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

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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

  • 2D and M-Mode

  • Colour Doppler

  • Pulsed Wave and Continuous Wave Doppler

  • 3D


M mode

M-Mode

  • Left atrial dilatation

  • Left ventricular dilatation

  • Left ventricular volume overload pattern

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


How to diagnose and assess severity of mitral regurgitation by echo

2-D

  • Status of the Mitral Valve Apparatus

    • Leaflet prolapse

    • Rheumatic disease

    • Myxomatous degeneration


Organic aetiology

Organic Aetiology

  • Calcification

  • Vegetation

  • Mass


Functional ischaemic

Functional Ischaemic

  • Left ventricular impairment

    • Chordal/papillary muscle involvement


Functional lv la dilatation

Functional. LV/LA dilatation

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

  • LA dilatation

  • LV dilatation


Disease process

Disease Process

Aetiology

Mechanism Non-Ischaemic Ischaemic

Organic Rheumatic Ruptured PM

Prolapse

Endocarditis

Flail leaflet

Functional Cardiomyopathy Post-MI


Colour flow doppler

Colour Flow Doppler

  • 1.Flow distribution (jet size)

  • 2.Vena contracta

  • 3.PISA


1 flow distribution

1.Flow distribution

  • 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

  • Jet position in relation to the mitral leaflets.

    • Evidence of leaflet perforation.

    • Multiple or single jets


Colour doppler

The direction of the regurgitant jet

Centrally

anteriorly

posteriorly directed.

Away from abnormal leaflet.

Colour doppler


Consider image quality

Consider Image quality

  • Poor image quality may underestimate severity


Consider jet direction

Consider –Jet direction

Direction of the Jet (entrainment effect)

  • Central jet overestimated

  • Eccentric jet underestimated


Influence of colour gain settings on colour jet size 50 60 cm s

Influence of Colour Gain Settings on Colour jet size -50-60 cm/s


Consider frame rate sector and colour box size

Consider Frame rate- Sector and colour box size


2 vena contracta width

2.Vena Contracta width

  • 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

  • VC width is inaccurate with multiple jets


Consideration1

Consideration

  • 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)

  • Hemishells

  • Flow convergence area

  • Increases with severity of regurgitation


Calculating pisa

Calculating (PISA)

  • Apical 4Ch view

  • Narrow sector width

  • Minimise depth

  • Zoom

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


How to diagnose and assess severity of mitral regurgitation by echo

PISA

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

    • PISA radius =2πr2 (cm2)

      • Mild MR: <0.4

      • Severe MR:>1.0


Consideration2

Consideration

Non-circular orifice


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