ΑΝΕΠΑΡΚΕΙΑ ΜΙΤΡΟΕΙΔΟΥΣ Βασικές αρχές...

ΑΝΕΠΑΡΚΕΙΑ ΜΙΤΡΟΕΙΔΟΥΣΒασικές αρχές απεικόνισης, εκτίμησης και ερμηνείας των.

Ηλίας Κ Καραμπίνος

Γ’Καρδιολογική Κλινική, Ευρωκλινική Αθηνών

DECLARATION OF INTEREST

No conflict of interest regarding this presentation

Prevalence of Mitral Regurgitation

• Framingham study found mild MR present in 19% of men and woman (asymptomatic)

• Severe MR, dependent on the study, is present from 0.2-1.9% of the general population.

Frequency of MR in heart failure pts

90% of pts with NYHA III-IV, 50% mod/sev

Echocardiography: a complementary approach to conventional clinical

examination

Agenda

• Recognizing mechanisms of pathophysiology

• Recognizing the “topology” of the pathology

• Approaching MR severity

• Identifying consequences derived from MR

• Coexistence with other valvulopathies

• Follow up

The role of echocardiography: we have to understand the problem

Recognizing pathophysiology?

Characteristics of true MR– Flow convergence

– Proximal flow acceleration

– Ejection flow with a vena contracta

– Downstream appearance-blood ejected through a constraining orifice

– Confined to systole

– Doppler signals appropriate in color

Mitral regurgitation

2D Echocardiography: Etiology of mitral regurgitation

Primary:

- Myxomatous

- Endocarditis

- Rheumatic

- Trauma

- Congenital

- Drugs

Secondary:

- Non-ischemic dilated CMP

- Ischemic heart disease

- HCM

Type I = normal leaflet motion but with annular dilatation or leaflet perforation

Type II = excessive leaflet motion

Type III = restricted leaflet motion.

IIIa =during both systole and diastole

IIIb = during systole

Carpentier classification

Carpentier’s classification of mitral valve disease

Type I Leaflet perforation (IE) Annular dilatationCleft valve

Type II Mitral valve prolapse (eg myxomatousdisease) or papillary muscle rupture

Type IIIa Rheumatic disease

Type IIIb Ischemic or idiopathic cardiomyopathy

Carpentier classification

annular dilatation the ratio

annulus/anterior leaflet is .1.3 (in diastole)

the annulus diameter is >35 mm

Mitral Regurgitation:classification

Identifying mechanism of MR: cleft associated

Identifying mechanism of MR: functional MR-dilated cardiomyopathy

«Καρδιακή Ανεπάρκεια. DVD-ηχωκαρδιογραφικές περιπτώσεις»Α Κρανίδης-Ι Παρασκευαϊδης-Η Καραμπίνος, Εκδόσεις Παρισιάνος 2014

Identifying mechanism of MR: functional MR-Ischemic Cardiomyopathy

FMR Pathophysiology: the balance between “tethering” and “closing”

The coaptation triangle and the mitral valve geometry

Mitral regurgitation with distorted mitral valve geometry: trapeze (IIIB)

Absence of the ‘standard triangle of coaptation’,transformed into a ‘trapeze’

Identifying mechanism of MR: flail mitral valve

Identifying mechanism of MR: flail mitral valve

Posterior leaflet

Anterior leaflet

Identifying mechanism of MR: papillary muscle rupture

Identifying mechanism of MR: rheumatic heart disease

Identifying mechanism of MR: related to hypertrophic cardiomyopathy

Venturi effect or “drag forces” causes SAM of the anterior mitral leaflet AND failure of posterior leaflet to move anteriorly

Identifying mechanism of MR:mixed aetiology

The role of echocardiography: we have to know where is the problem

Recognizing “topology” of pathology?

Normal anatomy and function of mitral valve apparatus

Otto CM: Evaluation and management of chronic mitral regurgitation. N Engl J Med 345:740, 2001.

Coaptation Zone 1 cm

Scallops of anterior and posterior leaflets:A1, A2,A3 & P1,P2,P3

Normal anatomy and function of mitral valve apparatus

Schematic representation of the mitral valve from multiple perspectives

A)A2 and P2 (standard view)B)A1 and P1 (tilting of the probe toward the aortic

valve)C) A3 and P3 (tilting of the probe toward the tricuspid valve)

Lancellotti P et al. Eur J Echocardiogr 2010;11:307-332Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013

Mitral Leaflet Lesion Topology: 2D Transthoracic echocardiography


D) Short axis A1-A3, P1-P3E) 4-champers view A3-A2, P1F) 2-champers view P3-A2-P1

Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013


«Ηχωκαρδιογραφία Doppler-Νεώτερες Τεχνικές DVD»Α Κρανίδης-Η Καραμπίνος, Εκδόσεις Πασχαλίδης 2007

Mitral Leaflet Lesion Topology: 2D Transesophageal echocardiography

A)A1 and P1 (midesophageal 5-champers view)B)A2 and P2 (deeper midesophageal 4-champers view)C) A3 and P3 (even deeper midesophageal 4-champers view)



D) A1 and P1 (bicommisural 2-champers view 45o)E) A2 and P2 (midesophageal 3-champers view 120o)F) A1-A3 and P1-P3 (transgastricview)




40 to 90 degrees, effect of clockwise and counterclockise probe rotation

Transthoracic 3D echocardiography

In order to simulate a surgeon’s view of the valve, the 3D TEE image is positioned with the aortic valve the 11-o’clock position.


The role of echocardiography: we have to know the problem

Is MR severe?

Non Volumetric Methods

Quantification of MR: Severity

Quantification of MR: color flow a fast track tool!

Colour flow Doppler –jet area

Mild = Less than 20% of LA area (10 cm2 )

Zoghbi et al. ASE valve regurg document (JASE 03)

Quantification of MR: color flow doppler jet area

Pitfalls using color flow:Mimics of mitral regurgitation!!!

• Appearance of color Doppler in LA in systole– posterior motion of blood pool by MV closure (billiard’s effect)

– Reverberation from aortic flow

– Normal pulmonary vein inflow

– low velocity overall atrial motion augmented by inappropriate gain and Nyquist limits

Apical view : early systolic blue colour Doppler encoding within the left atrium

Very early systole: billiard’s effect

Recorded 50 mseclater

Colour reverberation in the left atrium

colour artefact arising from the aorta

Prominent pulmonary vein flow in the left atrium in systole

Signal encoded as red

Flow towards the transducer

Factors affecting jet area-instrument factors

• Use a Nyquist limit (aliasing velocity) of 50-60cm/sec.

• Use Color gain that just eliminates random color speckle from nonmoving regions.

• Jet area inversely proportional to pulse repetition frequencyhigher or lower settings –substantial error can occur

Advantages• Ease of use

• Evaluates the spatial orientation of regurgitant jet

• Good screening test for mild vs. severe regurgitation

Limitations• Can be inaccurate for

estimation of regurgitation severity

• Influenced by technical and haemodynamicfactors

• Underestimates eccentric jet adhering the atrial wall (Coandaeffect)

Quantification of MR: color flow


Quantification of MR: color flow

• The colour flow area of the regurgitant jet is not recommended to quantify the severity of MR.

• The colour flow imaging should only be used for detecting MR.

• A more quantitative approach is required when more than a small central MR jet is observed.


Vena contracta:an “old” modern index

Narrowest portion of a jet that occurs at or just downstream from the orifice.

CSA of the VC represents a measure of EROA which is the narrowest area of actual flow.

Size of the VC independent of flow rate and driving pressure for a fixed orifice.May change with hemodynamic or during the cardiac cycle.

Vena contracta: basic tips in a minute

TEE

Recommended approach - perpendicular to jet direction- Narrow sector width- Zoom mode- Minimum depth

Vena Contracta: methodology

• Two orthogonal planes (PT-LAX, apical four-chamber view)

• Optimize colour gain/scale

• Identify the three components of the regurgitant jet (VC, PISA, jet into LA)

• Reduce the colour sector size and imaging depth to maximize frame rate


Vena Contracta: methodology

• Expand the selected zone (Zoom)

• Use the cine-loop to find the best frame for measurement

• Measure the smallest VC (immediately distal to the regurgitant orifice, perpendicular to the direction of the jet)


Mild Moderate Severe

VC width (cm)

● Simple Quantitative measurement

● Intermediate values require confirmation

● Usefull for Central/Eccentric jets

●Not useful for Multiple jets

Vena Contracta: key points

Vena Contracta

The shape of effective regurgitant orifice results in under- or over-estimation of Mitral Valve Pathology: a common limitation

Advantages• Relatively quick and easy

• Relatively independent of haemodynamic and instrumentation factors

• Not affected by other valve leak

• Good for extremes MR: mild vs. severe

• Can be used in eccentric jet regurgitation

Limitations• Not valid for multiple

jets

• Small values; small measurement errors leads to large % error

• Intermediate values need confirmation

• Affected by systolic changes in regurgitantflow

Quantification of MR: Vena contracta


• When feasible, the measurement of VC is recommended to quantify MR.

• Intermediate VC values (3–7 mm) need confirmation by a more quantitative method, when feasible.



SD

1-Normal 2-Systolic blunting

D

4-Systolic Flow Reversal

S

3-Diastolic dominant

S

SD

D

Pulmonary vein flow

Severe MR:Pulmonary vein systolic flow reversal

Pulmonary vein flow

• Atrial fibrillation and elevated LA pressure: blunted forward systolic pulmonary vein flow.

• Systolic flow reversal in more than one pulmonary vein is specific for severe.

• Absence does not rule out severe MR

Pulmonary vein flow: key points

False – negative results# Severely dilated and compliant LA

False – positive results# Eccentric jet directed into PV

Pulmonary vein flow:pitfalls

Advantages• Simple

• Systolic flow reversal is specific for severe MR

Limitations• Affected by LA

pressure, atrial fibrillation

• Not accurate if MR jet directed into sampled vein

Pulmonary Vein Flow


Trans Mitral Flow: pulsed doppler

# MR results in increased flow rate across mitral valve

# Mitral inflow velocity in significant MR

# “E” velocity > 1.5 m/sec

# Rule out coexisting MS

# Normal PHT

• In patients with an RF 60%, the E wave always exceeded 1.0m/sec

J Am Coll Cardiol 1998;31:174 –9

Correlation between peak E wave velocity and Regurgitant Fraction

P=

Trans Mitral Flow: pulsed dopplerTVI transMV/TVI transAV


• TVI ratio >1.4 strongly suggests severe MR

• TVI ratio

Advantages• Simple, easily available

• Dominant A-wave almost excludes severe MR

Limitations• Affected by LA

pressure, atrial fibrillation, LV relaxation

• Complementary finding

Transmitral Flow: pulsed doppler


Transmitral Flow:Continuous Wave Doppler

MILD SEVERE

# Density Faint Dense

# Shape Symmetrical Asymmetrical

Shape of regurgitant signal-V cut off sign

• Mild MR: atrial pressure low and gradient remain high throughout systole

• Significant MR : atrial pressure increased in end systole and gradient decreases

• Produces a V shaped doppler signal

Volumetric Methods

Quantification of MR: Severity

PISA Method

Flow profile of blood approaching a circular orifice forms concentric, hemispheric shells of increasing velocity and decreasing surface area.

Color flow mapping able to image one of these hemispheres that corresponds to the aliasing velocity or Nyquist limit of the instrument.

The aliasing velocity should be adjusted to identify a flow convergence region with a hemispheric shape.

# Flow (cc/sec) = 6.28 x [r (cm)]2 x Va (cm/sec)

# ERO (cm2) = Flow (cc/sec) VMR (cm/sec)

# RV (CC) = ERO (cm2) x TVIMR (cm)

PISA Method:

• Apical four-chamber

• Optimize colour flow imaging of MR

• Zoom the image of the regurgitant mitral valve

• Decrease the Nyquist limit (colour flow zero baseline)/Downward shift of zero

• With the cine-mode select the best PISA

• Display the colour off and on to visualize the MR orifice

PISA Method:step by step

• Measure the PISA radius at mid-systole using the first aliasing and along the direction of the ultrasound beam

• Measure MR peak velocity and TVI (CW)

• Calculate flow rate, EROA, R Vol

PISA Method:step by step

PISA methodology: the three components

PISA radius Max Vo of MR VTI of MR

PISA Method:variation of convergence flow during systole

Flow convergence zone changes during systole using colour M-Mode.Functional mitral regurgitation: early and late peaks and mid-systolic decreases early systolic peak

Variation of the PISA during systole in FMR

In early and late systole, closing forces are relatively low and so the ERO and PISA relatively large

In midsystole,coincident with peak regurgitant velocity closing forces are maximal and so the ERO and PISA smaller.

Pitfalls in the quantitative echo assessment of Functional MR

PISA Method

Rheumatic mitral regurgitation end-systolic decrease in flow convergence zone

Mitral valve prolaspelate systolicenhancement

PISA Method:eccentric jets?

It can be

used in both central and eccentric jets.


PISA Method:limitations?

Multiple jets


Distorted jets by lateral wall

Angle correction

Non circular orifices in Functional MR: if long axis to short axis ratio>1.5

the error is significant

PISA Method:limitations?

Mild

Grade I

Moderate

Grade 2 Grade3

Severe

Grade 4

Regurgitation

volume ml / beat 60

Regurgitation

Fraction % 50

Regurgitation

Orifice area cm2 0.40

QUANTITATIVE METHODS MR severity by PISA Method

In functional ischemic MR: EROA ≥ 20 mm2 or a R Vol≥ 30 mL identifies a subset of patients at increased risk of cardiovascular events.

Advantages• Can be used in eccentric

jet

• Not affected by the aetiology of MR or other valve leak

• Quantitative: estimate lesion severity (EROA) and volume overload (R Vol)

• Flow convergence at 50 cm/s alerts to significant MR

Limitations• PISA shape affected– by the aliasing velocity

– in case of non-circular orifice

– by systolic changes in regurgitant flow

– by adjacent structures

• PISA is more a hemi-ellipse

• Errors in PISA radius measurement are squared

• Inter-observer variability

• Not valid for multiple jets

Quantification of MR: PISA methodology


The principle of conservation of mass:In the absence of valvular regurgitation or intracardiac shunts, the stroke volume through each of the four valves should be equal

Quantification of MR:Doppler Volumetric Method

Qs = systemic stroke volumeQv = stroke volume across regurgitant valveRV = regurgitant volume.

James D Thomas Heart 2002;88;651-657

Doppler Volumetric Method

MV FLOW = CSAMV x MV TVI

LVOT FLOW = CSALVOT x LVOT TVI

CSA MVA = D2x0.785

CSA LVOT= D2x0.785


MV REGURGITANT VOLUME = MV FLOW - LVOT FLOW

MV REGURGITANT FRACTION = MV REGURG FLOW

MV FLOW

EROA = MV REGURG VOL

MR VTI


Advantages• Quantitative: estimate

lesion severity (ERO) and volume overload (R Vol)

• Valid in multiple jets

Limitations• Time consuming

• Requires multiple measurements: source of errors

• Not applicable in case of significant AR

• Difficulties in assessing mitral annulus diameter

• Affected by sample volume location

Quantification of MR: doppler volumetric method


The Doppler volumetric method is a timeconsuming approach that is not recommended as a first-line method to quantify MR severity.




Mitral regurgitation Severity

Specific signs of severity :

Large central MR jet > 8cm2

MR area / LA area > 40%

Eccentric wall- impinging jet of any size, swirling in LA

Vena contracta width > 7mm

Large flow convergence

Systolic reversal in pulmonary veins

Supportive signs :

Dense, triangular CW Doppler MR jet

E-wave dominant mitral inflow ( > 1.2 m/sec)

Enlarged LV and LA

( particularly with normal LV function )

Quantitative Parameters:

R Vol (ml / beat) > 60 // RF (%) > 50 // EROA (cm2) > 0.40

Mitral Regurgitation Severity

MR color flow imaging

Vena contracta

Jet direction

Severe MR

≥0.7cm

PISARV and ROA

Pulsed DopplerRV & ROA

Mild MR

Central jetNo PISA seenJet area

The role of echocardiography: we have to know the problem

MR consequences ?

The role of echocardiography: questions to be answered

What to measure?

When MR is more than mild MR, providing the LV diameters, volumes, and ejection fraction as well as the LA dimensions (preferably LA volume) and the pulmonary arterial systolic pressure in the final echocardiographic report is mandatory.

The quantitative assessment of left ventricular (LV) diameters, volumes, and ejection fraction is mandatory.

The qualitative assessment of LV function is not recommended.

The 2D measurement of LV diameters is strongly advocated if the M-mode line cannot be placed perpendicular to the long-axis of the LV.

The 2D-based biplane summation method of discs is the recommended approach for the estimation of LVvolumes and ejection fraction.

LV size and function: recommendations

The 3D echo assessment of LV function provides more accurate and reproducible data.

Contrast echo is indicated in patients with poor acoustic window.

Left atrial volume is the recommended parameter to assess its size.

LV size and function: recommendations

Quantifying LV: dimensions

M Mode

2D-guided linear measurements

Quantifying LV: biplane disk summation

Quantifying LV:

• Apex frequently foreshortened

• Heavily based on geometrical assumptions

• Limited published data on normal population

Area Length Method

Quantifying LA

M-Mode Tracing 2D linear measurements

Quantifying LA

Biplane Method of disks Area Length Method

Left Atrial Volume=

π/4 h Σ D1D2

Do not forget consequences on the right heart: RV dimensions-function / PAP

The quantitative assessment of myocardial function (systolic myocardial velocities, strain, strain rate) is reasonable, particularly in asymptomatic patients with severe primary MR and borderline values in terms of LV ejection fraction (60–65%) or LV end-systolic diameter (close to 40 mmor 22 mm/m2)

Echo assessment of FMR:Global left ventricular remodelling

Dimensions of LV LV Volumes

Sphericity Index

Echo assessment of FMR:Local left ventricular remodelling

Apicaldisplacement of the posteromedial papillary muscle

Interpapillary muscle distance

Second order cords

Echo assessment of FMR:Mitral valve deformation

systolic tenting area

coaptation distance

posterolateral angle

Echo assessment of FMR:Closing Forces

Reduced Contractility:LV dp/dt

LV dyssynchrony

Sometimes we are not alone…

Mixed mitral valve pathology: stenosis and regurgitation. Effect on doppler indices

Multiple valvulopathy: Aortic stenosis and Mixed mitral valve pathology.

Effect on doppler indices of MV

Mean Gr MV=3,8mmHgMVA=0,8cm2Peak Gr AV=75mmHg

Multiple valvulopathy: Aortic Regurgitation and Mitral Regurgitation pathology.

Effect on doppler indices

AR PHT=290msec!!!

Mitral Regurgitation Follow upModerate organic MR: clinical examination every

year and echocardiogram every 2 years

Severe organic MR: clinical assessment every 6 months and echocardiogram every 1 year

If EF=60–65% and/or if end-systolic diameter =40 or 22 mm/m2, the echocardiogram should be performed every 6 months

Progression of MR severity is frequent with important individual differences.

Average yearly increase RV=7.5 mL and EROA=5.9 mm2


Mitral Regurgitation Follow upParameters need to be assessed:

increase in annular size

development of a flail leaflet

the evolution of LV end-systolic dimension

LV ejection fraction

LA area or volume

pulmonary systolic arterial pressure

exercise capacity

occurrence of atrial arrhythmias


When CABG and EF>30%

When CABG and EF

Ηχωκαρδιογραφία:λήψη αποφάσεων στη σοβαρή ανεπάρκεια μιτροειδούς

• Διάγνωση και εκτίμηση της βαρύτητας της ανεπάρκειας της βαλβίδος.

• Ανάδειξη στοιχείων παρουσίας στεφανιαίας νόσου.

• Δυναμική ηχωκαρδιογραφία με δοβουταμίνη ή άσκηση, για κατάδειξη μυοκαρδιακήςβιωσιμότητας.

• Κατάδειξη ή αποκλεισμός συνυπάρχουσας παθολογίας των γλωχίνων και των τενοντίωνχορδών.

• Μελέτη της γεωμετρίας της αριστερής κοιλίας ως και των θηλοειδών μυών, ειδικά με την 3D ηχωκαρδιογραφία.

Διοισοφάγειος ηχωκαρδιογραφίαδιεγχειρητικά

ΠΟΤΕ; ΧΕΙΡΟΥΡΓΙΚΗΠΑΡΕΜΒΑΣΗ

TI;ΕΠΙΔΙΟΡΘΩΣΗ ήΑΝΤΙΚΑΤΑΣΤΑΣΗ

ΕΠΙΤΥΧΙΑΕΠΕΜΒΑΣΗΣ

Peter Bruggel 1527-69, « Hunters of the winter »

ΕΥΧΑΡΙΣΤΩΣτην ιερή μνήμη του πατέρα μου

semi quantitative guide to MR severity

Mitral Regurgitation Index

MR Index is a composite of six echo variables: Colour Doppler regurgitant jet penetration

PISA

CWD of the regurgitant jet

Tricuspid regurgitant jet-derived PAP

Pulse wave Doppler pulmonary venous flow pattern

2D echocardiographic estimation of left atrial size

JACC Vol. 33, No. 7, 1999: 2016–22

Grading = 0 to 3

MR INDEX =Total score/number of variables


Correlation graph of Mitral Regurgitation Index versus three grades of mitral regurgitationJACC Vol. 33, No. 7, 1999: 2016–22


Regression plot of correlation between the MitralRegurgitation Index and the regurgitant fraction

JACC Vol. 33, No. 7, 1999: 2016–22


Ηχώ Δείκτες που προβλέπουν υποτροπή της λειτουργικής ανεπάρκειας μετά από πλαστική

επιδιόρθωση • Τελοδιαστολική Διάμετρος ΑΚ>65χιλ

• Γωνία οπίσθιας γλωχίνας με το μιτροειδικό δακτύλιο>45ο

• Γωνία άπω τμήματος της πρόσθιας γλωχίνας με το μιτροειδικό δακτύλιο>45ο

• Επιφάνεια μεταξύ των γλωχίνων και του επιπέδου του μιτροειδικού δακτυλίου (tenting area) >2,5 cm2

• Απόσταση σημείου σύγκλεισης των γλωχίνων από το επίπεδο του μιτροειδικού δακτυλίου (coaptation distance) >10χιλ

• Απόσταση μεταξύ των δύο θηλοειδών μυών (short axis) στην τελοσυστολή >20χιλ

• Δείκτης σφαιρικότητας στην τελοσυστολή >0,7.

• The VC can often be obtained in eccentric jet.

• In case of multiple jets, the respective values of the VC width are not additive.

• The assessment of the VC by 3D echo is still reserved for research purposes.



The PISA method is based on - the properties of flow dynamics- the continuity principle.`

PISA Method

Goal of the PISA method: to calculate the effective regurgitant orifice area (EROA)

Flow proximal= flow distal

Flow rate is the same at all points along the circuit

ΑΝΕΠΑΡΚΕΙΑ ΜΙΤΡΟΕΙΔΟΥΣ Βασικές αρχές...

Documents

Transcript of ΑΝΕΠΑΡΚΕΙΑ ΜΙΤΡΟΕΙΔΟΥΣ Βασικές αρχές...