Structural and Functional

Mitral Regurgitation:
Echo Subleties and Hallmarks

Steven A. Goldstein, MD
Director, Noninvasive Cardiology
Washington Hospital Center
Sunday, February 21, 2010
The Mitral Apparatus

• Mitral leaflets
• Chordae tendinae
• Papillary muscles
• Mitral annulus
• Left ventricle
• Left atrium
 Mitral Valve Anatomy
Dilatation Left atrium Dilatation
Calcification
Prolapse
Redundancy
Annulus Thickening
Perforation
Leaflets Cleft
Commissural fusion

Chordae Abnormal insertion

Elongation
tendinae Rupture
Thickening/fusion
Papillary Ischemia
muscles Fibrosis
Rupture

LV free Lateral displacement

(ischemia, fibrosis,
wall dilatation)
 Mechanisms of Mitral Regurgitation

Normal Prolapse
Apical
Tethering

Dilated anulus

Restricted PML Ruptured pap muscle

 Mitral Valve Repair
Mechanisms to be Discussed

• Ruptured chordae tendinae

• Mitral valve prolapse (MVP)

• Ischemic/functional MR
Ruptured cords
 Case 1
Ruptured cords P2
 1.6 cm

+
.
.
.
+
Gastric short-axis view
(PSR view)
 L-upper pulm vein

Systolic flow reversal  severe MR

Roadmap for the surgeon
 Mitral Valve Repair
Information Required by Surgeon

• Exact lesion(s) - affected segment(s)

• Extent

• Degree of calcification (leaflet/annulus)

• Dilatation/size of annulus
Case 2
Ruptured cord P2
 Case 3
Ruptured cords A2 and A3
Surgeon’s roadmap  A2 and A3
MVP
 Case 4
Mitral Valve Prolapse
AML
S/P repair
Functional MR
 Morphologic Changes in Heart Failure

Papillary muscles displaced apically and laterally

Bolling J Heart Valve Dis 11:S28(2002)
 Functional Mitral Regurgitation
• Global LV dysfunction
• Regional LV dysfunction
• Sphericity of LV
• Excessive pap muscle displacement
• Decreased overlap of leaflets
• LA enlargement
• Loss of systolic mital anular contraction
• Increased “tenting” area
• Delayed activation of P-M pap muscle (dyssynchrony)
Ischemic Mitral Regurgitation

B
C
A

Mitral leaflets are tented apically

Mitral annulus is enlarged (A-B = 45mm)
Mitral coaptation depth is increased (C-D = 13 mm)
Effect of Annular Dilatation on
Tethering Area

MROP340
Apical Tethering of Mitral Leaflets

Basal cord tents

anterior leaflet
(“seagull sign”)
Basal cord tents
anterior leaflet
(“seagull sign”)

Increased tenting area

 Distance from Mitral Annulus to
Mitral Leaflet Coaptation Point

Normal Ventricle Spherical Ventricle

Ischemic MR
 Ischemic Mitral Regurgitation

"Ischemic MR" is a commonly used term,

but its definition is not clearcut; Most
articles discussing ischemic MR do not
even define it !
 Ischemic Mitral Regurgitation
Definition

Moderate to severe MR due to CAD

(MI, myocardial ischemia, or resulting
LV remodeling) in the absence of primary,
preexisting leaflet or chordal pathology
 Ischemic Mitral Regurgitation
Mechanisms

• Dislocation of papillary muscles

• Increased tenting length and area
• Antero-posterior dilatation of the MV annulus
• Kinetics of MV annulus during cardiac cycle
• Intraventricular synchrony/dyssynchrony
• Atrio-ventricular synchrony
 Ischemic Mitral Regurgitation
Single Papillary Muscle Involved

Local malfunction of LV wall adjacent to a single pap muscle

Calafiore Eur Assoc Cardio-Thorac Surg 2005
 Abnormal Mitral Valve Coaptation

Normal coaptation Abnormal coaptation

 Case 7
Ischemic MR  restricted PML
 LVIDd = 6.4 cm

Dilated LV; posterior wall thinner than septum

Bent anterior mitral leaflet
Increased tenting area
Mitral Annular Calcification
(MAC)
Mitral Annulus Calcification
Ventricular and Leaflet Extension
 Ischemic Mitral Regurgitation
Mechanisms

• Dislocation of papillary muscles

- Papillary muscles dislocated toward apex
- Apply traction to chorade
- Chordae tendinae lack elasticity

• Increased tenting length and area

• Antero-posterior dilatation of the MV annulus
• Kinetics of MV annulus during cardiac cycle
• Intraventricular synchrony/dyssynchrony
• Atrio-ventricular synchrony
 Ischemic Mitral Regurgitation
Mechanisms
• Dislocation of papillary muscles

• Increased tenting length and area

1. Anterior MI  displacement of the 2 pap muscles
in the global LV enlargement

2. Posterior MI  displacement of the postero-medial

pap muscle responsible for an asymmetric tethering
• Antero-posterior dilatation of the MV annulus
• Kinetics of MV annulus during cardiac cycle
• Intraventricular synchrony/dyssynchrony
• Atrio-ventricular synchrony
 Ischemic Mitral Regurgitation
Mechanisms
• Dislocation of papillary muscles
• Increased tenting length and area
• Antero-posterior dilatation of the MV annulus
A-P dilatation of the mitral annulus can determine
the degree of MR, even if no anomaly of the mitral
leaflets exists

• Kinetics of MV annulus during cardiac cycle

• Intraventricular synchrony/dyssynchrony
• Atrio-ventricular synchrony
 Ischemic Mitral Regurgitation
Mechanisms
• Dislocation of papillary muscles
• Increased tenting length and area
• Antero-posterior dilatation of the MV annulus
• Kinetics of MV annulus during cardiac cycle
Progress in echo imaging, particularly including 3D-echo
have demonstrated the importance of motion and
specific features of kinetics of the annulus
• Intraventricular synchrony/dyssynchrony
• Atrio-ventricular synchrony
 Ischemic Mitral Regurgitation
Mechanisms
• Dislocation of papillary muscles
• Increased tenting length and area
• Antero-posterior dilatation of the MV annulus
• Kinetics of MV annulus during cardiac cycle
• Intraventricular synchrony/dyssynchrony
- Several investigators have demonstrated correlation
b/w width of QRS and degree of “functional” MR

- Observational data on resynchronization by pacing

can improve functional ischemic MR

• Atrio-ventricular synchrony