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ΑΝΕΠΑΡΚΕΙΑ ΜΙΤΡΟΕΙΔΟΥΣΒασικές αρχές απεικόνισης, εκτίμησης και ερμηνείας των.
Ηλίας Κ Καραμπίνος
Γ’Καρδιολογική Κλινική, Ευρωκλινική Αθηνών
DECLARATION OF INTEREST
No conflict of interest regarding this presentation
Prevalence of Mitral Regurgitation
• Framingham study found mild MR present in 19% of men and woman (asymptomatic)
• Severe MR, dependent on the study, is present from 0.2-1.9% of the general population.
Frequency of MR in heart failure pts
90% of pts with NYHA III-IV, 50% mod/sev
Echocardiography: a complementary approach to conventional clinical
examination
Agenda
• Recognizing mechanisms of pathophysiology
• Recognizing the “topology” of the pathology
• Approaching MR severity
• Identifying consequences derived from MR
• Coexistence with other valvulopathies
• Follow up
The role of echocardiography: we have to understand the problem
Recognizing pathophysiology?
Characteristics of true MR– Flow convergence
– Proximal flow acceleration
– Ejection flow with a vena contracta
– Downstream appearance-blood ejected through a constraining orifice
– Confined to systole
– Doppler signals appropriate in color
Mitral regurgitation
2D Echocardiography: Etiology of mitral regurgitation
Primary:
- Myxomatous
- Endocarditis
- Rheumatic
- Trauma
- Congenital
- Drugs
Secondary:
- Non-ischemic dilated CMP
- Ischemic heart disease
- HCM
Type I = normal leaflet motion but with annular dilatation or leaflet perforation
Type II = excessive leaflet motion
Type III = restricted leaflet motion.
IIIa =during both systole and diastole
IIIb = during systole
Carpentier classification
Carpentier’s classification of mitral valve disease
Type I Leaflet perforation (IE) Annular dilatationCleft valve
Type II Mitral valve prolapse (eg myxomatousdisease) or papillary muscle rupture
Type IIIa Rheumatic disease
Type IIIb Ischemic or idiopathic cardiomyopathy
Carpentier classification
annular dilatation the ratio
annulus/anterior leaflet is .1.3 (in diastole)
the annulus diameter is >35 mm
Mitral Regurgitation:classification
Identifying mechanism of MR: cleft associated
Identifying mechanism of MR: functional MR-dilated cardiomyopathy
«Καρδιακή Ανεπάρκεια. DVD-ηχωκαρδιογραφικές περιπτώσεις»Α Κρανίδης-Ι Παρασκευαϊδης-Η Καραμπίνος, Εκδόσεις Παρισιάνος 2014
Identifying mechanism of MR: functional MR-Ischemic Cardiomyopathy
Identifying mechanism of MR: functional MR-Ischemic Cardiomyopathy
FMR Pathophysiology: the balance between “tethering” and “closing”
The coaptation triangle and the mitral valve geometry
Mitral regurgitation with distorted mitral valve geometry: trapeze (IIIB)
Absence of the ‘standard triangle of coaptation’,transformed into a ‘trapeze’
Identifying mechanism of MR: flail mitral valve
Identifying mechanism of MR: flail mitral valve
Posterior leaflet
Anterior leaflet
Identifying mechanism of MR: papillary muscle rupture
Identifying mechanism of MR: rheumatic heart disease
Identifying mechanism of MR: rheumatic heart disease
Identifying mechanism of MR: related to hypertrophic cardiomyopathy
Venturi effect or “drag forces” causes SAM of the anterior mitral leaflet AND failure of posterior leaflet to move anteriorly
Identifying mechanism of MR:mixed aetiology
The role of echocardiography: we have to know where is the problem
Recognizing “topology” of pathology?
Normal anatomy and function of mitral valve apparatus
Otto CM: Evaluation and management of chronic mitral regurgitation. N Engl J Med 345:740, 2001.
Coaptation Zone 1 cm
Scallops of anterior and posterior leaflets:A1, A2,A3 & P1,P2,P3
Normal anatomy and function of mitral valve apparatus
Schematic representation of the mitral valve from multiple perspectives
A)A2 and P2 (standard view)B)A1 and P1 (tilting of the probe toward the aortic
valve)C) A3 and P3 (tilting of the probe toward the tricuspid valve)
Lancellotti P et al. Eur J Echocardiogr 2010;11:307-332Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
Mitral Leaflet Lesion Topology: 2D Transthoracic echocardiography
Mitral Leaflet Lesion Topology: 2D Transthoracic echocardiography
D) Short axis A1-A3, P1-P3E) 4-champers view A3-A2, P1F) 2-champers view P3-A2-P1
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
Mitral Leaflet Lesion Topology: 2D Transthoracic echocardiography
«Ηχωκαρδιογραφία Doppler-Νεώτερες Τεχνικές DVD»Α Κρανίδης-Η Καραμπίνος, Εκδόσεις Πασχαλίδης 2007
Mitral Leaflet Lesion Topology: 2D Transesophageal echocardiography
A)A1 and P1 (midesophageal 5-champers view)B)A2 and P2 (deeper midesophageal 4-champers view)C) A3 and P3 (even deeper midesophageal 4-champers view)
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
Mitral Leaflet Lesion Topology: 2D Transesophageal echocardiography
D) A1 and P1 (bicommisural 2-champers view 45o)E) A2 and P2 (midesophageal 3-champers view 120o)F) A1-A3 and P1-P3 (transgastricview)
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
«Ηχωκαρδιογραφία Doppler-Νεώτερες Τεχνικές DVD»Α Κρανίδης-Η Καραμπίνος, Εκδόσεις Πασχαλίδης 2007
Mitral Leaflet Lesion Topology: 2D Transesophageal echocardiography
40 to 90 degrees, effect of clockwise and counterclockise probe rotation
«Ηχωκαρδιογραφία Doppler-Νεώτερες Τεχνικές DVD»Α Κρανίδης-Η Καραμπίνος, Εκδόσεις Πασχαλίδης 2007
Mitral Leaflet Lesion Topology: 2D Transesophageal echocardiography
Transthoracic 3D echocardiography
In order to simulate a surgeon’s view of the valve, the 3D TEE image is positioned with the aortic valve the 11-o’clock position.
Mitral Leaflet Lesion Topology: 3D Transesophageal echocardiography
The role of echocardiography: we have to know the problem
Is MR severe?
Non Volumetric Methods
Quantification of MR: Severity
Quantification of MR: color flow a fast track tool!
Colour flow Doppler –jet area
Mild = Less than 20% of LA area (10 cm2 )
Zoghbi et al. ASE valve regurg document (JASE 03)
Quantification of MR: color flow doppler jet area
Pitfalls using color flow:Mimics of mitral regurgitation!!!
• Appearance of color Doppler in LA in systole– posterior motion of blood pool by MV closure (billiard’s effect)
– Reverberation from aortic flow
– Normal pulmonary vein inflow
– low velocity overall atrial motion augmented by inappropriate gain and Nyquist limits
Apical view : early systolic blue colour Doppler encoding within the left atrium
Very early systole: billiard’s effect
Recorded 50 mseclater
Colour reverberation in the left atrium
colour artefact arising from the aorta
Prominent pulmonary vein flow in the left atrium in systole
Signal encoded as red
Flow towards the transducer
Factors affecting jet area-instrument factors
• Use a Nyquist limit (aliasing velocity) of 50-60cm/sec.
• Use Color gain that just eliminates random color speckle from nonmoving regions.
• Jet area inversely proportional to pulse repetition frequencyhigher or lower settings –substantial error can occur
Advantages• Ease of use
• Evaluates the spatial orientation of regurgitant jet
• Good screening test for mild vs. severe regurgitation
Limitations• Can be inaccurate for
estimation of regurgitation severity
• Influenced by technical and haemodynamicfactors
• Underestimates eccentric jet adhering the atrial wall (Coandaeffect)
Quantification of MR: color flow
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2010
Quantification of MR: color flow
• The colour flow area of the regurgitant jet is not recommended to quantify the severity of MR.
• The colour flow imaging should only be used for detecting MR.
• A more quantitative approach is required when more than a small central MR jet is observed.
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
Vena contracta:an “old” modern index
Narrowest portion of a jet that occurs at or just downstream from the orifice.
CSA of the VC represents a measure of EROA which is the narrowest area of actual flow.
Size of the VC independent of flow rate and driving pressure for a fixed orifice.May change with hemodynamic or during the cardiac cycle.
Vena contracta: basic tips in a minute
TEE
Recommended approach - perpendicular to jet direction- Narrow sector width- Zoom mode- Minimum depth
Vena Contracta: methodology
• Two orthogonal planes (PT-LAX, apical four-chamber view)
• Optimize colour gain/scale
• Identify the three components of the regurgitant jet (VC, PISA, jet into LA)
• Reduce the colour sector size and imaging depth to maximize frame rate
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
Vena Contracta: methodology
• Expand the selected zone (Zoom)
• Use the cine-loop to find the best frame for measurement
• Measure the smallest VC (immediately distal to the regurgitant orifice, perpendicular to the direction of the jet)
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
Mild Moderate Severe
VC width (cm)
● Simple Quantitative measurement
● Intermediate values require confirmation
● Usefull for Central/Eccentric jets
●Not useful for Multiple jets
Vena Contracta: key points
Vena Contracta
The shape of effective regurgitant orifice results in under- or over-estimation of Mitral Valve Pathology: a common limitation
Advantages• Relatively quick and easy
• Relatively independent of haemodynamic and instrumentation factors
• Not affected by other valve leak
• Good for extremes MR: mild vs. severe
• Can be used in eccentric jet regurgitation
Limitations• Not valid for multiple
jets
• Small values; small measurement errors leads to large % error
• Intermediate values need confirmation
• Affected by systolic changes in regurgitantflow
Quantification of MR: Vena contracta
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2010
• When feasible, the measurement of VC is recommended to quantify MR.
• Intermediate VC values (3–7 mm) need confirmation by a more quantitative method, when feasible.
Vena Contracta: key points
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
SD
1-Normal 2-Systolic blunting
D
4-Systolic Flow Reversal
S
3-Diastolic dominant
S
SD
D
Pulmonary vein flow
Severe MR:Pulmonary vein systolic flow reversal
Pulmonary vein flow
• Atrial fibrillation and elevated LA pressure: blunted forward systolic pulmonary vein flow.
• Systolic flow reversal in more than one pulmonary vein is specific for severe.
• Absence does not rule out severe MR
Pulmonary vein flow: key points
False – negative results# Severely dilated and compliant LA
False – positive results# Eccentric jet directed into PV
Pulmonary vein flow:pitfalls
Advantages• Simple
• Systolic flow reversal is specific for severe MR
Limitations• Affected by LA
pressure, atrial fibrillation
• Not accurate if MR jet directed into sampled vein
Pulmonary Vein Flow
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2010
Trans Mitral Flow: pulsed doppler
# MR results in increased flow rate across mitral valve
# Mitral inflow velocity in significant MR
# “E” velocity > 1.5 m/sec
# Rule out coexisting MS
# Normal PHT
• In patients with an RF 60%, the E wave always exceeded 1.0m/sec
J Am Coll Cardiol 1998;31:174 –9
Correlation between peak E wave velocity and Regurgitant Fraction
P=
Trans Mitral Flow: pulsed dopplerTVI transMV/TVI transAV
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
• TVI ratio >1.4 strongly suggests severe MR
• TVI ratio
Advantages• Simple, easily available
• Dominant A-wave almost excludes severe MR
Limitations• Affected by LA
pressure, atrial fibrillation, LV relaxation
• Complementary finding
Transmitral Flow: pulsed doppler
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2010
Transmitral Flow:Continuous Wave Doppler
MILD SEVERE
# Density Faint Dense
# Shape Symmetrical Asymmetrical
Shape of regurgitant signal-V cut off sign
• Mild MR: atrial pressure low and gradient remain high throughout systole
• Significant MR : atrial pressure increased in end systole and gradient decreases
• Produces a V shaped doppler signal
Volumetric Methods
Quantification of MR: Severity
PISA Method
Flow profile of blood approaching a circular orifice forms concentric, hemispheric shells of increasing velocity and decreasing surface area.
Color flow mapping able to image one of these hemispheres that corresponds to the aliasing velocity or Nyquist limit of the instrument.
The aliasing velocity should be adjusted to identify a flow convergence region with a hemispheric shape.
# Flow (cc/sec) = 6.28 x [r (cm)]2 x Va (cm/sec)
# ERO (cm2) = Flow (cc/sec) VMR (cm/sec)
# RV (CC) = ERO (cm2) x TVIMR (cm)
PISA Method:
• Apical four-chamber
• Optimize colour flow imaging of MR
• Zoom the image of the regurgitant mitral valve
• Decrease the Nyquist limit (colour flow zero baseline)/Downward shift of zero
• With the cine-mode select the best PISA
• Display the colour off and on to visualize the MR orifice
PISA Method:step by step
• Measure the PISA radius at mid-systole using the first aliasing and along the direction of the ultrasound beam
• Measure MR peak velocity and TVI (CW)
• Calculate flow rate, EROA, R Vol
PISA Method:step by step
PISA methodology: the three components
PISA radius Max Vo of MR VTI of MR
PISA Method:variation of convergence flow during systole
Flow convergence zone changes during systole using colour M-Mode.Functional mitral regurgitation: early and late peaks and mid-systolic decreases early systolic peak
Variation of the PISA during systole in FMR
In early and late systole, closing forces are relatively low and so the ERO and PISA relatively large
In midsystole,coincident with peak regurgitant velocity closing forces are maximal and so the ERO and PISA smaller.
Pitfalls in the quantitative echo assessment of Functional MR
PISA Method
Rheumatic mitral regurgitation end-systolic decrease in flow convergence zone
Mitral valve prolaspelate systolicenhancement
PISA Method:eccentric jets?
It can be
used in both central and eccentric jets.
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
PISA Method:limitations?
Multiple jets
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
Distorted jets by lateral wall
Angle correction
Non circular orifices in Functional MR: if long axis to short axis ratio>1.5
the error is significant
PISA Method:limitations?
Mild
Grade I
Moderate
Grade 2 Grade3
Severe
Grade 4
Regurgitation
volume ml / beat 60
Regurgitation
Fraction % 50
Regurgitation
Orifice area cm2 0.40
QUANTITATIVE METHODS MR severity by PISA Method
In functional ischemic MR: EROA ≥ 20 mm2 or a R Vol≥ 30 mL identifies a subset of patients at increased risk of cardiovascular events.
Advantages• Can be used in eccentric
jet
• Not affected by the aetiology of MR or other valve leak
• Quantitative: estimate lesion severity (EROA) and volume overload (R Vol)
• Flow convergence at 50 cm/s alerts to significant MR
Limitations• PISA shape affected– by the aliasing velocity
– in case of non-circular orifice
– by systolic changes in regurgitant flow
– by adjacent structures
• PISA is more a hemi-ellipse
• Errors in PISA radius measurement are squared
• Inter-observer variability
• Not valid for multiple jets
Quantification of MR: PISA methodology
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2010
The principle of conservation of mass:In the absence of valvular regurgitation or intracardiac shunts, the stroke volume through each of the four valves should be equal
Quantification of MR:Doppler Volumetric Method
Qs = systemic stroke volumeQv = stroke volume across regurgitant valveRV = regurgitant volume.
James D Thomas Heart 2002;88;651-657
Doppler Volumetric Method
MV FLOW = CSAMV x MV TVI
LVOT FLOW = CSALVOT x LVOT TVI
CSA MVA = D2x0.785
CSA LVOT= D2x0.785
Doppler Volumetric Method
MV REGURGITANT VOLUME = MV FLOW - LVOT FLOW
MV REGURGITANT FRACTION = MV REGURG FLOW
MV FLOW
EROA = MV REGURG VOL
MR VTI
Doppler Volumetric Method
Advantages• Quantitative: estimate
lesion severity (ERO) and volume overload (R Vol)
• Valid in multiple jets
Limitations• Time consuming
• Requires multiple measurements: source of errors
• Not applicable in case of significant AR
• Difficulties in assessing mitral annulus diameter
• Affected by sample volume location
Quantification of MR: doppler volumetric method
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2010
The Doppler volumetric method is a timeconsuming approach that is not recommended as a first-line method to quantify MR severity.
Doppler Volumetric Method
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
Mitral regurgitation Severity
Specific signs of severity :
Large central MR jet > 8cm2
MR area / LA area > 40%
Eccentric wall- impinging jet of any size, swirling in LA
Vena contracta width > 7mm
Large flow convergence
Systolic reversal in pulmonary veins
Supportive signs :
Dense, triangular CW Doppler MR jet
E-wave dominant mitral inflow ( > 1.2 m/sec)
Enlarged LV and LA
( particularly with normal LV function )
Quantitative Parameters:
R Vol (ml / beat) > 60 // RF (%) > 50 // EROA (cm2) > 0.40
Mitral Regurgitation Severity
MR color flow imaging
Vena contracta
Jet direction
Severe MR
≥0.7cm
PISARV and ROA
Pulsed DopplerRV & ROA
Mild MR
Central jetNo PISA seenJet area
The role of echocardiography: we have to know the problem
MR consequences ?
The role of echocardiography: questions to be answered
What to measure?
When MR is more than mild MR, providing the LV diameters, volumes, and ejection fraction as well as the LA dimensions (preferably LA volume) and the pulmonary arterial systolic pressure in the final echocardiographic report is mandatory.
The quantitative assessment of left ventricular (LV) diameters, volumes, and ejection fraction is mandatory.
The qualitative assessment of LV function is not recommended.
The 2D measurement of LV diameters is strongly advocated if the M-mode line cannot be placed perpendicular to the long-axis of the LV.
The 2D-based biplane summation method of discs is the recommended approach for the estimation of LVvolumes and ejection fraction.
LV size and function: recommendations
The 3D echo assessment of LV function provides more accurate and reproducible data.
Contrast echo is indicated in patients with poor acoustic window.
Left atrial volume is the recommended parameter to assess its size.
LV size and function: recommendations
Quantifying LV: dimensions
M Mode
2D-guided linear measurements
Quantifying LV: biplane disk summation
Quantifying LV:
• Apex frequently foreshortened
• Heavily based on geometrical assumptions
• Limited published data on normal population
Area Length Method
Quantifying LA
M-Mode Tracing 2D linear measurements
Quantifying LA
Biplane Method of disks Area Length Method
Left Atrial Volume=
π/4 h Σ D1D2
Do not forget consequences on the right heart: RV dimensions-function / PAP
The quantitative assessment of myocardial function (systolic myocardial velocities, strain, strain rate) is reasonable, particularly in asymptomatic patients with severe primary MR and borderline values in terms of LV ejection fraction (60–65%) or LV end-systolic diameter (close to 40 mmor 22 mm/m2)
Echo assessment of FMR:Global left ventricular remodelling
Dimensions of LV LV Volumes
Sphericity Index
Echo assessment of FMR:Local left ventricular remodelling
Apicaldisplacement of the posteromedial papillary muscle
Interpapillary muscle distance
Second order cords
Echo assessment of FMR:Mitral valve deformation
systolic tenting area
coaptation distance
posterolateral angle
Echo assessment of FMR:Closing Forces
Reduced Contractility:LV dp/dt
LV dyssynchrony
Sometimes we are not alone…
Mixed mitral valve pathology: stenosis and regurgitation. Effect on doppler indices
Multiple valvulopathy: Aortic stenosis and Mixed mitral valve pathology.
Effect on doppler indices of MV
Mean Gr MV=3,8mmHgMVA=0,8cm2Peak Gr AV=75mmHg
Multiple valvulopathy: Aortic Regurgitation and Mitral Regurgitation pathology.
Effect on doppler indices
AR PHT=290msec!!!
Mitral Regurgitation Follow upModerate organic MR: clinical examination every
year and echocardiogram every 2 years
Severe organic MR: clinical assessment every 6 months and echocardiogram every 1 year
If EF=60–65% and/or if end-systolic diameter =40 or 22 mm/m2, the echocardiogram should be performed every 6 months
Progression of MR severity is frequent with important individual differences.
Average yearly increase RV=7.5 mL and EROA=5.9 mm2
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2010
Mitral Regurgitation Follow upParameters need to be assessed:
increase in annular size
development of a flail leaflet
the evolution of LV end-systolic dimension
LV ejection fraction
LA area or volume
pulmonary systolic arterial pressure
exercise capacity
occurrence of atrial arrhythmias
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2010
When CABG and EF>30%
When CABG and EF
Ηχωκαρδιογραφία:λήψη αποφάσεων στη σοβαρή ανεπάρκεια μιτροειδούς
• Διάγνωση και εκτίμηση της βαρύτητας της ανεπάρκειας της βαλβίδος.
• Ανάδειξη στοιχείων παρουσίας στεφανιαίας νόσου.
• Δυναμική ηχωκαρδιογραφία με δοβουταμίνη ή άσκηση, για κατάδειξη μυοκαρδιακήςβιωσιμότητας.
• Κατάδειξη ή αποκλεισμός συνυπάρχουσας παθολογίας των γλωχίνων και των τενοντίωνχορδών.
• Μελέτη της γεωμετρίας της αριστερής κοιλίας ως και των θηλοειδών μυών, ειδικά με την 3D ηχωκαρδιογραφία.
Διοισοφάγειος ηχωκαρδιογραφίαδιεγχειρητικά
ΠΟΤΕ; ΧΕΙΡΟΥΡΓΙΚΗΠΑΡΕΜΒΑΣΗ
TI;ΕΠΙΔΙΟΡΘΩΣΗ ήΑΝΤΙΚΑΤΑΣΤΑΣΗ
ΕΠΙΤΥΧΙΑΕΠΕΜΒΑΣΗΣ
Peter Bruggel 1527-69, « Hunters of the winter »
ΕΥΧΑΡΙΣΤΩΣτην ιερή μνήμη του πατέρα μου
semi quantitative guide to MR severity
Mitral Regurgitation Index
MR Index is a composite of six echo variables: Colour Doppler regurgitant jet penetration
PISA
CWD of the regurgitant jet
Tricuspid regurgitant jet-derived PAP
Pulse wave Doppler pulmonary venous flow pattern
2D echocardiographic estimation of left atrial size
JACC Vol. 33, No. 7, 1999: 2016–22
Grading = 0 to 3
MR INDEX =Total score/number of variables
Mitral Regurgitation Index
Correlation graph of Mitral Regurgitation Index versus three grades of mitral regurgitationJACC Vol. 33, No. 7, 1999: 2016–22
Mitral Regurgitation Index
Regression plot of correlation between the MitralRegurgitation Index and the regurgitant fraction
JACC Vol. 33, No. 7, 1999: 2016–22
Mitral Regurgitation Index
Ηχώ Δείκτες που προβλέπουν υποτροπή της λειτουργικής ανεπάρκειας μετά από πλαστική
επιδιόρθωση • Τελοδιαστολική Διάμετρος ΑΚ>65χιλ
• Γωνία οπίσθιας γλωχίνας με το μιτροειδικό δακτύλιο>45ο
• Γωνία άπω τμήματος της πρόσθιας γλωχίνας με το μιτροειδικό δακτύλιο>45ο
• Επιφάνεια μεταξύ των γλωχίνων και του επιπέδου του μιτροειδικού δακτυλίου (tenting area) >2,5 cm2
• Απόσταση σημείου σύγκλεισης των γλωχίνων από το επίπεδο του μιτροειδικού δακτυλίου (coaptation distance) >10χιλ
• Απόσταση μεταξύ των δύο θηλοειδών μυών (short axis) στην τελοσυστολή >20χιλ
• Δείκτης σφαιρικότητας στην τελοσυστολή >0,7.
• The VC can often be obtained in eccentric jet.
• In case of multiple jets, the respective values of the VC width are not additive.
• The assessment of the VC by 3D echo is still reserved for research purposes.
Vena Contracta: key points
Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging 2013
The PISA method is based on - the properties of flow dynamics- the continuity principle.`
PISA Method
Goal of the PISA method: to calculate the effective regurgitant orifice area (EROA)
Flow proximal= flow distal
Flow rate is the same at all points along the circuit