Mitral Valve Disorders Mitral Valve Disorders...Mitral Valve Disorders — Echoc ardiography Findings and Assessment | Adela de Loizaga, M.D. 34. Mitral Valve Regurgitation Fi di d

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Mitral Valve Disorders — Echocardiography Findings and Assessment | Adela de Loizaga, M.D.2

Mitral Valve Disorders

Anatomy of the HeartOverviewAnatomy of the Mitral Valve

Mitral Valve Disorders and CausesMitral Valve Disorders and Causes– Mitral Valve Prolapse– Mitral Valve Regurgitation– Mitral Valve StenosisMitral Valve Stenosis

Mitral Regurgitation and Echocardiography

Mit l St i d E h di hMitral Stenosis and Echocardiography

New Gold Standards on the Horizon



Anatomy of the Heart



Anatomy and Blood Flow of the Heart

HeartHeart Chambers, ValvesValves, Blood Flow Through the gHeart



Source: Wikipedia


Val es ofValves of the Heart



Source: Wikipedia


V l t i l t f bl d i t th t i lValve Valves act as one-way inlets of blood into the ventricles

And one-way outlets of blood out of the ventricles

Valve Function

They prevent backward flow of blood passing through the heart

MV opens for forward flow into LV and closes to prevent backward flow out of LV.




As the heart muscle contracts and relaxes, the valves open and shut, letting blood into the atria and ventricles at alternate timesValve and ventricles at alternate times

– As LA fills pressure increases above ventricular pressure : the MV opens and blood flows into the LV (Early diastole)

Valve Function

– Late diastolic atrial contraction completes flow of LA blood into the left ventricle. (E/A)

LV contraction (systole) moves blood out of the ventricle into– LV contraction (systole) moves blood out of the ventricle into the aorta• Mitral valve is closed

A ti l i• Aortic valve is open

– The ventricles fill during ventricular diastole

The atria fill during ventricular systole


– The atria fill during ventricular systole


Anatomy of the Mitral Valve



Mitral valve

Bi id t t

Mitral Valve Open

Bicuspid structure

Anchored by h d t dichordae tendineae

Chordae tendineaett h t illattach to papillary

muscles

F ti i MV tFunctioning MV apparatus contributes a small portion of LV EF



Source: Wikipedia


Mitral Val eLeft atrial

appendageMitral ValveClosed

pp g

Posterior leaflet

Left atrium

Chordaetendineae

Anteromedialpapillary muscle

Anterior leaflet

Posterolateralpapillary muscle



Source: Wikipedia


Normal Mitral Valve – View from the Left Ventricle



Source: Wikipedia


Normal Mitral Valve

Surgical View 3-D ViewSurgical View 3 D View



Source: Wikipedia

Mitral Valve Disorders and Causes



Mitral Valve Disorders and Causes

Mit l V l P lVario s Mitral Valve Prolapse(primarily myxomatous degeneration)

Various Mitral Valve Disorders

Mitral Valve Insufficiency / Regurgitation

– Primary insufficiency

Disorders

– Secondary insufficiency

Mitral Valve StenosisMitral Valve Stenosis



Mitral Valve Prolapse

Mit l l l i th b ll i f b th l fl tMitral valve prolapse is the ballooning of one or both leaflets backwards into the left atrium

Th l fl t ll thi k d d t tThe leaflets are usually thickened due to myxomatousdegeneration

P lPrevalence• 2% to 4% US population• 5% to 10% worldwide




Mitral Valve Leaflet displacement of ≥ 2 mmMitral Valve Leaflets Protrude Into

Leaflet displacement of ≥ 2 mm above the mitral annulus

Left Atrium



Source: Wikipedia


The mitral valve doesn’tThe mitral valve doesn t close normally. One or both flaps don’t close in the correct way. yWhen this happens, blood can leak backward in the wrong direction.

Displacement of an Abnormally Thickened Mitral Valve Leaflet Into the Left Atrium During Systole



Source: UpToDate


Identification of mitral valve prolapse

The current accepted echocardiographic definition of MVP is billowing of any portion of the

valve prolapse

is billowing of any portion of the mitral leaflets at least 2 mm above the annular plane in the long axis views. On this parasternal long axis there is pronounced prolapse of the posterior leaflet (arrows) above the annular plane (red line).

LV: left ventricle; LA: left atrium; Ao: aorta.



Source: UpToDate


MitralMitral Valve Prolapse(Left Ventricular View)



Source: Wikipedia


MitralMitral Valve Prolapse(LA View)



Source: Wikipedia


Mit l l l ith di l t > 5 i hi h

Leaflet displacement and complications

Mitral valve prolapse with displacement > 5mm carries higher risk of complications, e.g. ,

– Leaflet asymmetry– Flail leaflet – Mitral regurgitation– Infective endocarditis




PartialPartial Mitral Valve ProlapseProlapse



Source: Wikipedia

Mitral Valve Prolapse Signs or Symptoms?

A lt ti f it l l l

Auscultation

Auscultation of mitral valve prolapse– Crisp mid-systolic click from the prolapse– Subvalve apparatus tightens abruptly

Heard best at the left apex– Patient in left lateral decubitus positionp

Pure MVP only does not cause symptomsy y p



Mitral Valve Insufficiency

Mitral valve insufficiency is caused by inadequate closure of the

Mitral Valve Insufficiency and Regurgitation

Mitral valve insufficiency is caused by inadequate closure of the mitral leaflets

Insufficient closure of the leaflets allows backward flow of blood into the left atrium during systole = regurgitation

Mitral regurgitation is the most common valve disorder in the U.S -th t d l i id lthe reported prevalence varies widely– Framingham Offspring study (1991-1995 ca. 3,000 individuals)

showed that prevalance depends on the definition of MRA d t t bl t MR 90%• Any detectable trace MR 90%

• ≥ mild MR 19%• ≥ moderately severe MR 0.4%-2.0%



Mitral Valve Regurgitation

A b liti f th it l l t

Causes of Primary Mitral Regurgitation

Any abnormalities of the mitral valve apparatus:

– Mitral annulus (e.g., calcification)

– Mitral leaflets (e.g., 50% of MVP, endocarditis, rheumatic heart disease, flail leaflet)

– Chordae tendineae (e.g., elongation, rupture)

– Papillary muscles (e.g., fibrosis, calcification, rupture)




V t i l di

Causes of Secondary Mitral Regurgitation

Ventricular myocardium – (e.g., ischemia, infarction)

Dilated cardiomyopathy– Dilated annulus

Hypertrophic cardiomyopathy– Deformed leaflets

Chordal slack– Chordal slack

– Displaced apparatus



Primary MR Due to Endocarditis

Verrucous endocarditisin SLE

Verrucous endocarditis with valvular vegetations (arrows) cardiac murmur had been heardcardiac murmur had been heard by auscultation.

Courtesy of Peter H Schur, MD.



Source: UpToDate

Primary Mitral Valve Insufficiency

Mitral Valve Vegetation in Bacterial Endocarditis




Mitral Val eMitral Valve Prolapse



Source: Wikipedia


R pt redRuptured ChordaeTendineae of theTendineae of the Mitral Valve



Source: Wikipedia


Mitral Val eMitral Valve Regurgitation From RupturedFrom Ruptured ChordaeTendineae



Source: Wikipedia


E i i t l ith dS mptoms Exercise intolerance with dyspneaupon exertion

Symptoms

Orthopnea

Palpitations, tachycardia

Symptoms increase with decreasing LV function




C ti h

Clinical Phases of Mitral Regurgitation

Compensation phase

• Gradual development of volume overload

• Asymptomatic for years or decades• Asymptomatic for years or decades

Transitional phase

• Onset of symptomsOnset of symptoms

Decompensation phase

• Increased symptoms, decreasing LV function

• Symptoms of congestive heart failure




Fi di d d th it d d ti f

Auscultation of Chronic MR

Findings depend on the severity and duration of mitral regurgitation

– High-pitched holosystolic murmur at the apex, radiating to the back or clavicular area

Loudness of the murmur does not correlate well with the– Loudness of the murmur does not correlate well with the severity of regurgitation

– A third heart sound is commonly heard– A third heart sound is commonly heard



Mitral Valve Prolapse with Regurgitation

Cli k S d

Auscultation

Click – murmur Syndrome– Mid-systolic click from the prolapse, a late systolic MR murmur

heard best at the apex

In contrast to most other heart murmurs, murmur of MV – Is accentuated by standing and valsalva maneuver, and – Diminished with squatting

The only other heart murmur that follows this pattern is the y pmurmur of hypertrophic cardiomyopathy



Mitral Valve Prolapse with Regurgitation

Patient Standing Patient Squatting

EKG and phonocardiogram of MVP heard at the apex. S1 (mitral and tricuspid valve closure) followed by a mid systolic click from the prolapse of the MV. After the prolapse occurs, there is the mid systolic murmur of MR Standing there is a decrease in venous

EKG and phonocardiogram of MVP at the apex. S1 (mitral and tricuspid valve closure)followed by a mid systolic click from the prolapsing MV which there is a systolic murmur of MR. With squatting there is an increase in systemic vascular resistance or

Provided by John M Criley, MD, The Physiological Origins of Heart Sounds and Murmurs, Little, Brown, Boston, 1996, 1-800-527-0145. This program contains a l t i t ti t t i l i t ti 200 h t d d ith i i hi h D l d h d i ti i t

systolic murmur of MR. Standing there is a decrease in venous return, a decrease in LV volume d/t decr pulm ven return and the mitral valve prolapses earlier in systole. Consequently, the MR murmur is lengthened.

afterload and an increase in LV pressure and volume. As a result, there is a delay in MV closure and the prolapse (and click) are delayed, occurring late in systole. Consequently, the MR murmur is late and shortened.



Source: UpToDate

complete interactive tutorial integrating over 200 heart sounds and murmurs with cineangiographic, echo-Doppler, and hemodynamic motion picture sequences.


Acute mitral regurgitation will have sudden onset of symptoms

Symptoms of Acute MR

Acute mitral regurgitation will have sudden onset of symptoms

– Suggestive of a low cardiac output state • Decreased exercise tolerance

– Of decompensated congestive heart failure• Shortness of breath, pulmonary congestion, orthopnea, paroxysmal

nocturnal dyspneanocturnal dyspnea

– Palpitations• Atrial fibrillation

– Cardiogenic shock• In individuals with acute mitral regurgitation due to papillary muscle

rupture or rupture of a chorda tendinea


p p


Acute Mitral Regurgitation Post MI

Papillary Muscle Rupture After MI

Complete transection of papillary muscle (arrow) after

After MI

an acute myocardial infarction

The patient died with severe mitral regurgitationmitral regurgitation.

Photograph courtesy of Dr. William D Edwards. From Reeder, GS, Gersh, BJ, Acute myocardial infarction. In: Internal Medicine, 4th ed, Stein, JH, Hutton, JJ, Kohler, PO, et al (Eds) Mosby Year Book St Louis 1994 pp 169 189



Source: UpToDate

et al (Eds), Mosby-Year Book, St Louis, 1994, pp. 169-189. By permission.

EKG Changes in Mitral Valve Regurgitation

P Mitrale is aP Mitrale is a Broad Notched P WaveP Wave



Source: Wikipedia

EKG Changes in Mitral Valve Regurgitation

ProminentProminent Late Negative ComponentComponent of P Wave in Lead V11



Source: Wikipedia


P it l i b d t h d P i l l d

Electrocardiogram in Mitral Regurgitation

P mitrale is broad notched P waves in several or many leads with a prominent late negative component to the P wave in lead V1

May be seen in mitral regurgitation

But also in mitral stenosisBut also in mitral stenosis

Potentially seen with any left atrial enlargement (LAE)



Mitral Regurgitation and Echocardiography



Mitral Valve Regurgitation and Echocardiography

Wh t i h di ?

Some Echocardiography Basics

What is an echocardiogram?

What can an echocardiogram tell us?

What is a Doppler study and what does it add to the echocardiogram?




Hi h f d ( 1MH )High frequency sound waves (> 1MHz)

Reflections from solid-fluid interfaces

Fluid density appears black on US (no echos)

The heart is a fluid filled structure » allows excellent imaging of structures



Courtesy: UpToDate


D l ff t

Doppler Echocardiography

Doppler effect

Sound waves bouncing off moving blood elements causes shift in wave length of the echoin wave length of the echo

Can be used to indicate direction, speed, and magnitude of flow

Revolutionized understanding of valve disorders

Echocardiography and Doppler studies continue to evolve




Fl di ti d tit ti

Doppler Echocardiography

Flow – direction and quantitation

Gradients

Pressure calculations



Courtesy: UpToDate


Anatomic basis for the presence of mitral2 D and Anatomic basis for the presence of mitral regurgitation (e.g., mitral annular calcification)

Left atrial enlargement with systolic bowing of the

2 D andM–Mode

Left atrial enlargement with systolic bowing of the interatrial septum

Increased LA / RA ratio (normal is 1:1)Increased LA / RA ratio (normal is 1:1)

Left ventricular volume overload pattern– Hyperkinesia of the left ventricular walls with left

ventricular dilatation– Evidence of pulmonary hypertension




R it t j tPulse Wave Regurgitant jet

R it t f ti

Pulse WaveDopplerMeasurements Regurgitant fraction

P l i fl

Measurements

Pulmonary venous inflow• Diminished or reversed with significant

mitral regurgitationmitral regurgitation



Mitral Regurgitation and Echo Measurements

A ll j t i <20% f th l ft t i l i id d

Color Flow Doppler

A small jet occupying <20% of the left atrial area is considered mild regurgitation.

A large jet occupying > 40% of the LA area and extending intoA large jet occupying > 40% of the LA area and extending into the pulmonary veins is considered severe mitral regurgitation.

These jets are very sensitive to instrument settings,These jets are very sensitive to instrument settings, may be misleading.

They should be used in conjunction with other findings, not alone.




Regurgitant jet width is measured at the regurgitant orifice: it

Color Flow Doppler

Regurgitant jet width is measured at the regurgitant orifice: it can be calculated using the Proximal Isovelocity Surface Area (PISA).

–PISA is based on the hemodynamic principles of flow through a small circular orifice.

–There is flow acceleration of the regurgitant blood on the ventricular side as it moves towards and through the mitral valve opening into the LA.

–There are different layers of equal velocity in this regurgitantblood flow as it converges proximal to the valve opening.



Mitral Regurgitation Echocardiography

Proximal Isovelocity Surface Area

Limitation of PISA

Measures the flow at one moment in time in the cardiac cycle

May not reflect the average



y gperformance of the regurgitant jet


Th l it i li d t i h i h i

Color Flow Doppler

These velocity areas are visualized as concentric hemispheric rings above the mitral valve opening on color flow Doppler.

The smaller the opening the higher the velocity The larger theThe smaller the opening, the higher the velocity. The larger the opening, the slower the velocity.

Using the size of the “velocity areas” and the velocity the orificeUsing the size of the velocity areas and the velocity the orifice can be calculated.

The diameter of the ring closest to the regurgitant orifice is used g g gas the assumed jet width.

1cm jet width is consistent with severe mitral regurgitation.



PISA and JET Width (Severe Mitral Regurgitation)

Color Flow Doppler

Four chamber view with typical

Color Flow Doppler Severe MR

Four chamber view with typical features of severe mitral regurgitation; a large proximal isovelocity surface area (PISA) y ( )and a broad crossing jet from left ventricle (LV) into the left atrium (LA).



Source: UpToDate


Eff ti R it t O ifi ERO i th f th

Quantification of Mitral Valve Regurgitation

Effective Regurgitant Orifice area = ERO is the area of the regurgitant flow at the level of the valve

ERO l t ith th i f th d f t i th it l lERO correlates with the size of the defect in the mitral valve

MR severity is quantifiable with Regurgitant Fraction

Regurgitant Fraction = RF is the percentage of the left ventricular stroke volume that regurgitates into the left atrium




MitralMitral Regurgitation Measured by Left

Atrium

Jet Width

Left Ventricle

MV

Vena Contractaand Central Jet Width

Vena Contracta

Ventricle

Jet WidthVena contracta is the point in a fluid stream where the diameter of the stream is the least. The maximum contraction takes place slightly downstream of an orifice p g ywhere the jet is more or less horizontal. This phenomenon is because fluid streamlines cannot abruptly change direction.



Source: Wikipedia


Vena Contracta in Mitral RegurgitationFIGURE 15-50 Measurement of the vena contracta (VC between arrows) in twocontracta (VC between arrows) in two different patients: A – a central mitral regurgitation jet; B – an eccentric mitral regurgitation jet (note change in color flow baseline).

LA = left atrium; LV = left ventricle.

(Modified from Oh JK, Seward JB, Tajik AJ: The Echo Manual. 3rd ed. Philadelphia, Lippincott Williams & Wilkins, 2006. Used with permission of Mayo Foundation for Medical Ed cation and Research ) Vena contractaEducation and Research.) Vena contractaBraunwald




MR Severity and Vena Contracta vs. Regurgitant Fraction (RF)

Mitral Regurgitation

Vena ContractaWidth

Regurgitant Fraction(RF)

G d 1 4 20%Grade 1 < 4 mm < 20%Grade 2 4–5.9 mm 20%–30%Grade 3 6–8 mm 30%–49%Grade 4 > 8 mm > 50%




Regurgitant Jet in Mitral Insufficiency

Panel A. apical four chamber view of mild MR and mild TR also present. Regurgitant jets have a mosaic of color; they begin

Panel B. The size of the MR jet at the site of origin is wider, the jet reaches the posterior LA wall characteristics of

Panel C. The jet is even wider, almost filling the LA, and it reaches the posterior LA wall and enters the pulmonary veinsmosaic of color; they begin

with a very narrow point of origin at the valve, remain narrow and penetrate only partially into LA cavity.

characteristics of moderate to severe MR.

pulmonary veins.



Source: Braunwald

Flow Reversal in Pulmonary Veins

Re ersedReversed Pulmonary Venous FlowVenous Flow



Source: Wikipedia

Guide for Quantitating Severity of Mitral Regurgitation

N l hi t iblMild MR Normal history, possible murmur

Normal left atrial and left ventricular dimensions b E h di h

Mild MR(Grade 1+)

by Echocardiography

Regurgitant fraction <20%

Normal EF >55%

May never progress




Lik l t ti iblModerate MR Likely asymptomatic, possible murmur

Mild left atrial and left ventricular enlargement b h di h

Moderate MR (Grade 2+)

by echocardiography

Regurgitant fraction 20% to 30%

High EF >60%, compensation




Onset of symptoms murmur EKG and /or chest x rayModerately Onset of symptoms, murmur, EKG and /or chest x-ray

Moderate left atrial and left ventricular enlargement

Moderately Severe MR(Grade 3+)

Left atrial dimension > right atrial dimension

Significant coaptation defect of the mitral valve leaflets, with large EROwith large ERO

Wide mitral regurgitation jet

Regurgitant fraction 30% to 49%Regurgitant fraction 30% to 49%

EF 50%-59%, transitional phase




S mptomatic m rm r EKG and / or chest raSevere MR Symptomatic, murmur, EKG and / or chest x-ray

No systolic coaptation of the mitral valve

V l ERO d PISA 1

Severe MR(Grade 4+)

Very large ERO and PISA 1 cm or more

Moderate to severe left atrial and left ventricular enlargement (cardiomegaly)

Regurgitant fraction > 50%

Regurgitant jet area / left atrial area ratio > 40%g g j

EF <50%, decompensation



Chest X-Ray Findings in Chronic Severe MR

Normal Chest Film PA CXR Chronic MR

Posteroanterior view of a normal F l ith k it l it tiPosteroanterior view of a normal chest radiograph.

Female with known mitral regurgitation cardiomegaly with left atrial (black arrow) left ventricular enlargement (red arrow), as well as mild pulmonary venous redistribution,



Source: UpToDatePhotos courtesy of Jonathan Kruskal, M.D. features characteristic of mitral regurgitation.


Look for:LA dil t ti

Findings– LA dilatation– LV dilatation

Symptoms: Red Flag!Symptoms: Red Flag!– Palpitations (tachycardia, atrial fibrillation)– Exercise intolerance– Dyspnea with mild exertion or at rest– Dyspnea with mild exertion or at rest– LH Failure

• SOB• Pulmonary edema• Cardiogenic shock



Assessment of Mitral Valve Regurgitation

Echo Measurements for Mitral Regurgitation

Parameters Grade 1 Grade 2 Grade 3 SevereParameters Grade 1 Grade 2 Grade 3 SevereStructural Left Ventricular Size Normal Normal or dilated Dilated, except acute MR

DopplerColor Doppler regurgitant jet <20% <20% LA area >40% of LA area

Doppler vena contracta width <3-3.9mm 4-6mm 6-8 mm >8mm pp

QuantitativeRegurgitant volume <30 mL/beat 30-44mL/beat 45 to 59 mL/beat ≥60 mL/beat

Regurgitant fraction <20% 20 to 30% 30 to 49% ≥50%

Regurgitant orifice area < 20 mm2 20-24 mm2 25 to 39 mm2 ≥ 40 mm2

American College of Cardiology/American Heart Association, Guidelines 2006Source: UpToDate

Mild M d t SLeft Atrial Enlargement Normal Mild Moderate SevereDiameter in cm Men <4.1 4.1–4.6 4.7–5.1 >5.2

Diameter in cm Women <3.9 3.9–4.2 4.3–4.6 >4.7



Source: American Society of Echocardiography

Mitral Stenosis



Mitral Valve Disorder with Inflow Obstruction

S diti li iti ifiObstr cted Flo Some conditions cause a limiting orifice that obstructs diastolic transit of blood from atrium to ventricle

Obstructed Flow from LA to LV

Hemodynamic consequence: a holo-diastolic pressure gradient between the left atrium andbetween the left atrium and left ventricle



Mitral Valve Disorder with Inflow Obstruction

The most common lesion of the mitral valve Mitral Val e that causes inflow obstruction is:

– Mitral stenosis– Usually acquired as the result of rheumatic

Mitral Valve Stenosis

heart disease– Estimated prevalence 0.1% (range 0.02% to 0.2%)

Lancet study 2006 on burden of valve disorders; also based on 1500 reviewed valvotomies as indicators of severe MSon 1500 reviewed valvotomies as indicators of severe MS

Other causes include:Left atrial myxoma and other tumors– Left atrial myxoma and other tumors

– Severe mitral annular calcification – Left-sided carcinoid heart disease

C it l di d


– Congenital disorders



Sl d li f i t lSigns and Slow decline of exercise tolerance

Decreased stroke volume

Signs and Symptoms

Reduced arterial pulses

Left atrial hypertrophy

EKG with P-mitrale

Atrial fibrillation– Stroke


Stroke



P l h t iSigns and Pulmonary hypertension

Dyspnea, hemoptysis

Signs and Symptoms

Pulmonary edema

Right heart enlargement

Leg and sacral edema

Hepatomegaly, ascites




Marked thickening of the leaflets and LA hypertrophy



Mitral Valve Stenosis and Echo Findings

ICE Mitral Stenosis — Hockey Stick

Intracardiac ultrasound examination shows a stenotic mitral valve with some leaflet thickening and a hockey-stick appearance of the anterior mitral valve leaflet.



Source: UpToDate

Mitral Stenosis Echocardiographic Findings

TTE — Mitral Stenosis Alters Appearance and Motion of the Valve on Two-Dimensional Echocardiography

Normal is a rapid, biphasic motion of the valve

MS from partially fused leaflets causes the valve to open only partly and as a single unitand as a single unit

Persistent gradient develops between the left atrium and left ventricle

This gradient keeps the stenotic valve opened and causes the entire valve to bulge like a dome into the ventricle throughout diastole

Th l t d di t i iti t th i ti b tl tiThe elevated gradient initiates the opening motion abruptly, generating an opening snap and a characteristic “hockey stick / knee bend” appearance on the precordial long axis view



Mitral Stenosis and Echo Measurements

Doppler can measure velocity of mitral inflowy– In mitral stenosis the velocity

increases from < 1m/sec to > 1.5m/sec.

Continuous Wave Doppler MS– Peak velocity of 1.7 m/s in this

patient with rheumatic mitral stenosis (MS).

– Apply simplified BernoulliApply simplified Bernoulli formula: the initial diastolic gradient across the mitral valve is 12 mmHg.



Source: UpToDate


P k di t i H 4 k l it 2

Peak Velocity, Peak Gradient and Pressure Half Time

Peak gradient, in mmHg = 4 x peak velocity2

– Peak velocity of 1 m/sec indicates a peak gradient of 4 mmHg

– Peak velocity of 2 m/sec indicates a peak gradient of 4 x (2x2) = 16 mmHgy p g ( ) g

– Peak velocity of 3 m/sec indicates a peak gradient of 4x (3x3) = 36 mmHg

Transmitral gradient during diastole can be measured in the pressure half-time (PHT) – PHT = the time required for the gradient between the left atrium and the

left ventricle to fall to one-half of its initial value




Transmitral Gradient During Diastole can be Measured in the Pressure Half-time (PHT)

The mitral valve area can be obtained from the continuous wave Doppler by calculating the time y grequired for the opening pressure to reach one half of its value (P 1/2); this is called P 1/2 time and is calculated as shown. By regression analysis, a critically stenotic valve measuring 1 cm2 has a gPHT of 220 ms; the valve area can be calculated as shown above.



Source: UpToDate


E i i ll h lf ti f 220Velocit Empirically – pressure half-time of 220 msec= MVA of 1.0 cm2

Thus

Velocity and Pressure Thus

– MVA = 220 / PHT– With PHT 300 msec

MVA 220 / 300 0 7 2

Pressure Gradient

– MVA = 220 / 300 = 0.7cm2




Pressure half timeMitral Val e Pressure half-time

– Normal: 30 to 60 milliseconds (ms)• (MVA 220/60 =3 66 cm2)


• (MVA 220/60 =3.66 cm2)

– Mild MS: 90 to 150 ms • (MVA 220/150 =1.46 cm2)( )

– Moderate MS: 150 to 219 ms• (MVA 220/219 =1 cm2)

– Severe MS: > 220 ms• (MVA 220/300 = 0.73 cm2)




Look for:Indirect – Left atrial hypertrophy– Symptoms of low cardiac output– Pulmonary hypertension

Findings

Symptoms: Red Flag!– Atrial fibrillation, PAF– Right heart failure

• SOB, pulmonary edema• Leg edema

10 year survival at time of presentation– In asymptomatic individuals 80% or more

With se ere s mptoms 0% 15%


– With severe symptoms 0%- 15%


Mitral Stenosis Assessment of Severity

Echo Measurements for Mitral Stenosis

S it Mit l St iSeverity Mitral Stenosis (ACC/AHA 2006)

Normal Mild Moderate SevereValve Area (cm2) 4-6 1.5-2.5 1.0-1.5 <1.0

Mitral Jet Velocity (m/sec) ≤2.0 <3.0 3.0–4.0 >4.0

Mean Gradient (mmHg) <5 6-12 >12

Pulmonary Artery Systolic Pressure >50(mmHg) >50



Source: UpToDate





T d d t h l i kiTwo more advanced technologies are making their way into routine echocardiography

1. 3-D Echocardiography

2 Tissue Doppler Echocardiography (TDE)2. Tissue Doppler Echocardiography (TDE)




R l ti 3 D ll i di t l tiAdvantages of Real-time 3-D allows immediate evaluation without calculations and geometric modeling of two-dimentional measurements

Advantages of 3-D

echocardiography

Direct evaluation of cardiac valves

V l t i tifi ti f it t lVolumetric quantification of regurgitant valve lesions, shunts, and cardiac output




I d th d tifi tiAdvantages of Improved the accuracy and quantification of Mitral Regurgitation and Mitral Stenosis

More accurate direct measurements of mitral

Advantages of 3-D

echocardiographyMore accurate direct measurements of mitral valve area

Improved reproducibilityImproved reproducibility




3 D3-D echocardiography

Baseline image before mitral balloon valvuloplasty (A) shows a g p y ( )restricted mitral valve opening with bicommissural fusion. Post-valvuloplasty, splitting of the medial commissure and posterior leaflet tear can be seen (B).


Source: UpToDate



TDE h b t bli h d tAd antages TDE has become an established component of the diagnostic ultrasound examination

It it t f di l

Advantages of Tissue Doppler It permits an assessment of myocardial

motion, using Doppler ultrasound imaging, often with color coding

Doppler

This is similar to routine Doppler ultrasound used to assess blood flow




Th t h i l l t di l l itAd antages The technique calculates myocardial velocity

TDE offers an objective measure to quantify i l d l b l LV f ti

Advantages of Tissue Doppler regional and global LV function

It can be used to assess RV systolic function i h i l h t i d

Doppler

as in chronic pulmonary hypertension, and chronic heart failure.




TDETDE

This TDE shows normal left ventricular systolic functionThis TDE shows normal left ventricular systolic function. Panel A : color-coded 2-D tissue Doppler image; panel B : the corresponding color- M-mode tissue Doppler image for a single cardiac cycle panel C: the time-velocity plot of the posterior wall of the color-M-mode tissue Doppler image.


Source: UpToDateMitral Valve Disorders — Echocardiography Findings and Assessment | Adela de Loizaga, M.D.

90

pp gS: peak systolic velocity; E: peak early diastolic velocity; A: peak atrial velocity.


Th t t h l i t t3 D echo These two technologies are not yet the Gold Standard.

3-D echo and TDE

Scientific evidence seems strong enough to endorse 3-D echo and TDE as a new standardas a new standard.

They offer improved clinical assessment f th h t t d f tiof the heart anatomy and function.



Mitral Valve DisordersEchocardiography Findings and AssessmentMitral Valve DisordersWebinar 2013Adela de Loizaga M DAdela de Loizaga, M.D.


Mitral Valve Disorders Mitral Valve Disorders...Mitral Valve Disorders — Echoc ardiography Findings and Assessment | Adela de Loizaga, M.D. 34. Mitral Valve Regurgitation Fi di d

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