Mitral regurgitation echocardiography

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Overview

The echocardiogram is commonly used to confirm the diagnosis of mitral regurgitation. Color doppler flow on the transthoracic echocardiogram (TTE) will reveal a jet of blood flowing from the left ventricle into the left atrium during ventricular systole.

Because of the inability in getting accurate images of the left atrium and the pulmonary veins on the transthoracic echocardiogram, a transesophageal echocardiogram may be necessary to determine the severity of the mitral regurgitation in some cases.

Factors that suggest severe mitral regurgitation on echocardiography include systolic reversal of flow in the pulmonary veins and filling of the entire left atrial cavity by the regurgitant jet of MR.

ACC/AHA Guidelines- Indications for Transthoracic Echocardiography (DO NOT EDIT)

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Class I 1 Transthoracic echocardiography is indicated for baseline evaluation of LV size and function, RV and left atrial size, pulmonary artery pressure, and severity of MR (Table 4) in any patient suspected of having MR. (Level of Evidence: C) 2 Transthoracic echocardiography is indicated for delineation of the mechanism of MR. (Level of Evidence: B) 3 Transthoracic echocardiography is indicated for annual or semiannual surveillance of LV function (estimated by ejection fraction and end-systolic dimension) in asymptomatic patients with moderate to severe MR. (Level of Evidence: C) 4 Transthoracic echocardiography is indicated in patients with MR to evaluate the MV apparatus and LV function after a change in signs or symptoms. (Level of Evidence: C) 5 Transthoracic echocardiography is indicated to evaluate LV size and function and MV hemodynamics in the initial evaluation after MV replacement or MV repair. (Level of Evidence: C) Class IIa 1. Exercise Doppler echocardiography is reasonable in asymptomatic patients with severe MR to assess exercise tolerance and the effects of exercise on pulmonary artery pressure and MR severity. (Level of Evidence: C) Class III 1. Transthoracic echocardiography is not indicated for routine follow-up evaluation of asymptomatic patients with mild MR and normal LV size and systolic function. (Level of Evidence: C)

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ACC/AHA Guidelines- Indications for Transesophageal Echocardiography (DO NOT EDIT)

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Class I 1 Preoperative or intraoperative transesophageal echocardiography is indicated to establish the anatomic basis for severe MR in patients in whom surgery is recommended to assess feasibility of repair and to guide repair. (Level of Evidence: B) 2 Transesophageal echocardiography is indicated for evaluation of MR patients in whom transthoracic echocardiography provides nondiagnostic information regarding severity of MR, mechanism of MR, and/or status of LV function. (Level of Evidence: B) Class IIa 1. Preoperative transesophageal echocardiography is reasonable in asymptomatic patients with severe MR who are considered for surgery to assess feasibility of repair. (Level of Evidence: C) Class III 1. Transesophageal echocardiography is not indicated for routine follow-up or surveillance of asymptomatic patients with native valve MR. (Level of Evidence: C)

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Aetiology and Morphological Features in 2-D Echocardiography

Rheumatic Mitral Regurgitation

In rheumatic mitral regurgitation, there is some degree of commissural fusion and thickening of the tips visible in 2 dimensional echocardiography. The movement of the valve leaflets is restricted.

Myxomatous Mitral Valve

The leaflets and chordae are thick and reduntant. Reduced tensile strength leads to progressive elongation or rupture of chordae. Ruptured chordae appear as flail segments. To diagnose mitral valve prolapse, the following criteria should be fulfilled during echocardiography - Movement of any part of either leaflet more than 2mm behind the annular plane in parasternal long axis view and movement of point of co-aptation behind the annular plane in apical 4 chamber view.

Annular Calcification

Mitral annulus is usually smaller in systole. The increased rigidity due to annular calcification impairs contraction. In 2D- echocardiography, there is increased echogenicity on the LV side immediately adjacent to the attachment of the posterior mitral valve leaflet. Region of anterior mitral leaflet is only rarely involved. This is common in elderly subjects and younger ones with chronic renal failure and hypertension.

Ischaemic Mitral Regurgitation

Mitral regurgitation can occur in ischemia as a result of regional left ventricular dysfunction with abnormal contraction of papillary muscle or underlying ventricular wall. Myocardial infarction can result in MR at rest while if the underlying cause is ischemia the MR may be intermittent. The echocardiogram is characterized by restricted valve leaflet motion and tenting of mitral valve in systole.

Papillary Muscle Rupture

This is usually a complication of myocardial infarction. If entire papillary muscle is disconnected from the left ventricle severe MR results and few survive. Partial rupture is more common.

Functional Mitral Regurgitation

Functional MR results due to LV dilatation and systolic dysfunction in those with a structurally normal mitral valve apparatus.

Flail Posterior Mitral Leaflet M Mode

• Mitral Ring Dehiscence Post Repair With Severe Mitral Regurgitation

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• Severe Mitral Regurgitation From Ring Dehiscence Pulmonary Vein Pulsed Wave Doppler

• Severe Mitral Regurgitation Pulmonary Vein Pulsed Wave Doppler

Sources

• 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease .