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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

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How to Diagnose and Assess Severity of Mitral Regurgitation by Echo

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  1. How to Diagnose and Assess Severity of Mitral Regurgitation by Echo Noel Black Chief Cardiac Physiologist South Eastern Trust

  2. Modalities • 2D and M-Mode • Colour Doppler • Pulsed Wave and Continuous Wave Doppler • 3D

  3. M-Mode • Left atrial dilatation • Left ventricular dilatation • Left ventricular volume overload pattern • Increased D-E amplitude of the mitral valve anterior leaflet

  4. 2-D • Status of the Mitral Valve Apparatus • Leaflet prolapse • Rheumatic disease • Myxomatous degeneration

  5. Organic Aetiology • Calcification • Vegetation • Mass

  6. Functional Ischaemic • Left ventricular impairment • Chordal/papillary muscle involvement

  7. Functional. LV/LA dilatation • Mitral annular dilatation (normal 2.3+- 0.5cm) A4Ch view • LA dilatation • LV dilatation

  8. Disease Process Aetiology Mechanism Non-Ischaemic Ischaemic Organic Rheumatic Ruptured PM Prolapse Endocarditis Flail leaflet Functional Cardiomyopathy Post-MI

  9. Colour Flow Doppler • 1.Flow distribution (jet size) • 2.Vena contracta • 3.PISA

  10. 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

  11. Colour Flow Doppler • Jet position in relation to the mitral leaflets. • Evidence of leaflet perforation. • Multiple or single jets

  12. The direction of the regurgitant jet Centrally anteriorly posteriorly directed. Away from abnormal leaflet. Colour doppler

  13. Consider Image quality • Poor image quality may underestimate severity

  14. Consider –Jet direction Direction of the Jet (entrainment effect) • Central jet overestimated • Eccentric jet underestimated

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

  16. Consider Frame rate- Sector and colour box size

  17. 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

  18. Consideration • VC width is inaccurate with multiple jets

  19. Consideration • VC should not be measured in Apical 2Ch view • Parallel to the mitral orifice. • Overestimation.

  20. 3.Proximal Isovelocity surface area (PISA) • Hemishells • Flow convergence area • Increases with severity of regurgitation

  21. Calculating (PISA) • Apical 4Ch view • Narrow sector width • Minimise depth • Zoom • Adjust Colour Doppler alaising velocity (20-40 cm/s)

  22. PISA • Measure the radius of the hemisphere. (red/blue interface) • PISA radius =2πr2 (cm2) • Mild MR: <0.4 • Severe MR:>1.0

  23. Consideration Non-circular orifice