L5: Mitral Valve Anatomy and Regurg

Chris Benson and Pete lectures. loading conditions

What is mitral regugitation

backflow of blood into the LA during systole due to MV failing to close properly at the correct time

List of MV disorders?

Primary: Congenital cleft MV, MV prolapse, MV flail (PM rupture), MV billowing, elongated AMVL (HCM), redundant AMVL (Marfans), Rheumatic MS, degenerative MS, Barlows disease, myxomatous MV leaflets,

Secondary: leaflet perforation (surgery/ IE) MAD, MAC, MAD,

MAC

MR

Lumps: Papillary fibroelastoma,

Chordae rupture

Barlows disease

Rheumatic MV disease

Different ways of categorising MR?

• Primary/ Secondary (degenerative/ functional)

• Carpentiers classification

What are the main causes of primary MR?

• Prolapse/ flail leaflet —> Ischaemic event

• Chordae rupture

• Papillary muscle rupture

• Myxomatous MV —> Barlows disease

• MAC?

What is a descriptor for thickened MV, with soft excess tissue

myxomatous

What disease linked to thickened MV, with soft excess tissue

Barlows disease

What is another term for Barlow’s valve

myxomatous valves

Ways of qualitative MR description

• describing how much over the cycle

• density: faint/ dense

• jet direction: eccentric/ central/ posteriorly directed/ anteriorly directed

Ways of describing flow in terms of cycle

• brief/ holosystolic

MR is to do with loading conditions

At what cycle points can you have MR

• early systolic: common with mass

• holosystolic: functional MR, calcified tips, endocarditis on tip

• late systolic: common with prolapse: leak at the end

In which views does MR look worse?

• A2C

When can you not trace the MR for VTI or MR Vmax?

When not got a full parabolic CW envelope

What can be a contraindication for measuring PISA

• eccentric jet

• secondary MR jet

What is incorrect PISA a problem?

• because EROA, flow rate, and regurgitant volume follow from this and will all be affected

What is billowing vs prolapse vs flail

• the coaption level and the direction of the tips distinguish

• coapting l

What is definition of MV billowing?

Leaflet: is bowing but not 2mm below the annulus.

Tip: pointing apically

What is definition of MV prolapse ?

Leaflet: bowing 2mm below the annulus.

Tip: pointing apically

What is definition of MV flail ?

Leaflet:

Tip: pointing towards LA

What causes MV flail?

• caused by chordae rupture

• usually an acute event vs chronic progression:

• Ischaemic event causing PM rupture and chordae rupture

• Infective endocarditis causing chordae rupture

• Spontaneous degeneration

• Blunt chest trauma

What is the classification system for MR?

Carpentiers Classification

When do we have normal leaflets but MR

• functional MR

• perforation

What carpentiers class would be infective endo but normal movement?

Class 1

What can be a cause of type 3b Carpetnies

• also functional

What is primary MR / degenerative MR

What is another word for primary MR

degenerative MR

Different types of MR?

• primary MR / degenerative MR

• secondary mitral regurgitation / functional regurgitation

causes of What is primary MR / degenerative MR

myxomatous degeneration of MV leaflets causing prolapse:

• Flail MV leaflet

• Fibroelastic deficiency (elderly)

• Barlow’s disease: myxomatous leaflets

• Leaflet perforation (Infective endocarditis).

• Mitral annular calcification.

• Congenital (cleft leaflets).

• Rheumatic disease.

• Marfans syndrome

• Ehlers danlos

What is secondary mitral regurgitation / functional regurgitation

• valve is normal

• problem with tethering forces

What are different types of tethering forces for MV?

• Atrial FMR (functional

• Ventricular FMR

What does Atrial FMR (functional MR) look like?

• leaflets and tips lie flat. tips don’t point apically

What does Ventricualr FMR (functional MR) look like?

• leaflet tips point apicallly

causes of secondary mitral regurgitation / functional regurgitation

• ischaemic CM: RWMA/ Papillary muscle/ chordae —> flail

• LV dilatation:DCM

• LA dilatation: AF

• SAM: HoCm/Takotsubo --> Venturi effect --> SAM of MVL -->

When in cardiac cycle do you get MR?

• either systole or diastole

• mainly in systole

• can happen in diastole

• one or the other

What is acute MR?

• very dangerous

• RAP skyrockets, pressure in pulmonary veins, pulmonary edema

• Heart has no time to adjust to regurg so critically ill

Causes of acute MR?

• papillary muscle rupture (can be result of STEMI)

Symptoms of acute MR?

• LV hyperdynamic

If you have MR an hyperdynamic LV this can indicate severe MR

higher preload and reduced afterload

Doppler hallmark of severe MR

Traingular and early peaking not parabolic

Chronic MR

When is it too late really to operate on chronic MR

• pulmonary edema

How can MR affect the LVEF?

• can mask it and make it look higher

What is better repair or replacement?

• repair

What is lifespan for MV valve replacement?

• 10 years

What are the problems with MV replacement ?

• highest pressure valve so must be able to withstand high pressures and can be deformed over time

Mechanical valve pharmacology

• warfarin

What is the name of the surgery for anular repair?

Annuloplasty

What does TEER stand for?

Transcatheter edge-to-edge repair

What’s a good extra measurement to take for MR assessment?

• A4C pulmonary vein

What are issues of eccentric jets for the PISA radius equation

-Vmax and VTI could be an underestimation

How to optimise PISA

• specific image

• reduce depth/ zoom

• sector width

• small colour box

all to increase frame rate to find best frame that gives best neck

Error in PISA measurements

What’s another method to quantify MR Regurg volume?

• Stroke volume method: SV MV - SV LVOT

What are the problems with volumetric measurement of MR b

• assumes circular MV: its not —> saddle shaped

• assumes circular AV: its not —> elliptical

so cannot really compare the flow accurately

MV inflow VTI/ LVOT VTI

-last resort if no PISA but better than the volumetric method

What views can PISA be performed in?

• A4C

• A2C

• PLAX

Stenosis: what is a way of spotting stenosis in CFD

PISA but going other way

What measurements can you not do if you have 2 jets of MR?

Can’t do:

• PISA

• Vena contracta

• fractional area of jet

How to assess MR when 2 jets?

• Stroke volume method (SV regurg valve - SV compliant valve) as we cannot measure PISA

What is the coanda effect ? How is related to MR

• The Coanda effect refers to the phenomenon by which a narrow jet of liquid (or air) passing through an orifice directly in sequence with a solid (especially convex) surface will deviate from its path and adhere to this curved surface, following its shape in parallel.

MR- What is the stroke volume method? WHat does it relate to?

• calculation of regurg volume

Cannot use this method in the presence of MS

what are the problems with assessing Regurg volume from the stroke volume method

• assumed a circular MV orifice which it isn’t

What would the immediate consequences of this be?

• Eccentric anteriorly directed severe MR.

What does this show? What symtoms

-congenital cleft MV

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