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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. 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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  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

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