Mitral Regurgitation:

Emerging Concepts Elyse Foster, MD Professor of Medicine UCSF

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Disclosure: Grants from Evalve, Inc Guidant - Boston Scientific Corporation

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Classification of Mitral regurgitation:

Organic - Primary pathology of the leaflets Functional - Malcoaptation 2 to myocardial

process

Degenerative Rheumatic Endocarditis Congenital (eg. cleft)

Ischemic Dilated cardiomyopathy Hypertrophic cardiomyopathy

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Anatomy of the Mitral Apparatus

Leaflets Annulus Chordae tendinae Papillary muscles Left ventricle

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Mitral Valve Prolapse

Mitral Valve Endocarditis

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Physiology of Primary Mitral Regurgitation

Left ventricular volume overload LA enlargement Eccentric hypertrophy LVEF normal to hyperdynamic Pulmonary hypertension Acute vs. Chronic

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Normal
EF 66% LAp 10 mmHg SV 100 ml EDV 150 ml

Acute MR
SV 70 ml RV 70 ml ESV 50 ml LAp 25 mmHg ESV 30 ml EF 82% EDV 170 ml RF 50%

Chronic compensated
EF 79% RF 50% SV 95 ml EDV 240 ml RV 95 ml LAp 15 mmHg ESV 50 ml

Chronic decompensated
SV 65 ml EF 58% RF 57%

EDV 260 ml RV 85 ml LAp 25 mmHg ESV 110 ml

Adapted From Carabello, NEJM 1997

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The Roles of Echocardiography

How severe is the MR? What is the mechanism for MR? How well compensated is the LV? What is the best way to reduce the MR?

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Mitral Regurgitation by Echocardiography

Extremely common Increases with age Severity exaggerated due to an

overreliance on qualitative rather than quantitative parameters If there is no apparent leaflet pathology, LV and LA size are normal, probably not severe.

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How severe?

The severity of mitral regurgitation

should be evaluated based on a constellation of 2-dimensional and Doppler echocardiographic findings.

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Journal of the American Society of Echocardiography July 2003

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MR: Color Flow Evaluation

Mild central jet

Severe eccentric encircling jet

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Mild Central MR

Severe Central MR

Severe Eccentric MR

< 4 cm2
< 10% LA Area

> 8 cm2
> 40% LA Area

Adapted from Zoghbi et al. ASE valve regurg document (JASE 03) UC SF

Spatial Mapping Color Jet Area in MR

Most widely used, most helpful at extremes Regurgitant volume only weakly related to area (r = 0.64)* More severe, eccentric jets have smaller area Significantly affected by instrument settings

Nyquist limit optimal at 50 - 60 cm/sec Gain should be adjusted for slight speckle Optimize frame rate by reducing depth and using narrow sector angle to minimum of 16 - 18 Hz Low blood pressure smaller jet High blood pressure larger jet

Driving pressure important - record BP on screen

*From Hall, Circ 97

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Color Flow Jet in MR

Jet Penetration:

Mild - central Moderate - eccentric to 1st PV Severe - eccentric and extends past 1st PV

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The limitations of color flow Doppler necessitate an integrative approach to assessment of MR severity
Qualitative and quantitative parameters

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MR Quantitation based on Doppler and 2-D measurements

MILD VC width (cm) ROA(cm2) RV (ml) RF (%) < 0.3 < 0.2 < 30 < 30 MOD MODSEV 0.3 - 0.69 SEV > 0.7

0.2 - 0.29 0.3 -0.39 > 0.4 30 - 44 30 - 39 45 - 59 40 - 49 > 60 > 50

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PISA

Vena contracta

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

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Color Flow Jet Width in MR

Vena Contracta Width

ROA > 0.4 cm2 ROA < 0.4 cm2

Parasternal LAX most accurate > 0.5 cm: RV > 60 ml < 0.3 cm:
RV < 60 ml

*From Hall, Circ 97

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EF 79% RF 50%

SV 95 ml

Regurgitant Volume and Fraction

EDV 240 ml RV 95 ml ESV 50 ml

Regurgitant volume (RV) = TSV - FSV = 190 - 95 = 95 ml Regurgitant Fraction (RF) = RV/TSV = 95/190 = 50%
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Total SV = EDV - ESV = 56 ml

EDV = 114 ml

ESV = 58 ml
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LVOTd = 2.0 cm

LVOTVTI = 15 cm

FSV = 45 ml RV = 11 ml RF = 11/56 = 20%

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Regurgitant Orifice Area (PISA Method)

Regurgitant flow = 2r2 X Va ROA = 2r2 X Va/V2
- 40

Quantitative

r va

measurement of:

ROA (cm2) Regurgitant Volume

v2

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PISA radius = 1.1 cm Alias vel = 0.4 m/sec

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PISA Calculation

ROA = 2r2 X V/V2 = 6.28(1.1cm)2 X .40/5 = .60 cm 2 Regurgitant Volume = ROA X VTIMR = .60 X 150 = 91 ml
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Pulmonary Vein Flow

S

1-Normal

2-Systolic blunting

3-Diastolic dominant

4-Systolic Flow Reversal

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Pitfalls: Pulmonary venous flow patterns in MR

PV flow pattern reflects LA pressure and

loading conditions Influenced by factors other than MR severity

Systolic flow reversal may present in only

one PV especially when jet is eccentric Most useful when systolic dominant or clear systolic flow reversal is present

Diastolic function LA size Atrial fibrillation

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What is the mechanism underlying MR?

Carpentier Leaflet Motion Classification

Normal (I) motion

Primary annular disease

Excessive (II) motion

(Non-rheumatic) Degenerative valve disease

Restricted (III) motion

Systolic (III a): Functional MR Diastolic (III b): Mitral stenosis; Dystrophic leaflet calcification

Combination

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Carpentier Classification
I II III

Type I Normal leaflet and chordal motion Type II Prolapse or excessive motion Type III Restricted motion
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Degenerative MR: Prolapse vs. Flail

Prolapse - leaflet displacement above the annulus by 2 - 4 mm in which the free edges of the leaflets remain supported

Flail leaflet has both ruptured chordae and an unsupported free edge that extends above the opposing leaflet during systole

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Role of TEE

Mapping of anatomic defect Inadequate TTE

Acoustic shadowing due to prosthetic

valve or dense annular calcification Endocarditis Annular abscess

Intraoperative evaluation of MV repair

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Mitral Valve Scallops

Sup/Ant

Ao

LA

A1 A3 P1 P3 A1, P1 anterolateral A2, P2 central A3, P3 - posteromedial

A1
Medial

A2 A3 P2 P3
Inf/post

P1
Lateral

Adapted from Foster et.al. Ann Thorac Surg 1998

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How to fix it: Anatomic definition critical

Surgical Approach
Posterior leaflet Anterior leaflet
Quadrangular resection Higher short-term and long-term success May require chordal switch Less successful

Percutaneous approaches
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Complex mapping for leaflet localization

0 degrees

60 degrees
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3-Dimensional Echocardiography

Prolapsed segment

Courtesty of TomTec Corporation

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How well is the LV compensated?

Echo evaluation of LV dimensions and LVEF Basis for ACC/AHA recommendations for valve replacement

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Mitral regurgitation: Indications for surgery in non-ischemic MR

Bonow et al JACC 2006 Indication
Acute syx severe MR Symptomatic chronic severe MR with EF > 30% and/or ESD < 55 mm Asyx MR with LVEF <55% and/or LVESD > 40 mm Repair recommended over replacement Asyx pt with preserved LVEF when repair likelihood > 90% Asyx with preserved EF and Afib or PHT Severe LV dysfxn with EF< 30%, ESD >55 with primary MR when repair likelihood is high Severe LV dysfxn with EF< 30%, ESD >55 with functional MR unresponsive to med Rx + CRT

Class
I I I I IIa IIa IIa IIb
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Mitral regurgitation: Indications for surgery in non-ischemic MR

Bonow et al JACC 2006

Indication
MVP and preserved LVEF with recurrent ventricular arryhthmias despite med Rx Asyx pts with preserved LVEF when repair unlikely Mild or moderate MR

Class
IIb III III

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Functional mitral regurgitation

Symmetric leaflet tethering

Central MR jet Severity dependent on:
Coaptation depth Tenting angle

Asymmetric leaflet tethering

Eccentric jet Ipsilateral to tethered leaflet
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Causes of Functional MR in Dilated cardiomyopathy

Left Ventricular dilation Papillary muscle splaying Mitral annular dilation

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Functional MR

MR CHF

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Coaptation Depth
(Leaflet tenting)

2.0 cm

Symmetric tethering due to splaying of papillary muscles in DCM

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Asymmetic tethering Inferior infarct with remodeling Restricted posterior leaflet motion Usually in setting of IMI with remodeling

Posterior MR jet
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Functional MR

More likely respond to medical therapy and

CRT More difficult to address surgically

Annuloplasty ring for symmetric leaflet

tethering Ischemic MR with asymmetric tethering technically challenging

Lesser degrees of MR may be clinically

important ie. EROA of 0.2 cm2
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Conclusions:

Echocardiography currently provides the

best qualitative and quantitative assessment of mitral regurgitation Directed imaging provides important anatomic information vital to MV repair Indications for intervention in hemodynamically significant MR still evolving Percutaneous repair likely to become a viable option

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