolapse can happen as early as 3y/o
     No c/s or murmur
     High incidence of insufficiency later in life
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22
Q

Features on echo of MV prolapse

A

o Both leaflets buckle back toward LA in systole
o MV annulus: base of AoV → point of attachment of parietal MV leaflet
o Avoid apical 4 chamber view for dx
 Normal curving of anterior leaflet in LA
 Posterior leaflet buckling always abnormal in any plane

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23
Q

LV assessment for MV disease

A

LV size
LV fct

24
Q

LV size evaluation

A
  • Hemodynamically significant chronic MR result in LV and LA dilation
    o Degree of LAE = indicator of HF stage
     Correlate with severity of MR
     LA/Ao >1.7 = poor px indicator for survival
     Eq: 4 chamber LAX view → LAD > 13.5cm
    o Significant insufficiency w/o LAE suggest acute process (chordal rupture)
    o LV remodeling: ↑sphericity and hyperkinetic
25
Q

Accuracy of LA/Ao w/ CVD progression

A
  • As MR ↑, LA/Ao may not accurately reflect ↑ LA size
    o Ao size will ↓ with ↓ forward flow or ↓ circulating blood volume
26
Q

LA rupture

A

o Inter atrial septum → ASD
o Free wall → pericardial effusion
 Presence of thrombus in effusion or LA = confirm atrial splitting
* Linear layer of hyperechoic material that conform to the shape of the heart
 MV motion can reflect ↑ LV diastolic pressures
* Delayed closure of MV after atrial contraction
* B bump (LVP >30mmHg)
 ↑ septal motion: affected to greater extent by volume changes in RV and LV

27
Q

Mechanisms of LV function w/ CVD

A

o LV systolic contraction → mvt of blood to low pressure LA → ↓ needs for LVH compensation for MR volume overload
 Thin LV walls = compliant → allow ↑ ventricular filling and ↑ SV
* MR hearts: lowest mass to volume ratio
o CHF is 2nd to severe MR and volume overload (not myocardial failure)

28
Q

FS% with MR

A

measure of myocardial motion
o Should be elevated with MR → ↑ preload, ↓ afterload, ↑ contractility
 Normal contractility = normal LV end systolic dimension event if volume overload
 FS > normal with normal myocardial contractility
 FS in normal range (33-45%) with impaired contractility
 ↓ FS = myocardial failure

29
Q

Systolic index equation

A

Systolic index = (End systolic volume)/BSA

30
Q

Myocardial failure indices in dogs w/ MR

A
  • FS, end systolic dimensions, systolic index can detect myocardial failure in dogs w MR

o End systolic dimensions and systolic index = not affected by preload
 Normal systolic index in dogs <30ml/m2
* Severe myocardial failure >100ml/m2
* Moderate reduction in contractility = 70-100ml/m2 (mean 73)
* Mild myocardial impairment = 34-70 ml/m2 (52±6)
o Expected end systolic dimensions (ESDe): based on allometric ratio
 Ratio of ESD/ESDe >1.13 in large breed dogs, >0.89 in small breeds
o Large breed tend to develop myocardial failure more frequently (vs small breeds)
 Lack of adequate hypertrophy 2nd to volume overload → ↓ myocardial fct

  • LA dimension normalized to BW: 76%sens, 81%spe to identify myocardial failure for LA size >1.55
31
Q

Wall stress equation and changes w/ MR

A

ratio of radius to wall thickness
o MR → eccentric hypertrophy → normal to high wall stress (limited hypertrophy)
o > ratio = ↓ wall stress

Wall stress = (P x r)/h

32
Q

Diastolic Lv dimension

A

o LV end diastolic radius
o Wall thickness: normal = 0.47 ± 0.11 in large breeds (>20kg), 0.53 ± 0.11 in small breeds.

33
Q

Color flow Doppler eval of MR

A

Jet size/area
PISA
Vena contracta

34
Q

Jet size/area of MR

A
  • Semiquantitative assessment:
    o Size of regurgitant jet w/I atria (largest jet in any plane): Hu → ratio RJarea/LAarea
     Mild insufficiency: <20% of LA (Hu)
     Moderate insufficiency: 20-40% of LA
     Severe insufficiency: >50% of LA
     Dogs: mild <30%, moderate 30-70%, severe >70% in L apical 4 chamber view

o Regurgitant jet area correlates well with jet volume
o LA area correlates well with RF% (not if ruptured chordae)

35
Q

Pitfalls of semiquatitative eval of jet size area

A

o Poorest method: lot of factors can influence.
 Abnormal systemic pressures: driving pressure affect velocity and area of flow
* ↓ systemic BP → large jet despite mild MR
 ↓ systemic and ↑LAP → small jet area despite severe MR
 HR: fast HR underestimate jet area
 Eccentric regurgitant jet: limit accuracy → jet directed toward LA wall and prevent its dispersion in LA → underestimation of severity = Coanda effect
 Influenced by transducer frequency and gain

36
Q

Qualitative eval of jet size/area

A

o Eccentric jet suggest pathologic regurgitation
 Abnormal posterior leaflet → anterior jet
 Abnormal anterior leaflet + pap muscle dysfct → posterior jet
o Central jet suggest physiologic regurgitation
 LV/MV annulus dilation
 Mild MR

37
Q

What is PISA a

A
  • Area of flow acceleration/convergence proximal to MV
    o Lack of flow convergence area consistent with mild MR vs large area = severe MR
38
Q

PISA assumption

A

Assume that flow accelerates in concentric hemispheres approaching the small orifice on ventricular side

39
Q

PISA: echo

A

o Apical 4 chamber view
o Centrally directed MR
o Flow convergence, vena contracta, jet expansion
o Nyquist limit 40-70cm/s
o Largest MR in mid systole: use zoom, adjust baseline and then Nyquist limit to 18-40cm/s
 Visualize flow convergence: as close as possible to perfect hemisphere

40
Q

Echo measures PISA

A

o Radius of hemisphere of proximal flow convergence (r in cm)
 Hemicircles too close to MV underestimate radius (flat)
 Hemicircles too far to MV overestimare radius (>parabole)
o Peak MR velocity (MRvmax in cm/s)
o MR VTI (in cm)

41
Q

Effective regurgitant orifice area normals, equation

A

o Mild insufficiency <0.2cm2
o Moderate insufficiency = 0.2-0.39cm2
o Severe insufficiency = >0.4cm2

EROA (cm2) = 〖Flow rate〗_MR/〖MR〗_vmax

42
Q

Regurgitant fraction classification (kittleson)

A

o Severe MR: >75% of LV volume move to LA
o Moderate MR: 45-75%
o Mild MR: <45%

43
Q

Limitations of PISA

A

o More accurate with central jets: if eccentric, regurgitant flow rate can be overestimated
o Needs holosystolic jet
o Contour of convergence zone changes w stage of regurgitation
 Smaller zone flattened
 Larger zone elliptical
o Measure radius in the center of convergent zone, where flow is// to radius

44
Q

Vena contracta def

A

Smallest regurgitant color flow jet at MV orifice

45
Q

Vena contracta measure

A
  • Echo: use multiple planes and small color sector to optimize lateral and temporal resolution
    o Parasternal LAX
    o See flow convergence, vena contracta and jet expansion → zoom in
  • No affected by driving pressures/flow rate
46
Q

Spectral doppler evaluation

A

Jet area
Reg volume and fraction
Transmitral valve flows

47
Q

Spectral Doppler eval of jet area

A

PW gate at various depth in LA → provide information on how wide/deep MR extends

48
Q

Spectral Doppler eval of regurgitant volume/fraction

A
  • Regurgitant volume: total ventricular volume (through MV) - forward SV through Ao
  • Regurgitant fraction: % of total SV flowing back into LA
  • Calculated with CSA and VTI (discussed above)
    o The valve used for normal SV should not be insufficient

RV (ml) = Total SV MV – Forward SV Ao
RF (%) = (Total SV MV-Forward SV Ao)/(Total SV MV)

49
Q

Transmitral valve flows changes MR

A
  • E wave >1.2cm/s = significant regurgitation
    o Predictive of poor survival time
    o Affected by LAP and LVP
  • Rapid E wave deceleration correlated with poor px in Hu and dogs (<80ms w DCM)

E>1.25m/s
E/E’>12
IVRT<45ms
E/IVRT>2.5

50
Q

LAP evaluation w/ transmitral valve flows

A
  • Evaluation of LAP (↑LAP>20mmHg)
    o Mean LAP calculation from E:Ea
     E:Ea < 6 → predicts MLAP <20mmHg
     E:Ea > 9 → predicts MLAPD >20 mmHg
    o ↑LAP → ↓IVRT, ↑E/E’, E/IVRT

MLAP = 6.38 x E:Ea -28.3

51
Q

MR flow profile

A
  • Peak velocity: no information regarding severity of MR
  • Flow profile: usually symmetrical
    o V wave on deceleration portion: suggest rapid ↑LAP 2nd to regurgitation
    o Asymmetric: high LAP and compliant chamber
     Seen w acute severe MR
     Triangluar shape indicates ↑LAP
    o Dense flow profile: significant regurgitant volume
52
Q

Changes in PV flow w/ severe MR

A
  • Changes with severe MR
    o ↓ S wave velocity ± reversal of flow
  • If LA severely enlarged and compliant: excess volume contained in LA and no flow reversal
  • Reversal of flow can also happen with
    o Eccentric jet directed into PV
    o Arrhythmia with loss of atrial contraction or AV asynchrony
    o Other physiologic factors: respiratory phase, cardiac phase/rhythm, atrial/venous compliance, age, diastolic filling
53
Q

PH 2nd to CVD

A
  • Pressure gradient from TR with Bernoulli equation = systolic PAP
    o Added RA pressure
     Normal <5mmHg
     RA dilation, no R-CHF, 50% collapse of CaVC = 10 mmHg
     RA dilation, R-CHF, <CaVC mvt = 15mmHg
  • Pressure gradient from PI = mean PAP
  • LA/Ao positively correlates with sPAP/mPAP
    o PAP ↑ passively 2nd to ↑LAP
    o PVR can ↑ in chronic ↑ LAP
54
Q

Diastolic MR causes

A
  • Seen with AV conduction abnormalities
    o 1st, 2nd , 3rd AVB and retrograde P waves
55
Q

Diastolic MR features on echo

A
  • Late diastole → atrial contraction not followed by appropriate ventricular contraction → normally closes MV
  • Hemodynamically insignificant

6. Echocardiographic principles (10 decks)

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