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

12 13 14 15 PARAMETERS Symptoms/ History Physical signs: -JVP -Pulse -BP

Chamber enlargement Cardiac murmurs Dynamic auscultation 16 PHYSICAL SIGNS Influenced by : - Heart rate - Blood pressure - Cardiac output - Heart failure Volume & volume of Blood flow Cardiac murmurs Low output Alters the murmurs (intensity & duration) 17

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

Sensitivity : 24% 21 CLINICAL ASSESSMENT OF VALVULAR HEART DISEASE Symptom evaluation : severity Complications AF,PH, CHF Cardiomegaly chamber enlargement Sounds :S1&S2 S4/S3 Cardiac murmurs: - length of murmur - Intensity - Conduction 22

ECHO DOPPLER EVALUATION-REGURGITATIONVALVULAR M-mode temporal resolution 2DE: TTE Multiple views TOE Pulse Doppler/CW Doppler -Flows/VTI Colour Doppler - Qualitative jet parameters - Quantitative - Vena Contracta - PISA(for EROA) Tissue Doppler - for LV function Stress Echo : - Physical - Pharmacologic

RT3DE 23 ECHO DOPPLER: VALVULAR REGURGITATION Anatomy : Valve Size of LV Aorta Function: Complications: 24

ECHO-DOPPLER GRADING Severity MR Primary Qualitative Length 1/2 Length LA Area

<4cm2 - >10cm2 Area/LA area <20% - > 40% VC width (mm) <3 >7mm VTI: Mitral/Aorta

<1 >1.4 Mitral Flow A>E E>1.5cm/sec Systolic Dominance Systolic flow reversal

EROA (mm2) <20 >40 Reg Volume <30 >60 MR Jet

Semi Quantitative Pulm Vein Flow Quantitative LA/LV Size/PA pressure European Association Imaging - 2013 26 27 28

MITRAL REGURGITATION INDEX Six parameters : Jet length PISA Jet Density Pulm venous flow pattern PA pressure (RVSP) LA Size Each Parameter Grade: 0-3/6 MR index: <1.6 >2.1 29

ECHO DOPPLER GRADING Severity AR Qualitative Colour flow jet Diastolic Flow reversal (Desc Thor Aorta) Abd Aorta Width Length

Pan diastolic Semi Quantitative VC (width) <3mm >6mm PHT (msec) >500 <200

EROA (mm2) <10 >30 Reg Volume (ml) <30 >60 Quantitative

LV Size/Function 30 MR - SEVERITY Stress Testing - Physical stress - Pharmacological Exercising capacity Symptoms Response PA Pressure (PA > 60 mmHg) LV function: response to stress EF: % - contractile reserve - Tissue doppler parameters

- 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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