MITRAL REGURGITATION FROM BEDSIDE TO HEMODYNAMICS Dr. DayaSagar Rao. V DM(Cardiology) FRCP(Canada) FRCP(Edinburgh) Senior Consultant Interventional Cardiologist KIMS Secundrabad MITRAL REGURGITATION Regurgitation LV to LA: Decrease effective forward flow Severity is expressed Regurgitant fraction (%) Regurgitant volume
VALVULAR REGURGITATION NATIVE VALVE Primary Secondary Prosthetic valve 3 RgV = RoA x Cd x MPG x T (Levine and Gaasch JACC:1996, 28: 1083-91) ROA = Regurgitant orifice area
- Fundamental determinant directly proportional - Dynamic : Size & Shape - Load Dependent DISCHARGE CO-EFFICIENT Cd = Discharge Co-efficient. Geometric area Effective orifice area smaller by 15-20% (0.8 0.85 of geometric area) Orifice geometry Flow Viscosity SYSTOLIC MPG LV-LA Pressure gradient
Important determinant RV MPG on RV function of its square root 25% reduction MPG results 13% reduction RV SBP at time of assessment should be considered With HTN Intraop evaluation of MR on CPB with low SBP Therapeutic Decrease SBP Decrease RV DURATION: SYSTOLE - MR Patients MVPS
Late MR Single frame measurement jet area Vena Contracta PISA Over estimation severity MR Analysis Doppler-cw: onset-offset There is no mitral regurgitation (MR) in early (A) or mid (B) systole. In late systole, a large MR jet with a large proximal flow convergence region (black arrow) and wide vena
contracta is seen (C). Continuous-wave Doppler of the same MR jet shows that it is present only during late systole (D). In such cases, a single-frame measurement, such as proximal isovelocity surface area or vena contracta, overestimates MR severity. MITRAL REGURGITATION CAUSES PRIMARY - CRHD - MVPS - Connective Tissue - Infective Endocarditis Congenital
- Part AV canal - Isolated cleft Drug induced - Anorectic - Antiparkinsonian - Radiation injury Interventional 11
SYMPTOMS - Filling pressures: (LA/RA) - Cardiac output : Low output Extent of disability: Self care Activity : 3 Mets Household Activity Leisure Activity Sport Activity : 10 Mets More symptomatic - More severe lesion Discrepancy - Symptoms & Severity - Co- Morbidities : Anemia Infections Thyroid Etc. 18
COMPLICATIONS - Cardiomegaly - CHF / Ventricular Dysfunction - PAH - Atrial Fibrillation/Dysrhythmias Related Severity & Duration of valvular Disease 19 MITRAL REGURGITATION Cardiomegaly / LV apex / PH Auscultatory findings - severity MR & valve morphology Wide splitting II, Early closure of A2
S3 + PSM Grade IV Conducted Axilla & Interscapular region MDM 20 Murmur is harsh (instead of soft blowing) indicating low & medium frequency. usually indicates lot of flow & thus significant regurgitation Variable correlation between intensity of MR murmur & severity of regurgitation. Loud murmur associated with thrill (grade IV / greater) Specificity : 91% Severe MR
- Strain: long axis - Global CMR (cine MRI) Volumes calculated : short axis slices Stroke volume: Phase contrast velocity encoding (distal sinotubular ridge) Contraindications Arrhythmias: ECG gating - AF in MV disease Medical devices Pacemakers - CRT - ICD Availability Ecpertise interpretation
- Cost Claustrophobia CMR (cine MRI) Volumes calculated : short axis slices Stroke volume: Phase contrast velocity encoding (distal sinotubular ridge) Contraindications Arrhythmias: ECG gating - AF in MV disease Medical devices Pacemakers - CRT - ICD Availability Ecpertise interpretation
- Cost Claustrophobia CATH LAB EVALUATION -SEVERITY REGURGITATION Cardiac cath - Symptomatic patient Non invasive tests inconclusive Discrepancy Non invasive test & physical exam (Severity of lesion) -Asymptomatic Exercise testing - confirm absence of symptoms
- Assess Hemodynamic response to exercise - prognosis ACC/AHA Guidelines 2014 Management of patients Valvular heart Disease 34 ANGIOGRAPHIC ASSESSMENT OF SEVERITY BY LEFT VENTRICULOGRAPHY LA opacificatio n Time
required Clearance of Comparison with LA opacification of LV opacification 1+ (Mild) Partial (Never complete) -----
Single beat Less 2+ (Moderate) Faint complete Several beats Several beats Less
3+ (moderately severe) Complete Several beats Several beats Same 4+ (severe)
Complete Single beat Several beats More dense with each beat Reflux of contrast in pulmonary veins 35 VALVULAR REGURGITATION SEVERITY ASSESSMENT
Cli ni ca l EC G Cx RPA 2DEcho + Doppler
Qualitati ve Quantita tive Cath Data Obsolete for many 36
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