Valvular Regurgitation

1. Valvular Regurgitation Mitral Regurgitation

2. Mitral Valve Apparatus Components • Left Atrial wall • Mitral annulus • Anterior and posterior leaflets

3. Mitral Valve Apparatus • Chordae tendinae • Papillary muscle • Left ventricular wall underlying the papillary muscle.

4. Mechanism of Mitral Regurgitation Papillary Muscle Dysfunction Annular Dilation Underlying LV wall

5. Mechanism of Mitral Regurgitation Leaflet Coaptation Leaflet Flexibility Leaflet Apposition

6. Mitral Valve Apparatus • Saddle shaped • Most apical points seen in Apicl 4 chamber view • Most basal points seen in LAX view

7. Mitral Annular Dilation • Normal mitral leaflets have area of overlap. • Mild degree of dilation may be tolerated without significant regurgitaion

8. Mitral Annular Dilation Causes • Left atrial dilation • Left ventricular dilation

9. Mitral Annular Calcification Mitral Annulus • Annulus area smaller in systole than in diastole. • Mitral annular calcification leads to increased rigidity – impairs systolic contraction.

10. Mitral Annular Calcification • Increased echogenicity on the LV side of the annulus immediately adjacent to the attachment point of the PMVL. • May be focal or extensive involving the entire U-shaped annulus.

11. Mitral Annular Calcification • The region of AMVL-aortic root continuity is rarely involved. • Seen as incidental findings in the elderly • Premature annular calcification seen in patients with renal failure or hypertension.

12. Mechanism of Mitral Regurgitation Annular Calcification

13. Mitral Annular Calcification Annular Calcification

14. Disease of the Mitral Valve • Myxomatous Disease • Rheumatic Disease • Endocarditis

15. Disease of the Mitral Valve • Marfan’s Syndrome • Infiltrative diseases • Collagen-vascular disorders

16. Myxomatous Disease • Thickened, redundant leaflets and chordae • Sagging of portions of the leaftet into the LA in systole • Severity – range from MVP to Flail leaflet segments

17. Myxomatous Disease Thickened Valve

18. Myxomatous Disease Sagging Valve

19. Myxamatous Disease Sagging Leaflet Distance Time Diastole Systole

20. Rheumatic Heart Disease • Commissural fusion • Thickening of leaflet tips

21. Endocarditis • Leaflet destruction • Leaftlet perforation • Leaftlet deformity

22. Marfan Syndrome • Long redundant AMVL • AMLV sags into LA in systole.

23. Infiltrative Diseases • Amyloidosis • Sarcoidosis • Mucopolysaccaridosis

24. Infiltrative Disease • Irregular leaflet thickening • Inadequate coaptation

25. Degenerative Changes • Age-related • Irregular areas of thickening and increased echogenicity. • +/- mitral annular calcification

26. Hypertrophic Cardiomyopathy • Abnormalities of Leaflet Motion • AMVL obstructs LVOT in systole • Disrupts coaptation of AMVL and PMVL • Posteriorly directed MR jet.

27. Hypertrophic Cardiomyopathy • Increased SA of MVL • Increased length of MVL especially AMVL • Excessive degree of coaptation

28. Hypertrophic Cardiomyopathy • Coaptation plane is displaced posteriorly. • 10% of patients have anomalous papillary muscle anatomy with direct insertion of PM into the leaflet.

29. Chordal Elongation • Inadequate tensile support of the closed leaflet in systole. • Severe bowing of the leaflet/leaflet segment into the LA. • Tip of the leaflet still directed towards the LV apex.

30. Chordal Rupture • No tensile support of the closed leaflet in systole. • Flail leaflet segment with displacement of leaflet into the LA in systole. • Tip of the leaflet is pointing away from the LV apex.

31. Regional LV Dysfunction • Abnormal contraction of papillary muscle or underlying LV wall. • Inadequate support of the closed leaflet during systole

32. Abnormal Papillary Muscle Function • Hypertrophic cardiomyopathy • CAD • LV dilatation • Systolic dysfunction

33. Partial Papillary Muscle Rupture • Rupture of one of the several heads or • Partial disconnection of the base of the papillary muscle.

34. Response of the Left Ventricle • Acute/Early stages – hyperdynamic – Increased SV. • Chronic – ventricular dilatation. • Irreversible decline in LV systolic function.

35. Response of Left Ventricle LVIDd

36. Response of the Left Atrium Chronic MR • Gradual dilation of LA • LA compliance increases • Left atrial pressure- volume relationship is shifted downwards and to the right.

37. Response of the Left Ventricle Acute MR • Small non- compliant LA • Significant increase in LAP • V-wave in the LA pressure curve.

38. Response of the PA Chronic • Chronic mildly elevated LAP – passive elevation of PAP Acute • Severe elevation of LAP – passive elevation of PAP

39. Response of the PA cm/s Chronic

40. Response of the PA cm/s Acute, V wave

41. Response of the PA Evaluation of the Pulmonary Artery Pressure • TR jet velocity • Estimation of RAP

42. M-mode Finding • Increased in aortic root motion in systole.

43. M-mode Finding Seen in Mitral Regurgitation Exaggerated anterior motion of aortic root

44. Doppler Flow Mapping • Color flow Doppler • Several tomographic planes • A4C, • A3C, • PLAX, • PSAX.

45. Doppler Flow Mapping

46. Doppler Flow Mapping

47. Volume Flow at Two Intracardiac Sites Mitral Regurgitant SV = Transmitral SV – Transaortic SV

48. Volume Flow at Two Intracardiac Sites

49. Volume Flow at Two Intracardiac Sites VTI cm/s

50. Volume Flow at Two Intracardiac Sites