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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
Accuracy of LA/Ao w/ CVD progression
* As MR ↑, LA/Ao may not accurately reflect ↑ LA size o Ao size will ↓ with ↓ forward flow or ↓ circulating blood volume
26
LA rupture
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
Mechanisms of LV function w/ CVD
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
FS% with MR
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
Systolic index equation
Systolic index = (End systolic volume)/BSA
30
Myocardial failure indices in dogs w/ MR
* 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
Wall stress equation and changes w/ MR
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
Diastolic Lv dimension
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
Color flow Doppler eval of MR
Jet size/area PISA Vena contracta
34
Jet size/area of MR
* 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
Pitfalls of semiquatitative eval of jet size area
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
Qualitative eval of jet size/area
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
What is PISA 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
PISA assumption
Assume that flow accelerates in concentric hemispheres approaching the small orifice on ventricular side
39
PISA: echo
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
Echo measures PISA
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
Effective regurgitant orifice area normals, equation
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
Regurgitant fraction classification (kittleson)
o Severe MR: >75% of LV volume move to LA o Moderate MR: 45-75% o Mild MR: <45%
43
Limitations of PISA
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
Vena contracta def
Smallest regurgitant color flow jet at MV orifice
45
Vena contracta measure
* 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
Spectral doppler evaluation
Jet area Reg volume and fraction Transmitral valve flows
47
Spectral Doppler eval of jet area
PW gate at various depth in LA → provide information on how wide/deep MR extends
48
Spectral Doppler eval of regurgitant volume/fraction
* 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
Transmitral valve flows changes MR
* 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
LAP evaluation w/ transmitral valve flows
* 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
MR flow profile
* 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
Changes in PV flow w/ severe MR
* 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
PH 2nd to CVD
* 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,
54
Diastolic MR causes
* Seen with AV conduction abnormalities o 1st, 2nd , 3rd AVB and retrograde P waves
55
Diastolic MR features on echo
* Late diastole → atrial contraction not followed by appropriate ventricular contraction → normally closes MV * Hemodynamically insignificant

6. Echocardiographic principles (10 decks)

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