How to diagnose and assess severity of mitral regurgitation by echo
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How to Diagnose and Assess Severity of Mitral Regurgitation by Echo. Noel Black Chief Cardiac Physiologist South Eastern Trust. Modalities. 2D and M-Mode Colour Doppler Pulsed Wave and Continuous Wave Doppler 3D. M-Mode. Left atrial dilatation Left ventricular dilatation

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How to diagnose and assess severity of mitral regurgitation by echo

How to Diagnose and Assess Severity of Mitral Regurgitation by Echo

Noel Black

Chief Cardiac Physiologist

South Eastern Trust


Modalities
Modalities by Echo

  • 2D and M-Mode

  • Colour Doppler

  • Pulsed Wave and Continuous Wave Doppler

  • 3D


M mode
M-Mode by Echo

  • Left atrial dilatation

  • Left ventricular dilatation

  • Left ventricular volume overload pattern

  • Increased D-E amplitude of the mitral valve anterior leaflet


2-D by Echo

  • Status of the Mitral Valve Apparatus

    • Leaflet prolapse

    • Rheumatic disease

    • Myxomatous degeneration


Organic aetiology
Organic Aetiology by Echo

  • Calcification

  • Vegetation

  • Mass


Functional ischaemic
Functional Ischaemic by Echo

  • Left ventricular impairment

    • Chordal/papillary muscle involvement


Functional lv la dilatation
Functional. LV/LA dilatation by Echo

  • Mitral annular dilatation (normal 2.3+- 0.5cm) A4Ch view

  • LA dilatation

  • LV dilatation


Disease process
Disease Process by Echo

Aetiology

Mechanism Non-Ischaemic Ischaemic

Organic Rheumatic Ruptured PM

Prolapse

Endocarditis

Flail leaflet

Functional Cardiomyopathy Post-MI


Colour flow doppler
Colour Flow Doppler by Echo

  • 1.Flow distribution (jet size)

  • 2.Vena contracta

  • 3.PISA


1 flow distribution
1.Flow distribution by Echo

  • How far the regurgitant jet extends into the LA.

  • Trace area of the jet and LA

    • Jet area (cm)2

      • Severe MR: >10

    • Jet area / LA (%)

      • Severe MR: >40


Colour flow doppler1
Colour Flow Doppler by Echo

  • Jet position in relation to the mitral leaflets.

    • Evidence of leaflet perforation.

    • Multiple or single jets


Colour doppler

The direction of the regurgitant jet by Echo

Centrally

anteriorly

posteriorly directed.

Away from abnormal leaflet.

Colour doppler


Consider image quality
Consider Image quality by Echo

  • Poor image quality may underestimate severity


Consider jet direction
Consider –Jet direction by Echo

Direction of the Jet (entrainment effect)

  • Central jet overestimated

  • Eccentric jet underestimated




2 vena contracta width
2.Vena Contracta width cm/s

  • Narrowest region at the mitral valve level

  • 2 planes

  • Nyquist 50-60 cm/s

  • Zoom to optimise visualisation

  • Colour sector as narrow as possible

  • Maximal lateral and temporal resolution

    • Mild MR :

    • VC <0.3cm

    • Severe MR :

      VC >0.7cm


Consideration
Consideration cm/s

  • VC width is inaccurate with multiple jets


Consideration1
Consideration cm/s

  • VC should not be measured in Apical 2Ch view

    • Parallel to the mitral orifice.

    • Overestimation.


3 proximal isovelocity surface area pisa
3.Proximal Isovelocity surface area (PISA) cm/s

  • Hemishells

  • Flow convergence area

  • Increases with severity of regurgitation


Calculating pisa
Calculating (PISA) cm/s

  • Apical 4Ch view

  • Narrow sector width

  • Minimise depth

  • Zoom

  • Adjust Colour Doppler alaising velocity (20-40 cm/s)


PISA cm/s

  • Measure the radius of the hemisphere. (red/blue interface)

    • PISA radius =2πr2 (cm2)

      • Mild MR: <0.4

      • Severe MR:>1.0


Consideration2
Consideration cm/s

Non-circular orifice


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