Valvular regurgitation - MASTER SET

Murmur characteristics

• Low pitched

• Diastolic

• Increased with inspiration

PI murmur is called a

Graham Steel Murmur (Board question)

systolic murmurs are heard when there’s regurgitation with

Atrioventricular valves

diastolic murmurs are heard when there’s regurgitation with

Semilunar valves

Acute regurgitation always results in

pressure overload

Etiology (causes) 6

• Pathologic PI is not frequent

• MOST COMMONLY caused by pulmonary HTN

  • Leads to Annular dilation

• Endocarditis

• Rheumatic Heart Disease

• Tetralogy of Fallot

• Carcinoid

% of people with normal PI

40-87%

Pathologic PI

NOT FREQUENT

• This valve usually doesn’t have a lot of problems

Why is it difficult to see the valve cusps on a 2D echo

Pulmonic valve leaflets are very thin

Pulmonic insufficiency directed towards the Tricuspid leaflet causes:

Diastolic fluttering on M-Mode

RV Volume overload on M-Mode causes (2)

RV Enlargement and paradoxical septal motion

Evaluate _______ & ________ of the PI Color doppler jet

EXTENT & AREA

Assess CW Spectral doppler jet _______ for _______

assess CW spectral doppler jet DENSITY for SEVERITY

Severe PI causes

Rapid equalization of RV and Pulmonary artery pressures

Regurgitation for PI is above the baseline and SEVERE PI IS DAGGER SHAPED

• Rapid reversal

• rapid desceleration

• BAD BAD BAD!

Murmur - TV (2)

• holosystolic

• increase with respiration

Etiology (causes) TR (10)

• Pulmonary HTN

  • Due to RV enlargement and Annular Dilation

  • can be caused by MV Disease or Pulmonary HTN

• Rheumatic Heart Disease

• Triscupid valve prolapse

  • Often associated with Mitral valve prolapse

• RV Failure

• RV MI

• Carcinouid

  • TV is most affected by radiation

  • CHD

    • Marfans sydrome - poor connective tissue

• Ebstein Anomoly

  • CHD

• Trauma

• Endocarditis

• Pacerwire

  • Goes through the TV

Ebstein anomoly

Assessment of TR

• Extent, area, direction of TR Jet

• PW of hepatic vein in SUBC

Views for assessing TR

• RVIT

• PSAX

• A4C

• SUBC

• RT FOCUSED A4C

• A3C RT HEART VIEWS

Is PISA used often for TR

Nah bruh (rarely)

Vena contracta width severe for TR when its over

0.7 cm (7mm) SEVERE

Use TR peak velocity to assess

PAP

Severe TR

• vena contracta

• spectral waveform

• hep vein

• PISA

• Vena contracta >0.7 cm wide

• Dense spectral doppler waveform

  • early peaking

  • triangular shaped

• Hepatic vein

  • Blunted systolic wave, systolic flow reversal

• PISA Radius > 0.9 cm

RV Volume overload

Right ventricular englargement

Pardoxical septal motion

PISA Radius width

• mild

• moderate

• severe

Mild: <or= 0.5 cm

Moderate: 0.6-0.9 cm

Severe: >0.9 cm

what does this show and why

MILD TR

• Small color jet

• round CW doppler

• Systolic dominance in Hep vein

  • because LV is pushing blood through it

What is this and why

SEVERE TR

• Big color jet

• Steep and sharp reguritant CW Wwaveform

• systolic flow reverasal in PW Hep vein

• Dagger shaped high pressure that drops off quick

TR Due to RV enlargement and annular dilation common in what patient

IV Drug users because the dirty drugs hit the TV first

Severe TR is when there is more __________ flow than __________ flow

Severe TR is when there is more retrograde flow than antegrade flow

MODERATE TR

Systole and Diastole velocities are similiar

normal hepatic vein PW

• Systolic is larger than diastolic

Hepatic vein FLOW REVERSAL

• Look at systole! ITS GOING BACKWARDS BC PULMONARY PRESSURES ARE SO HIGH!!!

TR will causes a greater velocity in what part of diastole

TR = INCREASED E VELOCITY

Obtain peak CW TR for (2)

• PAP

• PISA Measurement

See what leaflets in these views

• RVIT:

• A4C

• PSAX

TV

RVIT: Posterior & anterior

PSAX: Anterior & septal

A4C: Anterior & septal

primary regurgiation

Problem with the leaflets

secondary regurgitation

problem with the valve appartatus

examples of secondary regurtation

cor pulmonal

• RT HF (W/ Embolos usually)

• RV MI

• Pacemaker wires going through TV

• Pulmonary HTN

  • RV Enlargement

  • annular dilation

  • leaflets fail to coapt

right sided failure will lead to

left sided failure

which fuction usually leads to the other

• systolic = diastolic?

• diastolic = systolic?

Systolic = diastolic

Primary regurgitation

– problem with the valve leaflets, e.g., rheumatic, age related, inflammation, congenital, therapy.

• Functional or secondary –

– The valve morphology is normal but there is a problem with supporting structures, e.g., ischemic heart disease and papillary muscle dysfunction and annular dilation.

Chronic regurgitation

results in chamber dilation with normal pressures

Acute regurgitation

results in normal chamber size with a sudden increase in pressure

Chronic mitral regurgitation will eventually lead to

o pulmonary hypertension and heart failure Increased afterload over time will lead to left ventricular hypertrophy

Regurgitation leads to

volume overload.

Left Ventricular Volume Overload

dilated left ventricle and hyperdynamic function

Right Ventricular Volume Overload

dilated right ventricle and paradoxical septal motion

Stenosis leads to

pressure overload.

Spectral Doppler waveform density –

the more severe results in a more prominent or dense spectral Doppler waveform.

• Flow convergence or PISA

– the flow velocity before the valve – small or none with mild regurgitation and more prominent when more significant regurgitation is present.

• Jet –

jet area and length, central or eccentric.

• Vena Contracta –

– the narrowest part of the jet at the valve leaflet tips.

know dis

Definition: MR

• AKA

• CAUSED BY

• Leaking of the mitral valve during systole from left ventricle to left atrium

• Also known as mitral insufficiency

• Due to incomplete closure of the mitral valve

decreased heart function causes what for regurge

decreased regurgitation but thick envelope

most common symptom of MR

MURMUR

• Blowing

• high pithed

• holosystolic

• cardiac apex radiates to axilla

MR can eventually lead to

Right heart failure due to backup in the pulmonary veins into the RA Increasing PAP

• TOO MUCH VOLUME

Etiology MR: Causes (6)

• Primary Mitral Regurgitation

• Functional Mitral Regurgitation

• Flail mitral valve leaflet

• Papillary muscle rupture

• Left ventricle

- ischemia, infarction, cardiomyopathy

• Mitral Valve Apparatus

MR Increases PRELOAD which causes the LV to become

hyperdynamic

WHAT VIEW IS MVP MITRAL VALVE PROLAPSE DIAGNOSED FROM ONLY!!!

PLAX!!! ONLY!!!

FLAIL MV

• Severe regurgitation

• leaflet fails to coap usually due to pap or chordae problem

• leaflet goes back into LA

• JET GOES IN DIRECTION OPPOSITE OF AFFECTED VALVE

Barlows syndrome

MV problems from fibrous disease

• primary MR

Primary Mitral Regurgitation

• problem with

problem with the leaflets

causes of primary MR (4)

o Mitral valve prolapse

o Endocarditis

o Rheumatic heart disease

o Mitral annular calcification

causes of Functional Mitral Regurgitation (4)

• Ischemic mitral regurgitation due to ischemia or cardiomyopathy

• Flail mitral valve leaflet

  • Papillary muscle rupture

  • Left ventricle - ischemia, infarction, cardiomyopathy

MV Apparatus

• any problem with these will cause MR

• Left atrial wall

• Mitral annulus

• Anterior and posterior leaflets

• Chordae

• Papillary muscles

• Left ventricular myocardium underlying the papillary muscles (tenting)

• Normal closure of the valve is at the annulus

Auscultation / Heart sound MR

High-pitched, blowing holosystolic murmur

Diseases of MV (6)

• Myxomastous Disease - MV Prolapse

• Rheumatic Disease

• Endocarditis

• Marfan Syndrome

• Ischemic MR

• Pap muscle rupture

Myxomatous disease – Mitral Valve Prolapse (5)

o Thickened, redundant leaflets and chordae

o Excessive motion and sagging into the left atrium in systole

o Mitral valve prolapse – minimal leaflet displacement

o Flail mitral valve leaflet – severe leaflet displacement

o Mid systolic click and mid-to-late systolic murmur

Rheumatic Disease

Thickening of the leaflet tips and restricted motion

Endocarditis

Thickening of the leaflet tips and restricted motion

Marfan Syndrome

Long, redundant anterior leaflet that sags into the LA in systole

Ischemic MR

• functional MR

• Caused by

• Relationship to MI

• What happens with PAP rupture

• what can happen to MV leaflets

• due to:

• results in _____ of leaflets

• MR is due to:

• MV

o Functional mitral regurgitation – the leaflets are normal – includes mitral regurgitation caused by ischemia and dilated cardiomyopathy

o Cause by papillary muscle displacement and dilation of the annulus

o Most common complication of an MI

o Severe mitral regurgitation can occur with papillary muscle rupture

o Tenting of the mitral valve leaflets (normal closure is at the annulus)

o Due to regional wall motion abnormalities or dysfunction

o Restricted leaflet motion – abnormal valve closure

o Results in apical displacement (“tenting”) and incomplete closure of the valve leaflets (normal mitral valve closure should be at the annulus)

o Mitral regurgitation is due to left ventricular distortion and annular dilation

o Mitral valve bend is caused by the basal chord

Papillary muscle rupture (Partial rupture of the papillary muscle)

• Comlication of :

• results in

• prognosis

o Complication of an acute myocardial infarction

o Acute, severe mitral regurgitation

o Poor survival

Ischemic MR caused by (6)

• PAP Muscle displacement and dilation of the annulus

• PAP rupture

• regional WMA

• Restricted leaflet motion-abnormal valve closure

• LV Distortion

• Annular dilation

What is the MC complication of MI

Ischemic MR

Pap muscle rupture can cause

severe MR

`Where is normal closure of MV leaflet tips

Annulus

What is it called when the MV closes distal to the annulus

tenting

tenting is _______ displacement which causes:

apicical displacement which causes incomplete closure

MV Bend is caused by what

basal chord

MR is due to

LV Distortion & annular dilation

The response to chronic volume overload on a chamber is

dilation with normal pressure

The response to acute volume overload on a chamber is

no dilation with marked increase in pressure

The initial response of the left ventricle to mitral regurgitation is

LV becomes hyperdynamic

Chronic mitral regurgitation

• progression

• wall thickness

• affect on systolic function

• LA

• PAP

o Progressive left ventricular dilation

o Normal left ventricular wall thickness

o Irreversible decrease in systolic function in the absence of symptoms

o Left atrium gradually dilates with normal left atrial pressure

o Pulmonary artery pressure increases

intermitant MR

• Due to ischemia

• pap displacement

• comes back to normal when ischemia is corrected

Acute mitral regurgitation

• LA

  • Size/pressure

o Normal left atrial size

o Significant increase in left atrial pressure

• can result in flail MV Leaflet

Two-Dimensional Evaluation: MR (5)

• Obtain careful, high-resolution imaging focusing on the mitral valve, chords and papillary muscles in both harmonics and fundamental modes in the parasternal and apical views

• Use magnification (zoom)

• Evaluate for flail mitral valve leaflet, mitral valve prolapse, mitral annular calcification

• Evaluate left atrial size

• Left Ventricle

How to evaluate LV 2D (3)

• Left Ventricle

o Evaluate left ventricular size and function - volume overload pattern

o Obtain end-systolic dimension

o Surgery needed with an end-systolic dimension greater than 45 mm and reduction in systolic function

Color Doppler Evaluation: (3)

• color doppler jet

• eccentric or central

• vena contracta width

Color Doppler Jet Area

• scale

• settings

• views

• jet (2)

o Normal Color Doppler Nyquist Limit Setting: 50 – 60 cm/s

o Correct color Doppler gain

o Parasternal and apical views

o Length of mitral regurgitation jet

o Area of jet –

▪ Less than 20% of the left atrial area indicates mild mitral regurgitation

▪ Greater than 40% of the left atrial area indicates severe mitral regurgitation

o Area of jet –

▪ Less than 20% of the left atrial area indicates mild mitral regurgitation

▪ Greater than 40% of the left atrial area indicates severe mitral regurgitation

Eccentric or central

▪ The severity of mitral regurgitant jets that hug a wall is underestimated

– it is more severe than appears due to the Coanda Affect (the jet stays attached to the curved surface, i.e., left atrial wall).

▪ Henri-Marie Coanda – Romanian aerodynamicist

o Timing (early, mid, late) and duration

▪ Mitral valve prolapse will produce late systolic mitral regurgitation

Vena Contracta Width

• where is the narrowest portion

• what view

• how to RES

• mild

• severe

o The narrowest portion of the color Doppler jet at the leaflet tips

o Parasternal long axis view - perpendicular to flow

o Magnify

o Mild = less than < 0.3 cm

o Severe = greater than 0.7 cm

Mitral Valve Inflow Doppler (LV Inflow)

o E velocity greater than 1.2 meters per second may indicate significant regurgitation with EF greater than 40%

o Deceleration time less than 150 milliseconds may indicate significant regurgitation

Continuous-Wave Doppler

o The jet is wider than the aortic stenosis jet – starts earlier

o More severe mitral regurgitation will produce a Doppler waveform that is complete and dark and triangular shaped