TTE & TEE IN AN YOUNG PT WITH NON-RHEUMATIC MR-NYHA II

FOR MV REPAIR/REPLACEMENT

Dr Debika Chatterjee

WHY IS IT IMPORTANT ?

MV Repair vs. Replacement

Valve Replacement:• Does not preserves valvular

& subvalvular apparatus• Mortality 2-7%• Longer hospital stay• Anti-coagulation• Tissue prosthetic valve

degeneration• Mechanical prosthetic valve

dysfunction/ thrombosis

Valve Repair• Preserves valvular &

subvalvular apparatus• Mortality 2-3%• Shorter hospital stay• No anticoagulation (unless AF)• Improved long-term survival

MV REPAIR IS ALWAYS PREFERABLE& is feasible in 70-90% of ptients

FACTORS INFLUENCING EARLY & LATE SUCCESS AFTER REPAIR

• Case selection• Accurate evaluation of cause of MR • Application of appropriate surgical technique

MITRL VALVE APPARATUS

Consists of : – Annulus– Leaflets – Chordae – Papillary muscles – Left ventricle

MR - Etiology

• Leaflets– Myxomatous MV disease– Rheumatic– Endocarditis– Congenital-clefts

• Chordae– Fused/inflammatory– Torn/trauma– Degenerative– IE

• Annulus– Dilatation, Calcification, abcess

• Papillary Muscles• -CAD (Ischemia, Infarction,

Rupture)– HCM– Infiltrative disorders

• Dilated LV Č functional MR

MR ASSESSMENT BY TTE, TEE & IOE TO DETERMINE:

• Severity of MR• Mechanism & site of MR • The success of repair• If further intervention is needed

MR - SEVERITY

• Can be assessed adequately by TTE• TEE is of additional value in pt with

suboptimal echo window

SEVERE MR contd…

Qualitative indices: Flail valve, Ruptured chordae/ pap muscle, Perforation, Eccentric MR( wall hugging jet)

Quantitative indices:Dilated LA≥5.5 cm LVEDD≥7 cm Vena contracta width ≥ 7mm ERO ≥ 0.40 cm2 RV ≥60 ml RF ≥55% Pulmonary vein flow reversal

Jet area>10 cm2 Colour flow area>40% of LA size

Increased E wave velocity Mitral leaflet Tenting area ≥6cm2(for func MR)

Vena Contracta Jet width

ASSESSMENT OF SITE & MECHANISM OF MR

• Conventional TTE-provides initial information

• TEE is indispensable to identify site & underlying mechanism of MR for planning MV surgery & predicting outcome of surgery

SITE & MECHANISM OF MR» Valve leaflets: Length-normal/elongated. AML(A2):22.8±2 mm,PML(P2):12.8± 1.0 mm Thickness, redundancy Prolapse- site, severity, symmetry Motion -normal, excessive or restrictive Flail leaflet Extent of systolic apposition of leaflets Tethering Cleft or perforation in the leaflet» Annulus: normal/dilated/calcified . A2-P2 diameter :29.1± 1.5 mm» Chordae: normal, thickened ,stretched ,restricted motion, elongated, ruptured» Pap muscle :Normal, displaced, ruptured» LV :Assessment & quantification of its function & dimensions

Comprehensive TEE Exam•ME4C View: A3 and P1•Commisural View:P3-A2-P1•Two Chamber View :P3-A1•Long Axis View : P2-A2

•Transgastric Short Axis ViewAML,PMLPosteromedial commissureAnterolateral commissure

•Transgastric Long AxisViewChordae TendinaePapillary Muscle

Assessment of the Mitral valveAssessment of the Mitral valve

MV ABNORMALITY

Carpentier Classification:• Type 1 : Normal leaflet mobility Annular dilatation or perforation• Type 2 : Increased leaflet mobility Elongated or ruptured chordae Prolapse or degeneration• Type 3 : Restricted mobility- 3a: Restriction both in systole & diastole due to leaflet

& subvalvular thickening & fusion as in RHD 3b: Restriction during systole due to apical displacement of pap

muscle due to ventricular enlargement as in DCM & Ischemic MR

CASE STUDY

YOUNG PT WITH-Non Rheumatic MR-SOB : NYHA-II for

last one year

TTE

TEE

ME-4-chView

Commissuralview

ME-2-ChView

ME-LaxView

TG-saxView

TG-laxView

To summarize :

• Myxomatous mitral valve leaflets. Elongated AML. Symmetric prolapse of all 3 scallops of AML & P2 & P3 scallops of PML

• A Cleft in A3 scallop of AML with severe MR( 2 jets)• Normal mobility of the leaflets• Dilated annulus• Normal Chordae • No MR from commissures• Normal papillary muscles• Good LV systolic function

THANK YOU

Mid-esophageal Long Axis ViewMid-esophageal Long Axis View

Transgastric Views(Transducer @ 0°)

Transgastric Long-axis View:Transgastric Long-axis View:Visualization of the Papillary MusclesVisualization of the Papillary Muscles

Posteromedial Papillary Muscle

Anterolateral Papillary Muscle

Posterior Mitral Leaflet Prolapse Posterior Mitral Leaflet Prolapse (Flail Posterior Leaflet)(Flail Posterior Leaflet)

Ruptured Chord Ruptured Chord

Mitral Valve ProlapseMitral Valve Prolapse

Classic MVP•Displacement > 2 mm•Thickness ≥ 5 mm

Non-Classic MVP•Displacement > 2 mm

Diagnostic Criteria

Papillary MusclesPapillary Muscles

• Ruptured papillary muscle • LV-papillary muscle dysfunction

Subtotal Ruptured Papillary Muscle Subtotal Ruptured Papillary Muscle

Myxomatous Mitral Valve Disease Ranges from minor leaflet thickening to involvement of entire valve apparatus

Mitral Valve Prolapse

Associated conditions- Ostium Secundum ASD, Aneurysm of Fossa,

Ebsteins anomaly, Marfans, Ehlers-Danlos, Pseudoxanthoma Elasticum

MITRAL VALVE PROLPSE

AKA: Click-Murmur, Barlow’s Syndrome, Floppy Valve, Myxomatous MV Disease

• A common, congenital disorder -4-5% of general population

• Clinical diagnosis confirmed by echocardiographyProlapse = Superior & posterior displacement of one or both leaflets across the plane of the MV annulus into LA

• Tricuspid valve sometimes involved• MVP Syndrome: CP, palpitations, dizziness,

anxiety/panic attacks

Mitral Valve Prolapse complications

• Usually a benign disease• ~10% of MVP pts will require surgery in their lifetime

• Mitral regurgitation : -2-7% of MVP pts have significant MR

-MR from MVP accounts for 25% of all Surgeries for Mitral Valve Repair

• Infective endocrditis• Arrhythmia• TIA/CVA Major Mortality/Morbidity Risk Factors:

Severity of MR, LVE and depressed LVEF

Ischemic Mitral Regurgitation• Accounts for 3-25% of MR• Proportional to degree of LV dysfunction

≈Incomplete leaflet closure

• Failure of papillary muscle contraction results in incomplete leaflet closure & inadequate tethering of chordae tendineae ≈ Late systolic murmur ≈ Anterior jet-posteromedial leaflet/papillary dysfunction≈ Posterior jet -> anterior leaflet/papillary

dysfunction

Ischemic Mitral Regurgitation Papillary Muscle Involvement

– Arterial supply

Posteromedial Papillary Muscle-Usually supplied by a single vessel-Posterior Descending Artery85% arise from distal RCA ,15% from LCx

Anterolateral Papillary Muscle- Dual blood supply - LAD + LCx

Ischemic Mitral Regurgitation Papillary Muscle Rupture

• Causes Acute MR and is often a surgical emergency

• Complicates 1-5% of MI

• Usually occurs @ Day 2-7 post MI

• 50-70% mortality without urgent surgery

• Support with pre/after-load reduction, IABP

Functional Mitral Regurgitation

• Pap muscles, chordae, & valve leaflets are normal

Etiology• Ischemia

Papillary muscle displacement due to remodeling (Ischemia/Infarct)

• LV DilatationAnnular enlargement (Cardiomyopathy)

• Also seen in ESRD maintained with dialysis due to volume expansion

Treatment of Functional Mitral Regurgitation

Standard Medical TherapyStandard Medical Therapy

MV Repair for patients with sever CHF and MRMV Repair for patients with sever CHF and MR

Reduces end-diastolic volume and may improve Reduces end-diastolic volume and may improve LV performanceLV performance

Long term follow up studies are needed to determine Long term follow up studies are needed to determine long term efficacylong term efficacy

MR in Healthy People

• Increases with age

– ‘Physiologic’

– No symptoms

• Normal echo, valves

• Hemodynamically unimportant

Bacterial Endocarditis 3-10% of all MR 1/3 involves chordae rupture Mitral Annular CalcificationAccelerated by DM, AS, HTN, Marfans, CRF,ageAnorectic Drug UseFenfluramine/phentermine

Similar to carcinoid changesCongenital AssociationsRare Causes –Kawasaki, HCM,CollagenVascular Diseases,SLE, Sarcoid,Amyloid, Infiltrating diseases

Other Causes of MR

Acute Mitral Regurgitation Mechanisms

Chord or Leaflet rupture

Infectious Endocarditis or Acute Rheumatic Fever

Traumatic Injury

Acute Papillary muscle dysfunction or infarction

Prosthetic valve dehiscence or dysfunction

Acute Mitral Regurgitation Consequences

Hemodynamic deterioration depends on etiology and degree of MR and left atrial compliance

Normally, the left atrium is not compliant

Acute MR results in sudden increase in left atrial and wedge pressure leading to acute pulmonary edema

Acute MRUsually a Surgical Emergency

– Medical TherapyAcute vasodilator treatmentNitroprusside, nitroglycerineInotropic support- Dobutamine, IABP

- SurgeryMitral valve repairMitral valve replacement

Concomitant CABG as needed

Chronic MR - Pathophysiology Eccentric LV hypertrophy (Dilated LV)

»LV mass: LV Volume relationship is normal »Maintains wall stress

Compensatory phase » INCREASED PRELOAD-INCREASED PRELOAD-Increase in LV end diastolic

volume to increase stroke volume in order to maintain forward cardiac output despite regurgitant flow

» DECREASED AFTERLOADDECREASED AFTERLOAD -Unloading of the LV by the low pressure left atrium

Chronic MR - Pathophysiology – Development of LV Dysfunction

»Often occurs after years of compensated MR»Prolonged volume overload leads to increased

LV end systolic volume ultimately causing impaired contractile function, LV dilatation and increased filling pressure

• EF may still be in lower limits of normal EF may still be in lower limits of normal range despite abnormal muscle functionrange despite abnormal muscle function

Ejection Phase Indices in MR

• Usually increased in chronic MR• But, can mask contractile dysfunction

»By the time the patient develops symptoms, the ejection indices usually fall from Supranormal to normal or slightly decreased»LVEF 40-50% may reflect severe LV dysfunction

<40% EF- Severe and advanced LV dysfunction which may not reverse with MV surgerywhich may not reverse with MV surgery

Load Independent Measures of LV Function • Ejection Phase Indices are Load Dependent and

may underestimate LV dysfunction in MR• End Systolic Volume & End Systolic

Dimension »Excellent measure of LV contractility »The larger the ESV or ESD for a given afterload (bp), the worse the LV function»Predictive of post-op outcome»Can be used to Follow asymptomatic patients -Serial increases in ESV or ESD on echo (with

constant bp) indicates progressive LV dysfunctionR

Survival After MV SurgeryComparison of Functional Class and EF

DOPPLER

Surgical Outcome by Etiology

Asymptomatic Pt with Chronic Severe MR – Asymptomatic pt with normal LV function (>60%)

– Q6 month exam; yearly echo

– Assess LV contractility and ESV/ESD

• By the time the EF is < 40%, may already have irreversible LV dysfunction

– Consider early surgery (repair) for pts with

– Atrial fibrillation

• Pulmonary HTN

– PA > 50 mmHg at rest or > 60 mmHg with exercise

• Left atrial enlargement

Optimal Timing of Surgery

• Operate before LV function deteriorates

• Consider surgery for chronic MR even in minimally or even non symptomatic patients if repair is likely

• Reference guidelines for surgery: »Depressed LVEF

»LVEF < 55% »Increased LV end diastolic dimension > 70 mm»Increased LV end systolic dimension > 45 mm

Mitral Valve Repair

•

Surgical Risks • CABG alone »1-3%

• MVR + CABG »Up to 15%

• Risk is greater for Mitral surgeries compared to Aortic surgeries

• Risk is affected by pre op LV Contractility and can be predicted by pre op EF

• Mitral Repair is preferred to enhance preservation of LV function and avoidance of systemic anticoagulation

Survival After Mitral Valve SurgeryComparison of Functional Class and Surgery Type:

ANNULUS

Management Strategy for Chronic Severe MR OF 0.19-0.35 m/s

The Future of Mitral Valve Surgery? Is already here

Robotic Mitral Valve Repair

Beyond the Immediate Future?

Percutaneous Catheter Based TherapyPercutaneous Catheter Based Therapy

Catheter Based MV Repair • Alfieri edge-to-edge technique

• Stitches the center of the leaflets together leaving a ‘double orifice’ valve

• Annulopasty ring inserted into the coronary sinus via catheter techniques

MITRAL REGURGITATION ETIOLGIES

Primary • myxomatous deg• Rh pathology• Infective endocarditis• Congenital defects • Annulus Calcification• Papillary Muscles Secondary MR leaflets & chordae are structurally normal

IMPORTANT INFORMATION FROM TEE

• Extent ,site & severity of leaflet prolapse or fixity• Relative size of AML & PML• Flexibility or fixity of AML & PML• Extent of systolic apposition of the leaflets• Size of the annulus & any associated calcification• Direction of the regurgitation jet

MR Echocardiography

• Etiology: – flail leaflets (chord/pap rupture)– thick (RHD)– post mvt of leaflets (MVP)– vegetations(IE)

• Severity: – regurgitant volume/fraction/orifice area– LV systolic function– increased LV/LA size, EF

How Severe is the MR?

• 2-D Anatomy • Color jet area • Color jet penetration • Proximal jet (vena contracta) width • Regurgitant orifice area • Regurgitant fraction • PV flow pattern

Results

• “A proximal jet width of 6 mm accurately separates patients with and without severe MR”

Symptoms

• Class III or IV symptoms (even if transient) always indicate need for surgery

• Class II symptoms indicate need for surgery in patients with repairable valves

• ETT may reveal concealed symptoms

Mitral RegurgitationACC/AHA recommendations

Surgery Recommended in patients who are• Symptomatic• Asymptomatic with

– Any LV dysfunction– Atrial fibrillation– Pulmonary hypertension– Reparable valves– Recurrent VT

Indications for Surgery Isolated,Severe Chronic MR

• Definite (major criteria):– NYHA Class III or IV heart failure (any

duration)– EF <60%– EF >60% but decreasing on serial measurements– LVIDs >45mm– ESVI >50cc/m2

Indications for Surgery Isolated,Severe Chronic MR

• Emerging (minor criteria):– Any symptoms of heart failure

or sub optimal exercise tolerance test– Flail mitral leaflet– Left atrial diameter >45mm– Paroxysmal atrial fibrillation– Abnormal exercise end-systolic volume index

or ejection fraction

SURGICAL TECHNIQUES

• Annuloplasty• Leaflet resection• Leaflet plication • Artificial chordal replacement• Chordal resection• Papillary muscle

EVALUATE MR BY TTE, TEE & IOE TO DETERMINE:

• The cause & severity • The site & mechanism • The success of repair• If further intervention is needed