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ASE Guidelines for the Evaluation of Mitral Regurgitation

JASE 2003; 16:777-802. Endorsed by: American College of Cardiology American Heart Association European Society of Cardiology. Integrated Approach. 2-D EchocardiographySpectral DopplerPWCWColor Flow Doppler. Role of 2D Echo. . 2-D Echocardiography. Thorough evaluation of the MV apparatus including:LeafletsAnnulusChordae tendonaePapillary musclesSupporting LV walls.

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ASE Guidelines for the Evaluation of Mitral Regurgitation

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    1. ASE Guidelines for the Evaluation of Mitral Regurgitation Ken Horton RCS, RDCS, FASE MedStar Research Institute Washington Hospital Center Washington, DC Good Morning Good Morning

    3. Integrated Approach 2-D Echocardiography Spectral Doppler PW CW Color Flow Doppler

    4. Role of 2D Echo

    5. 2-D Echocardiography Thorough evaluation of the MV apparatus including: Leaflets Annulus Chordae tendonae Papillary muscles Supporting LV walls

    6. 2-D Echocardiography Allows for assessment of affected leaflet segment A1, A2, A3 P1, P2, P3 Helps guide treatment (replacement vs. repair)

    7. 2D Echocardiography Assessing LA Size A-P Measurement (= 2 cm/m2) LA Volume (= 36 ml/m2) Assessing LV size and function A-P Measurement (= 2.8 cm/m2) LA Volume (= 82 ml/m2)

    8. 2D Echocardiography Allows you to define the mechanism of the regurgitation Give clues as to the severity of the regurgitation Helps determine the feasibility of repair over replacement Helps determine if regurgitation is functional or primary

    9. 2D Echocardiography Functional Regurgitation Regurgitation is secondary to some other anatomical abnormality LV Dilatation Papillary muscle dysfunction

    10. 2D Echocardiography Primary Regurgitation Regurgitation is caused an abnormality of the valve leaflets or supporting apparatus

    11. Integrated Approach 2-D Echocardiography Spectral Doppler PW CW Color Flow Doppler

    12. Role of Spectral Doppler

    13. Color Flow Doppler Used to quickly screen for MR Small regurgitant jets (trace MR) are seen in approximately 40% of the population and considered to be a normal variant Color Flow Quantitation Methods Regurgitant Jet Area Vena Contracta Proximal Isovelocity Surface Area (PISA)

    14. Jet Area

    15. Regurgitant Jet Area In general The larger the jet the more severe the MR The deeper the jets extends into the LA the more severe the MR

    16. Regurgitant Jet Area In reality Many physiologic factors impact the jet area It is not recommend to rely on eyeballing of tracing jet areas alone

    17. Regurgitant Jet Area Factors that affect jet area/size Systemic blood pressure Left Atrial pressure Left Atrial size Jet direction

    18. Regurgitant Jet Area

    19. Regurgitant Jet Area Criteria Mild Regurgitation Small, central jet Area < 4 cm2 Area >20% of LA area Severe Regurgitation Large, central jet Wall impinging jet swirling in LA Area >10 cm2 Area >40% of LA area

    20. Vena Contracta

    21. Vena Contracta Use zoomed view for assessment Search in multiple planes Align jet perpendicular to the commissural line Regurgitant orifice is dynamic and vena contracta may change during systole

    22. Vena Contracta Width Criteria Mild Regurgitation < 0.3 cm Moderate Regurgitation 0.3 0.69 cm Severe Regurgitation = 0.7 cm

    23. Flow Convergence (PISA)

    24. Flow Convergence Proximal Isovelocity Surface Area (PISA) More accurate for concentric jets More accurate for circular orifices Usually performed from the 4 chamber view PISA seen at a normal Color Flow scale of 50-60 cm/s is indicative of significant MR CW tracing needs to be well aligned with flow direction

    25. PISA Information Needed The radius of the aliased region (r) The alias velocity (VA) The MR Peak Velocity (MRVEL)

    26. PISA Mitral Regurgitant Flow (Flow MR) Flow MR (cc/sec) = (6.28) (r2) (VA) = (cm/sec) Effective Regurgitant Orifice Area EROA = MVF(cc/sec)/Peak Vel(cc/sec)

    27. PISA

    28. PISA

    29. PISA

    30. PISA

    31. PISA EROA = 0.8 cm Vmax = 5.11 m/sec or 511 cm/sec Alaising Velocity = 28.2 cm/sec

    32. PISA EROA = 0.8 cm Vmax = 5.11 m/sec or 511 cm/sec Alaising Velocity = 28.2 cm/sec

    33. PISA EROA = 0.8 cm Vmax = 5.11 m/sec or 511 cm/sec Alaising Velocity = 28.2 cm/sec

    34. PISA EROA = 0.8 cm Vmax = 5.11 m/sec or 511 cm/sec Alaising Velocity = 28.2 cm/sec

    35. Effective Regurgutant Orifice Grade I MR - ERO < .10 cm2 Grade II MR ERO .10 - .25 cm2 Grade III-IV ERO > .25 - .35 cm2 PISA

    36. Effective Regurgutant Orifice Grade I MR - ERO < .10 cm2 Grade II MR ERO .10 - .25 cm2 Grade III-IV ERO > .25 - .35 cm2 PISA

    37. CW Doppler

    38. Continuous Wave Doppler MR velocities can be as high as 4-6 m/sec Velocity not useful in determining severity Contour/shape and density are useful Assess TR and PASP Pulmonary HTN may provide clues of the MR severity

    39. Continuous Wave Doppler

    40. PW Doppler

    41. Pulsed Doppler Used to measure E and A wave velocities Increased LA volumes and early filling results in increased E wave E/A ratios >1.2 seen in severe MR (without stenosis) PW also used for calculating regurgitant volumes and fractions

    42. Pulmonary Veins PW Doppler

    43. Pulmonary Veins Usually best imaged from the 4 chamber view Place PW sample volume 1 cm into the pulmonary vein Sometimes difficult to image

    44. Pulmonary Vein Flow

    45. Role of TEE Superior images make TEE well suited for identifying MR mechanism Plays a large role is surgery planning Same assessments can be made by TEE as TTE Vena Contracta and PISA slightly more sensitive by TEE Jet size can be overestimated by TEE

    46. Role of TEE Spectral Doppler best performed from the deep gastric view where the sample volume is more parallel to flow Generally feasible to assess al the pulmonary veins by TEE

    47. Regurgitant Volume Regurgitant Volume The amount of blood (volume) that passes through a incompetent valve.

    48. Regurgitant Fraction Regurgitant Fraction The percentage of the total stroke volume of blood that passes through an incompetent valve.

    49. Regurgitant Fraction What to measure? LVOT Diameter LVOT TVI MV Annulus Diameter MV TVI

    50. Regurgitant Fraction Mitral Valve Stroke Volume CSAMV X TVIMV Aortic Valve Stroke Volume CSAAV X TVIAV

    51. Mitral Regurgitation Regurgitant Volume (RV) (25cc) SVMV (100cc) SVAV (75cc) Regurgitant Fraction RV 25cc SVMV 100cc Unit = .25 or 25%

    52. Regurgitant Fraction Normal < 20% Mild Regurgitation 20 30 % Moderate Regurgitation 30 50 % Severe Regurgitation > 55%

    53. Pitfalls of RV/RF PW Sample Volume location Must be at valve annulus Diameter Measurements Error is squared Arrhythmias Measure 5-10 beats and average Multivalvular lesions Invalid with shunt Invalid with > mild regurgitation of non-measured valve

    55. Summary Vena Contracta Regurgitant Area Regurgitant Volumes and Regurgitant Fraction Effective Regurgitant Orifice Area (PISA)

    56. One More Thing Regurgitation Duration Holosystolic Brief

    57. Case 1

    58. PISA

    59. PISA

    60. PISA

    61. PISA EROA = 0.9 cm Vmax = 4.20 m/sec Alaising Velocity = 28 cm/secc

    62. PISA EROA = 0.9 cm Vmax = 4.20 m/sec Alaising Velocity = 28 cm/secc

    63. PISA EROA = 0.8 cm Vmax = 5.11 m/sec or 511 cm/sec Alaising Velocity = 28.2 cm/sec

    64. PISA EROA = 0.8 cm Vmax = 5.11 m/sec or 511 cm/sec Alaising Velocity = 28.2 cm/sec

    65. Effective Regurgutant Orifice Grade I MR - ERO < .10 cm2 Grade II MR ERO .10 - .25 cm2 Grade III-IV ERO > .25 - .35 cm2 PISA

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