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Echocardiography in the Diagnosis of Mitral Regurgitation


... from parasternal and apical views provide estimation of ... All three apical views. Subcostal long axis. Doppler/color Doppler. Severe 4 Grade IV ... – PowerPoint PPT presentation

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Title: Echocardiography in the Diagnosis of Mitral Regurgitation

Echocardiography in the Diagnosis of Mitral
  • Dysfunction or altered anatomy of any one of the
    components of the mitral valve apparatus can
    result in mitral regurgitation.

Etiology and Presumed Mechanisms of MR
2-D Criteria
  • The left ventricle ejects blood both forward into
    the aorta against systemic vascular resistance
    and backward into the low-resistance left atrium.
  • Since the left ventricle effectively pumps
    against the low afterload early in the disease
    course, the increase in left ventricular stroke
    volume is achieved mainly by more complete left
    ventricular emptying (an increase in ejection
    fraction) rather than by left ventricular

2-D Criteria
  • 2-D and M-mode echo are useful in detecting the
    underlying cause of mitral regurgitation
  • The left ventricle is expected to appear
    hyperdynamic on 2D imaging when mitral
    regurgitation is present.

2-D Criteria
  • With chronic regurgitation, progressive left
    ventricular dilation eventually occurs as the
    regurgitant volume increases the LV is
    hyperdynamic. So accurate LV measurements should
    be taken.
  • The left atrium gradually dilates to accommodate
    the regurgitant volume while maintaining a normal
    left atrial pressure. So the LA should be

2-D Criteria
  • With acute MR, the regurgitant volume is
    delivered into a small, noncompliant left atrium,
    resulting in a significant increase in left
    atrial pressure.
  • Echocardiographic evaluation of the patient with
    mitral regurgitation includes noninvasive
    measurement of pulmonary artery pressure from the
    tricuspid regurgitant jet velocity and estimate
    of RA pressure

2-D Criteria
  • This is performed because, pulmonary artery
    pressure rises passively in response to both the
    chronic mildly elevated left atrial pressure seen
    with chronic mitral regurgitation and the acute
    severe elevation seen with acute regurgitation.
  • When left atrial pressure is chronically
    elevated, pulmonary vascular resistance may

CM-mode and M-mode
  • Can help in the evaluation of the time of the MR
    relative to the systolic cycle
  • LA and LV size are usually dilated although could
    be normal in mild MR
  • Can cause early systolic closing of the aortic
  • Rounded E point
  • Hyperdynamic LV motion

Evaluation of Hemodynamic Severity
  • The amount of regurgitant flow must be determined
  • The effect of the regurgitation on the left
    ventricle, i.e., the degree of left ventricular
    volume loading, must be assessed
  • The effect of the regurgitation on left atrial
    and pulmonary venous pressure, i.e., the degree
    of LA/pulmonary venous loading, must be determine

Doppler/color Doppler
  • Multiple Doppler parameters can be used to assess
    the quantity of mitral regurgitant flow. These
    include both semi-quantitative parameters such as
  • peak velocity of forward flow across the MV
    during diastole, which increases as the
    regurgitant volume increases,
  • area, and length of the regurgitant jet as assess
    by color Doppler,
  • width of the regurgitant jet by the point of
    valve leaflet apposition (vena contracta)
  • and the intensity of the spectral Doppler
    velocity profile

Doppler/color Doppler
  • All these parameters correlate with angiographic
    estimations of severity when MR is either mild or
  • However, in patients with moderate degrees of MR
    these parameters have been less definitive

Doppler/color Doppler
  • CW may be useful in quantitative assessment of
    severity (increase density of the envelop)
  • The velocity of the mitral regurgitation tends to
    be lower lt5m/sec with increasing severity because
    the increase LA pressure reduces the transmitral
    systolic gradient
  • Acute MR the jet will peak in early systole

Doppler/color Doppler
Doppler/color Doppler
  • In MR, antegrade flow (mitral inflow) velocity
    may be increased with severe regurgitation.
  • Peak mitral diastolic velocity (E point) gt1.5
    m/sec with normal pressure ½ time is severe MR

Doppler/color Doppler
  • In the parasternal views use pulsed color Doppler
    flow in the LA for systolic turbulence and to
    evaluate the Vena Contracta
  • Vena Contracta gt0.5cm is considered significant

Doppler/color Doppler
  • mapping technique of flow disturbance from
    parasternal and apical views provide estimation
    of severity using pulsed and more commonly color

Doppler/color Doppler
  • MR should be assessed in all views
  • Parasternal long and short axis
  • All three apical views
  • Subcostal long axis

Doppler/color Doppler
Doppler/color Doppler
  • In color flow imaging of MR, the area of the
    regurgitant jet relative to the size of the LA is
    most predictive of regurgitant severity
    determined by angiography

Doppler/color Doppler
  • Jet area is more reliable than jet length method
    in mapping. It is done by planimetry of the
    regurgitant jet in the LA and RA then dividing by
    the left or right atrial areas

Doppler/color Doppler
  • Pulmonary Vein Flow reversal
  • Use the right upper pulmonary vein
  • Place the PW Doppler cursor at least .5 to 1 cm
    into the pulmonary vein
  • Open the Doppler gate to 1 cm
  • Set the Doppler spectral sweep speed to 100 msec

Doppler/color Doppler
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