Transcript

Hello, this is, uh, Dr. Cox at Institute

for Advanced Medical Education.

I'd like to welcome all of the members from around the world

that are participating tonight for this, uh, special webinar

with, uh, Billy Cathy, uh,

ultrasound expert in advanced Cardiac imaging.

Um, tonight we're gonna have a one hour event.

Uh, we're gonna be discussing, um,

mitral regurgitation, uh, topics,

mechanisms, and quantification.

And, um, I just have some very interesting, um,

housekeeping things to do first.

So we're gonna read this, um, uh, statement here.

The activity has been planned

and implemented in accordance

with the accreditation requirements

and policies of the American Council,

but the Accreditation Council

for continuing medical education,

the A-C-C-M-E-I-A-M-E is accredited by the A-C-C-M-E

to provide continuing medical education for physicians.

IAME designates the live online webinar for a maximum

of one A-M-A-P-R-A category one credit physicians

and attendees should only claim the credit commensurate

with the extent of their ation in the activity.

In compliance with the essentials

and standards of the A-C-C-M-E, the authors

of the CME activity are required

to disclose any significant financial

or other relationships that they may have

with commercial interests.

Myself and Billy Kathy

disclose no such relationships exist.

Uh, no other, uh, people that were involved in the planning

or creation of this event have any, um, conflicts,

any identified relative context, conflicts

that may have arose have been mitigated, and IME planners

and content reviewers and editorial staff disclosed no other

relationships with ineligible entities.

So, uh, with that said, we're gonna go ahead

and start moving forward with the, uh, the conference.

I'd like to introduce Billy Kathy.

He's a, um, experienced advanced cardiac, um,

sonographer here in St.

Louis, Missouri. He works at a tertiary care center, um,

which is one of the top radiology

and cardiology programs in the world.

And, um, thanks to his, um, participation at this,

this institution, and also being president of the, uh,

Midwest, uh, cardiac society, he has a lot of, uh,

very useful information to share

and to teach, um, with everyone that hears to participate.

So, without further ado, I'd like to introduce,

uh, Billy Kathy.

Alright, thank you Jason for that, uh, introduction.

Good evening, everybody. Thanks for tuning in tonight.

Uh, as we talk about, uh, mitral regurgitation, uh,

I chose this topic because it's, uh, something

that I see often in my lab,

and I'm pretty sure, uh, those of you who do the same thing

that I do, you see it as well.

It's, uh, one of my favorite, uh, topics to talk about.

And, uh, we'll go ahead and, uh, get started here.

Uh, to fully understand mitral regurgitation, you have to,

uh, appreciate the anatomy of the mitral valve.

Uh, the mitral valve is not just the leaflets of the valve.

There's a lot of things, a lot of parts to this, uh,

mitral valve that makes it open and close normally.

Uh, so if you look at the diagram here, uh, you can see

that there's, uh, mitral annulus.

You have the, uh, leaflets.

You also have your, uh, commissures, your cord, a,

your papillary muscles, and the lv.

All of these parts work together in the normal, uh,

functioning of, uh, the mitral valve.

And, uh, when one

or more of these things aren't working correctly, uh,

it can cause the, uh, valve to leak.

And this next illustration here, this is a, uh, diagram

of the mitral valve looking at the mitral valve from

the left atrium.

This is what they call the surgeon's view,

and it's called the surgeon's view,

because this is what the surgeon sees, uh, when he,

when he opens up the heart to do surgery.

And you see everything is nicely labeled, uh, there for you.

Uh, you have your, uh, anterior

and posterior leaflets separated by the closure line,

and going from left to right, you have your a and A one

and P one scallops.

Then in the center you have the A two P two scallops.

And then on the right you have the A three P three scallops.

And if you look at the corners, uh, of the leaflets there,

you have your commissures on the left,

you have the anterior commissure.

On the right, you have the, uh, posterior commissure.

And, uh, these, these, these, uh, parts

of the anatomy can also be identified, uh,

with your 2D images.

And I have 'em nicely labeled here for you.

On the, uh, left side,

you can see traditionally when you're in the, uh,

peroneal long axis, you're seeing a two and P two,

and from your short axis,

the scallops are actually the opposite of

what you will see in the surgeon's view.

Your, uh, a three

and P three actually start on the left side of the screen

as opposed to the right side.

And you're going from left to right.

You have a three A two, A one, then you have P three,

P two, P one,

and, uh, right here would be the posterior commissure.

And then this here, uh,

to the right is your anterior commissure.

So whenever you're imaging a, a, a patient, uh,

whether it's, especially if it's for a mitral regurgitation,

you wanna make sure that you can visualize all

of the anatomy, uh, as best you can

and can be very useful, uh, when, uh, assessing someone

for a mitral regurgitation.

So, uh, we don't always see a two P two when we're in our

parasternal lung axis.

The, the scallops can vary depending on

how you angle your transducer.

And, uh, if you look here at the bottom, uh,

left hand corner of the screen, uh,

and this, uh,

is showing you the mitral valve from the short axis.

And this line right here shows you how, uh,

the valve is being cut here in the long axis.

So in this image, I'm actually, uh, to, to,

to bring in the A one and P one scallop.

If you, uh, angle your, uh, transducer, uh,

slightly up towards the A

or aortic valve, like you're going into your, uh,

right RVOT view to bring in the pulmonic valve, you'll, uh,

you'll start to see a one, uh, P one.

And I think I skipped slides.

So now, if we in the traditional, uh, view you, you'll,

you're seeing a two P two.

And if we go to the next slide, if you're angled, uh,

towards the, uh, down towards the,

to bring in the tricuspid valve, not all the way,

but where you can still visualize your, uh,

mitral valve leaflets,

you're actually seeing a three P three.

Okay? And, uh, here are the scallops labeled

that you see in your apical views, and it can vary.

So that's one thing.

It can be tricky, uh, about, you know, the anatomy

of the, uh, mitral valve.

When you're looking at it in, uh, 2D images, uh,

you're not always sure exactly what you're seeing.

Uh, so you know, when you're angling through,

it can be difficult to see.

The short axis of the mitral valve actually allows you

to see all of the anatomy together.

But when you go through your other views, it's not always,

uh, it's not always sure what, what what you're looking at.

So this is the, um, the scallops

that you traditionally see in your apical views,

as I have labeled here.

And then in your two chamber, going from left

to right, you have P three.

And then this, uh, scallop that's kind

of floating in the center will be your A two.

And then this scallop here on the right side

of the screen would be P one.

So I'm going to, uh, show you how this comes into play.

Uh, on a case that I did, uh, recently, uh, a patient was,

had an echo ordered for, uh, mitral regurgitation.

So we are here, looking here in the peroneal lung axis.

Really don't see anything, uh, abnormal.

Uh, the, the, the walls may be a little thick, uh,

and the, uh, la might be slightly, uh, enlarged,

but nothing is really, you know, stands out here as far

as the, uh, mitral valve is concerned.

And here's a zoomed up view of the mitral valve showing

what I believe to be a two P two.

And then when we place color on, on the, uh, leaflets,

we do see a, a small jet here, very eccentric jet.

It looks like it's going anterior towards the aortic valve.

So when I did a slight tilt towards the aorta,

and it bring, uh, you start to see, uh,

a little excessive motion of the posterior leaflet of the,

uh, mitral valve, you can see it here.

We'll zoom up for a closer look.

So we didn't see that before, is

because how the probe was angled.

So now we're really seeing a very,

very significant prolapse, uh, of the, uh, posterior leaflet

of the, uh, mitral valve.

And that shows us why that was at mr. That we were seeing.

And, uh, this, when I saw this, uh, I,

I labeled it P one

because how I had to angle the probe to bring in this, uh,

prolapse, it made me, uh, suspicious

that this was a P one prolapse.

And then when I angled it more, it allows me to see more

of the Mr very eccentric jet not seeing much,

but it's a lot of turbulence

and it's eccentric, which is normally a sign

for a significant mitral regurgitation.

Here's a zoomed up view.

I, And when we go to the apical four chamber view, uh,

we can see that this patient ha,

has a very large posterior leaflet.

And, uh, based on what I was seeing on the earlier views,

this may lead me, leads me to believe

that this is actually P one.

Then I put color, and, uh, you'll see, uh, you know,

zoom up on the valve.

You can see the very large posterior leaflet, very thick,

and it is definitely prolapsing.

And with color, you see this very large flow conversions.

And you see this very eccentric jet of, uh,

mitral regurgitation, hugging the wall of the, uh,

inner atrial septum them.

And then when I, uh, did a 3D, uh, acquisition of the, uh,

mitral valve that, that took, uh, any question that I had,

uh, as far as what we were seeing is clearly a P one, uh,

prolapse that we're seeing, uh, very, very, uh,

significant prolapse of the, uh, posterior leaflet.

The, with the P one scallop.

Uh, this 3D images is in the surgeon's view, uh,

just like we were seeing earlier,

where you have your aortic valve at the top,

and you're going from left to right.

A one P one, sorry about that.

A one P one, A two P two,

and, uh, A three P three.

So let's talk quickly about some of the, uh, causes of, uh,

mitral regurgitation.

Uh, there are various things that can cause someone to, uh,

have mr some of the most common causes.

Oradus, uh, degeneration, rupture, rheumatic heart disease,

infective endocarditis, coronary artery disease

and cardiomyopathy are more commonly known

as functional, mr.

And whenever we think about, uh, the causes of, uh, mr,

we have to think about carpentier's classification.

The surgeon, uh, created this, uh, model to describe, uh,

the causes, the different causes of, uh,

mitral regurgitation,

and he classified them in these different types.

You have type one, uh,

where there you have normal leaflet motion.

And these typically, uh, is due to things such

as endocarditis, uh, dilated annulus, AFib,

or restrictive cardiomyopathy.

Then you have what we call is a type two,

and that's when you have a prolapse

or flail leaflet, papillary muscle, or, uh, due to trauma.

Uh, then you have a type three A that's more common

with the, that's classification for, uh,

rheumatic heart disease like mitral stenosis.

Uh, it's also can be due to, uh, radiation

and, uh, drugs, uh, and as well as lupus.

Then you have, uh, this type of, excuse me,

the type three A, uh, classification is normally,

you'll have restriction of the leaflets in both systole

and diastole, okay?

And that's what distinguishes it from type three B,

because in type three B, the restriction is only

during systole only,

and that's more commonly caused by ischemic heart disease

or a dilated cardiomyopathy.

Okay, so here's the car, the, uh, classification, uh, model

that I created from some cases

that I've have done in the past.

Uh, going from, uh, left to right, you have a type one due

to a cleft mitral valve.

Uh, you have type two mitral valve prolapse,

mitral stenosis,

and then you have ischemic, uh, cardiomyopathy.

And if you look at these 3D images here of the, uh,

mitral valve, all of these, uh,

images are showing the mitral valve in the surgeon's view,

looking from the atrial side of the valve.

They all have a distinctive look, uh, to them.

And if you look at the images below, uh,

where you see the ventricle

and the leaflets, you can see how, how the, uh,

abnormal motion of the leaflets, uh, can lead to, uh,

mitral regurgitation.

Our next slide here is showing a normal heart.

The, the leaflets here are, are, uh, nicely seen.

You can see the closure line.

There's no abnormal thickening.

You don't see any lumps or bumps.

Everything looks nice and smooth.

And you notice the event,

the ventricle here on the right side looks normal as well.

Normal motion, everything is, uh, working the way it should.

The valve valve leaflets are collapsing normally.

And this will be an example of a cleft mitral valve,

which will be a type one.

And if you look at the image here on the left side

of the screen, as the valve opens,

you see this little split down the middle of the,

uh, anterior leaflet.

That is a clef, which is a congenital type of, uh,

heart disease.

This is an interesting case that I did, a patient that had,

has a type two, uh, dysfunction due to, uh,

papillary muscle rupture.

And if you look starting here on the right side, you can see

where the papillary muscle has ruptured.

You see this dropout here between the, these,

these two parts of the muscle, it shouldn't be there,

and it's not allowing the valve to, uh, close properly.

It's actually, uh, causing this leaflet

to the anterior leaflet to prolapse until the left atrium,

which you can see here demonstrated on the 3D image.

You see, both a two

and a three are prolapsing into the left atrium

because the, uh, posterior medial, uh,

papillary muscle has ruptured.

Here's a multis slice image from the same patient.

Uh, and this is, uh, one thing that you can do when you

utilize 3D as well.

You can also pull up the, uh, 2D deck data sets

and look at the ventricle from the base to the apex.

And you can see here, uh, where the, uh,

anterior, uh, leaflet is, uh, flailing here.

And you can track it all the way up here to the, uh,

posterior medial, uh, papillary muscle,

where you can see it has ruptured.

This is another example of a type two, uh,

dysfunction of a mitral valve.

This patient has a flail mitral valve leaflet.

You can, uh, see it nicely here in a 3D image.

This little structure here that's coming in

and out of view, this is a flail leaflet from the, uh,

a two, uh, uh, scallop of the, uh, mitral valve.

Another example of a type two, uh,

mitral valve dysfunction would be the, uh,

mitral valve prolapse.

And you can see nicely on both images.

This is, if we look at this image on the right, notice

how when the valve closes, it buckles, uh,

below the, uh, annulus.

Here you have that nice little dip it takes,

and it's actually all it looks like.

It's also tug, uh, tugging down on the, on the corde

and the, uh, papillary, uh, muscles.

That's an, uh, abnormal motion there. Sorry about that.

And if you look at the, uh, 3D image here on the left,

notice how when the valve closes, you see this lumpy,

bulging, uh, area, uh, on both the anterior

and posterior leaflet.

So all, all of the scallops here are prolapsing back towards

the screen, uh, which is a good ex classic example of, uh,

barlows, uh, when you see, uh, very redundant, uh,

leaflets both the anterior

and posterior leaflet of the mitral valve.

And here's an example of a patient with, uh,

rheumatic heart disease, giving them, uh, mitral stenosis.

And if you notice here that the, uh, the valve, uh,

that you know, it's not, uh, it's,

you have restricted motion, both opening and closing.

You'll see it mostly while it's opening here in this image

on the right, uh, you see it, uh, and,

and on the left, you notice

that there's very tiny opening here

of the, uh, mitral valve.

The valve should open a lot more than that.

But due to the, uh, rheumatic heart disease,

it causes the commissures to fuse,

and it narrows the, uh, opening of the mitral valve.

And here's a 2D image of the same patient with the classic,

uh, hockey stick you see here of the anterior leaflet.

Looks like it's almost tethered here

to the posterior leaflet.

And then there's some, uh, thrombus

as well in the, uh, left atrium.

Here's an another example of a patient

that has type three B dysfunction,

where you have restriction of the leaflets when they close.

This 3D image really, uh, illustrates, uh,

why this valve would leak.

Uh, notice how the, uh,

papillary muscles here kinda lay flat

because they're, uh, they're, uh, they're, uh, tethered

or re uh, the, the LV is dilated,

and it's causing the, these, uh,

papillary muscles in the corde to be stretched out thin,

which not, is not gonna allow the, uh, leaflets

to close, uh, properly.

And you, the same thing will happen in a patient

with ischemic, uh, heart disease, where you have, uh,

ischemia, uh, causing dysfunction

with the papillary muscles.

So you have these, uh, segmental wall motion, abnormal

abnormalities, which will, uh, won't allow the valve

to close, uh, correctly as well.

As you can see here, this patient has a lot of, uh,

wall motion abnormalities,

and it's demonstrated with this, uh, multis slice image

of the same patient as well.

I really like this image, especially, uh,

when I'm assessing a patient for a mitral regurgitation,

because it allows you to see all

of the mitral valve on one view.

You can show them not all, you can show them all

of the leaflets, uh, looking from, uh, you know,

uh, show 'em all the leafs, as well as the entire, uh,

LV from, uh, base to apex.

And, uh, type two, this is another, uh, this is an example

of a flail P two scallop,

which you can see really well here in the 3D image.

This little, uh, projection here at the very top is the

flail, and this is the prolapse here,

and it's a P two flail.

So now we're gonna quickly, uh, go into

how do we quantify mitral regurgitation once we establish

that this patient's mitral valve is leaking?

That's just part of the work that we have to do.

We also have to quantify, is it mild, moderate, or severe?

And, uh, some of the common methods

that we use are the volumetric method, PISA, color, doppler,

vena, contracta, and 3D color.

So we're gonna start with the, uh, volumetric method.

And it's basically uses the continuity of flow principle,

which basically states

that the aortic stroke volume should be equal

to the mitral, uh, stroke volume.

So whatever goes into the ventricle should come out the

ventricle through the aortic valve.

So whatever leaves comes into the ventricle

through the mitral valve, that same volume

should leave the ventricle going through the aortic valve

unless there's, uh, a regurgitation.

Okay? So, uh, any differences between your, uh,

mitral stroke volume

and your aortic stroke volume would be

what we call regurgitant flow flow.

So it, the volumetric method would probably be,

be the best way to assess a patient that has multiple

or eccentric jets.

Okay? Some of the pitfalls

of using this method though, is, you know,

when you make these, uh, using this method,

there are many measurements that you have to make.

And any me, uh,

errors in diameter measurements, they're squared.

Okay? So you have to be very precise,

and it can't be used in patients that have moderate

to severe ai.

So this is how we calculate stroke volume, uh,

across the LVLT, we obtain a post wave doppler

of the LVLT from the five apical five chamber view,

and then we trace, uh, that, uh, pulse wave doppler.

Uh, we've off, we first though,

we measure the LVLT from the parasternal long axis.

And here's an example how to do that measurement.

Whenever you do the measurement of the, uh,

per sternal long axis, make sure that you zoom,

uh, use high res zoom.

So you wanna get a clear, uh, look at the, uh,

area that you're gonna measure.

And then, then, uh, when you do your doppler,

you wanna make sure you, uh, trace the laminar flow,

and you want to get, uh, you wanna pulse at the same area

where you did your measurement for the diameter

and for your, uh, to calculate the, uh,

mitral valve stroke volume, you wanna do this, uh,

measurement of the annulus from either the apical four

chamber or the, uh, apical long axis view.

And you need to measure the annulus at mid diastole. Okay?

And when we pulse, we pulse at the level

of the mitral valve annulus, not the tips

of the annulus when we're assessing diastolic function,

but right at the annulus,

because that's right where we measure.

And at the bottom there at the screen, you see the formula

for the, uh, uh, mitral valve stroke volume.

And this is where, how we, uh, make those, uh, measurements

for mitral valve stroke volume.

And these are the formulas that we use, uh,

to assess severity.

We, we calculate the, uh, regurg volume,

and that's done by subtracting the stroke volume on the LVLT

from the stroke volume of the mitral, uh,

valve l uh, stroke volume.

And then we do a regurgitate fraction.

And the regurg fraction is where we take the regurg volume

and we divide it by the stroke volume of the mitral valve

and multiply it times 100.

And then we calculate the effective, uh,

regurgit orifice area.

That's where we divide, divide the REGURGIT volume

by the Mr VTI.

Uh, another volumetric method that can be used is

what we call the quantitative volumetric

stroke volume method.

I know that's a lot to say there,

but this basically is when you get your stroke volume

by utilizing the, uh, volume from either your, uh,

biplane measurements

that you make when you do your assessing for, uh, when you,

you are, uh, getting your ef, uh, and it's best

and more accurately assessed with either 3D

or with contrast images.

Okay? And these are the formulas that are used to make

that, uh, calculation.

Another method that we use is PISA

and, uh, use some, some tips on

whenever you do pisa, uh, you know, you more, most times,

most of the time, PISA is, uh,

acquired from the apical views,

but it can also be done in a peroneal alone axis view,

if you have a very eccentric jet

that's posteriorly directed, uh,

or one example will be if you have a perforated anterior

leaflet, uh, you'll be lined up perfectly

and you can do your PISA there,

but you wanna optimize your flow conversions.

So whenever the, uh,

whenever the valve closes,

you'll see a nice, uh, ball there.

So we see here on the right side of the screen,

see a nice hemisphere,

and, uh, you wanna use high res zoom, zoom up on the valve.

I like to use color compare.

That way I can see what the valve is doing, uh, when it open

and closes, and it won't be anything won't

be obstructed with the color.

I like to use a three beat loop,

and it's important to adjust your aliasing velocity to

between either 30 or or 40 centimeters per second.

And you want to adjust it in that range.

Whatever gives you the most round ball

here for your measurements.

And another important tip

whenever you do your PISA, is you wanna make sure

that you measure from the first, uh, aliasing, uh,

shell to the hemisphere.

And that's typically done mid to late systole,

but it should always be at the time of your peak, Mr.

Velocity. So if you look at the right side there

of the screen where I have that line going

through the peak velocity of the MR Jet, that's the same,

uh, uh, locate part

of the cardiac cycle on your EKG,

where you should measure your pisa,

it should be done at the same time.

So the closer you get to the same time, the more accurate,

uh, that measurement is.

And here are the formulas for PISA.

And, uh, just like, uh, the other, uh, methods

PISA has its pit pitfalls.

Uh, when you, whenever you do pisa, you're, uh,

you make a lot of assumptions.

You assume that the Pisa hemisphere is symmetric,

and you, you assume that, that, that there is a hemisphere,

and that this, which is not always the case.

Uh, you, um, also, the plane

that is used to measure the PISA radius assume is assumed to

transverse the hemisphere at its peak height,

which is not always true.

And the effective regurg in orifice

and the regurg in volume of jets that are not holo systolic,

they're oftentimes overestimated.

It's not valid with multiple jets.

And whenever you have an eccentric jet,

they're very difficult to measure.

So sometimes we also use color doppler,

or some people like to call the eyeball method.

And basically, when more than 40% of the LA area, uh,

reaches the posterior wall, it's usually,

uh, considered to be severe.

You have a low, uh, a large flow conversions

at a color scale of between 50

and 70 that persists throughout the duration of, of the,

uh, flow is considered severe.

Whenever there's eccentric jet that hugs the walls of the,

uh, left atrium, usually su suggests a flail leaflet.

And whenever you have a splay of color,

it suggests significant mr.

But there are a lot of pitfalls within mr.

It's, it's good for excluding mr,

but it's not reliable for grading its severity, uh,

because a lot of times, you know, if the jet is real

eccentric, you're not seeing the entire jets.

So it can be underestimated.

It can also be affected by, uh, blood pressure

and how your, your gains are setting.

It plays a big role in, in how much color you see.

So you can also do a vena contract.

And, uh, whenever you measure your vena contract,

it's important that you see all three components

of the regurg and flow.

You need to see the, uh, flow convergence,

the vena contract, and the jet area.

All of these things have to be seen

before you measure, make this measurement.

So, as you can see there, um, again, uh,

the vena contract also has pitfalls

because it can overestimate when the mitral regurgitation

isn't holo systolic, it doesn't apply to multiple jets,

and it may underestimate elliptical orifices, okay?

And you can also do 3D color.

And some of the advantages of 3D color is, uh,

multiple jets in different directions,

or, uh, you're able to measure those with the 3D.

You can also identify severe functional mr in some cases

where PIs a underestimates the, uh, regurgit in orifice,

and you have less assumptions

whenever you, uh, utilize 3D you're, you're not making, uh,

as many assumptions because allows you to, uh,

to visualize the entire structure, whether it's a part

of the heart or whether it's, uh, the mitral regurgitation.

It also has pitfalls, just like our other methods,

it's subject to color blooming.

You have limited resolution. It's easy to overestimate.

If the MR is not holo systolic,

multiple jets may be in different planes.

It must be analyzed separately and then added,

and it can be very cumbersome

and, uh, takes, you know, taking a lot of time.

And here, real quickly, here are some signs of severe,

uh, mr.

And here are, uh, some de more definite signs of,

uh, severe mr.

Anytime you, if you have a regurg orifice

that is greater than

or equal to 0.4, you have a mitral, uh, regurg in volume

that's greater than or equal to 60 regurg infraction

that's greater and equal than to 55%.

Your vena contracted width is, uh, greater

or equal than to seven.

Uh, these are all definite signs of, uh, severe, uh,

mitral regurgitation, as well

as systolic flow reversal in the pulmonary veins.

And here's a, uh, summary of the, uh,

quantification, uh, scale for, uh, mitral regurgitation

with all of the, uh, some of the, uh, the vena contract,

the regurg of volume, and regurg infractions, he's, uh,

here are the numbers, uh, that you need to pay,

uh, close attention to.

And, uh, we're gonna go to our first case.

Here's a patient that has a very dilated, uh,

lv you see severe LV dysfunction.

And if you look at the mitral valve leaflets,

if we zoom up here, they're apically displaced.

And as you know, they're just barely touching each other.

You have, uh, partial coaptation looking here from the, uh,

short axis, you're saying, uh, if you look at the, uh,

this area here, you see where the area of, uh,

mouth coaptation is right at the A three P three,

and it's demonstrated nicely here with color as well.

And here are some more views showing the, uh, color flow

from the color here.

It looks like, looks to be severe, uh, mr.

And, uh, we did, uh, some calculations here. Here.

I used the, uh, we did the stroke

volume, uh, of the mitral valve

and the, uh, the continuity, uh, of flow, uh, method,

calculating the stroke volume across both the mitral

and the, and the, uh, LVLT gave me a regurg in volume

of 53 and a regurg infraction of 60.

So that's, that's, uh, the regurg infraction is consistent

with, uh, severe mr.

The regurg volume is consistent with moderate, uh, Mr.

Pisa showing a regurgit volume of 34

and a regurgitate orifice of 0.4,

and there is a systolic flow reversal in the, uh,

pulmonary veins.

Let's look at case two.

As you can see here, nicely, uh, that this patient, uh,

if you look at the, uh, posterior leaflet

of the mitral valve is prolapsing into the left atrium

very substantially.

And if you zoom up on the mitral valve,

you also see this area of, uh, mal coaptation, which, uh,

makes it suspicious for not only prolapse,

but possible flail as well.

We put color on there.

We see a very eccentric jet going all the way to the back

of the, uh, left atrium

anteriorly directed consistent with severe mr.

Looking here from the short axis, here is a area

of where the P two is.

And then you see this area here, it looks like appears,

appears to be some dropout on the, uh, P three

P two appears to be thick.

And this would color eccentric jet

looking at the same patient

from the apical four chamber view.

You can see where the, uh,

posterior leaflet is actually going.

Part of the posterior leaflet is going under the anterior

leaflet, Which is consistent with a flail leaflet.

We did a mitral, uh,

the mitral valve inflow is greater than 1.5,

which is showing restrictive filling patterns, suspicious

for severe, uh, mitral regurgitation,

see a very eccentric jet, a very large, uh,

flow conversions, and look at our color scale.

So I'm not even, I haven't moved the baseline,

but I'm seeing this very large flow conver conversions here

above the, uh, mitral valve leaflet

with this very eccentric jet that, that wraps around, uh,

the, uh, inter interatrial septum going all the way back

to the rear of the left atrium.

This is what we call the kawana effect.

And let's look at the numbers here.

So I got a, a stroke volume across the mitral valve

of 3 0 7, which is a very, uh, large number there.

Uh, and then for the LVLT, I got 70

and gave me a regurg in volume of 2 37,

and a regurg in fraction of 77.

So, um, I'm not, I don't have a lot

of confidence in the stroke volume across the mitral valve.

I think that's a little too large.

Uh, uh, and I think, uh, that's, that, that goes back

to the point I was making earlier about your measurements.

Remember, anytime you make a measurement, uh,

of the annulus, uh, any error

that you make would be squared.

So I think that's where probably my, the error came,

and that's why that number is so large.

But I also did the quantitative, uh, volumetric method.

That's where I utilized the, uh, the biplane.

Uh, and I used contrast.

So if you look at the left of the screen, left

of the screen, you'll see where I did those numbers

and how I got my, uh, my, um, stroke volume.

It's called the LV total stroke volume, where I subtract,

where you subtract the systolic volume from the end

diastolic volume, and, uh,

You to get the regurgitant flow, you take your

total stroke volume

and you subtract your LV outflow stroke volume.

And I, I did that and it gave me a regurgitant

volume of 1 0 7.

And then you take your, uh, you get the regurg infraction

by dividing, uh, your regurg in volume, uh, by the, uh,

total, uh, stroke volume

to get your regurgit infraction all showing, uh, severe mr.

So in a case like this, PISA wouldn't be good to use

because the jet is so eccentric

and you wouldn't be able to get a accurate measurement.

So I believe this will be, uh, this is a good,

a good example where this would be the best method to use.

And here's some 3D images of this patient.

Uh, I, I did a still frame image.

It's a little, uh, easier to see.

So what's exactly going on, uh, with this patient?

So from the images that we were looking at, uh, we noticed

that there was a flail.

And this 3D image shows you exactly where the flail is.

Here at the P two, uh, we also were seeing a prolapse.

So we see a prolapse not only at, uh, P two,

but all the way, also all the way over to P three.

So you have a P two P three prolapse with a P one flail,

and this patient has severe mr,

and here it is with color.

Again, you can see it better when I freeze it.

You can see here exactly this, uh, jet of mr.

You can see the little flail leaflet here in the color jet

going anterior towards the aortic valve.

Uh, and it's wraps.

And of course, it wraps around over to the, uh,

inter atrial septum as well.

Go to our next case here.

Let me back up one and see if I can get 'em both to move.

Okay. So here we have a patient that has, uh,

textbook rheumatic heart disease.

You notice how the tips of the leaflets here are thicken,

and, uh, when the valve opens, you have that nice, uh,

hockey stick appearance.

And then if you look from the short axis,

you see this fish mouth appearance.

And you look at the commissures here,

how they're fused together, restricting the, uh,

opening of the mitral valve.

And this patient also has Mr, of course,

and it's a jet here.

Going back into the, uh, left atrium, here's the, uh,

apical four chamber view.

So you're seeing two things here, uh,

which you'll see oftentimes with a patient with a rheumatic,

uh, heart disease when,

whenever there's a flow across the mitral valve.

You'll see this with the, uh, this flow very turbulent,

looks like a candle flame, which is a textbook, uh, example

of, uh, mitral stenosis.

You also see this exec eccentric jet of, uh,

mitral regurgitation going all the way back

to the back wall here of the, uh, left atrium.

And of course, the left atrium is markedly dilated.

So I did Pisa, uh, on this patient to quantify the, uh,

mitral regurgitation.

I was able to line up, uh,

to get the college up line up very well.

And I measured, I got a, uh,

A ERO of 0.3

and a regurgit volume of 39,

which is moderate mitral regurgitation.

And I got a mean gradient across the, uh, mitral valve

of 7.2.

Here are the 3D images of this patient.

So, uh, I also did a valve area

using the 3D.

3D is a, ve is the best way to get, uh, the area

of the mitral valve, I believe.

'cause it allows you to line up all your, your planes

in two orthogonal views.

You can get right down the center of the valve,

and you can put your, uh, your aligns right at the tip

of the leaflets, which will allow you

to ter more accurately, got a valve area of 0.6,

which is consistent with, uh, severe mitral regurgitation.

Here's the next case. This patient has a

market, uh, prolapse of both the anterior

and posterior leaflet of the mitral valve.

Notice how you see, you're seeing most of the, the,

uh, mr.

Late when the, uh, leaflets bowl back into the,

uh, left atrium.

Here again, you see the MR from all views.

So very significant mitral regurgitation,

late peaking Jett shown here with the, uh, color M mode.

So again, this would not be a good, uh, patient to utilize

PSA four because of the eccentric, uh, nature of the jet.

So we're, we, uh, use the, uh, volumetric method, uh,

by calculating stroke volume across the mitral valve

and the LVLT.

This gave me a regurg volume of 92, which is consistent

with severe mitral regurgitation

and a regurg infraction of 62%.

And, uh, also GA gave me a, uh, regurg orifice area

of 0.7, which is consistent with severe mr.

And here's the 3D rendering of the that patient.

And you can see how both the anterior

and post posterior leaflet are both buckling back into the

left atrium, which is, uh, uh, consistent with

what they call barlows, very redundant,

thick leaflets, flicks.

And we'll go to this next case here.

So if you look closely here at this patient, the leaflets,

uh, are, are restricted.

They're not, uh, coating at all.

It's, it's basically staying open.

And, uh, you have a reduced, uh, LV function.

Here's a closer look at the leaflets.

A lot of MR is what you would expect to see.

It's the LV function

and your apical four chamber, again, showing the same thing.

Mild market, mild coaptation of the, uh,

mitral valve leaflets, they're not even touching at all.

And as, as you expect, you see a lot of mr.

And the jet is primarily centrally directed.

So this will be a good, uh, case

to u utilize PISA is, which I did.

And from my PISA measurement, I got a regurgit orifice area

of 0.7, which is severe,

and a regurgit volume of 40, which is moderate.

And I utilize the, uh,

Volumetric method utilizing the 3D

and the, uh, 3D, uh, biplane, excuse me,

the 3D, uh, volumetric method

where I could calculate the,

utilizing the stroke volume calculated by the 3D,

which gave me 66 for the stroke volume.

And I subtracted the, uh, uh, stroke volume from the LVLT.

And being that this patient on the, uh,

when I was doing my LV OT pulse wave, you notice

that the doppler is inconsistent.

So I, I averaged, I measured all three of these

and took the average to, uh,

calculate the stroke volume across the LVOT.

And I got a stroke volume of 25.

And when I subtracted that from

the 3D stroke volume, I got a, a regurg volume

of 41, which is very close to

what I got with the pisa.

So the PISA and the, Uh, uh,

quantitative, uh, stroke volume, uh,

method utilizing 3D are pretty much the same.

So whenever you can use multiple ways to, uh,

quantify mitral regurgitation,

and you get multiple methods that are, uh,

the same or very similar, that gives you a very strong, uh,

case for how severe the, uh, mitral regurgitant

mi mitral regurg MR is for this particular patient.

So whenever I do, uh, when I try to quantify, uh,

mitral regurg, mr, I always like

to use more than one method.

Um, whenever we have in our lab,

if the MR is either moderate

or severe, we're required to, you know, utilize these, uh,

multiple methods, methods especially, except when there's,

you know, you have an eccentric jet where you have

to exclude pisa.

But I always try to do a stroke volume, uh, across the valve

and to, uh, when it, when it, when it lines up with my, uh,

PISA, then I feel very well here.

I get a, using the, uh, get to get my, uh,

regurg orifice area.

I get, I'm getting, uh, 0.9,

and then with a pisa it was 0.8.

So everything is lining up, uh, pretty, pretty consistent

that this patient definitely has, uh, severe, uh, mr,

which is quite obvious, uh, being

that the leaflets aren't closing as well.

But this is just a good example how multiple methods, uh,

can line up and, uh, work well together.

So we're gonna quickly move to this last case.

Uh, I actually covered this case on my last talk

on endocarditis.

So I, I thought it's a very good one to use for, uh,

mitral regurgitation, being that this patient had, uh,

mitral regurgitation as well.

Uh, you know, it's the patient that came into the hospital,

uh, with, uh, heart failure

and cardiogenic shock.

And, uh, while in the hospital, they developed, uh,

uh, endocarditis.

They didn't come in with endocarditis,

but they developed it while they were in the hospital.

The patient had two echos done.

Uh, the first echo, there wasn't any sign of endocarditis.

And in the second echo, which was done 12 days later,

you can see the endocarditis.

So we're gonna go to these images here,

and I've got 'em nice and labeled, nicely labeled for you.

Uh, the initial echo, you know, showing, like I said,

no endocarditis, the one

that I did 12 days later, very similar.

The function is the same. Not seeing anything on the

leaflets, uh, you know, I'm, I believe this is

what I'm, what I'm seeing here.

The scallops is a two P two.

And, uh, initially there was no Mr seen in the long axis.

And now you see this jet, uh,

that wasn't there 12 days earlier.

And if you notice, we're not really seeing the,

where this jet is coming from.

It's kind of out of plane, which is, uh, brings me,

makes me wanna, uh, remind everyone.

Whenever you're assessing a patient from MRI

and use color, it's important to sweep through the,

the leaflets by, you know, moving your, your, uh, transducer

where you're, you know, you wanna try

and find where this, uh, Mr is converging at so you can, uh,

isolate exactly where it's coming from.

Okay? But like I said, going from no Mr

to very significant Mr

because it's actually, it's hitting the back wall here

of the left atrium, and it's going up towards

the, uh, aortic valve.

So it's very significant, Mr.

So when I pan, uh, down towards the

tricuspid valve slightly to bring in

a one P one, I noticed this huge vegetation

that wasn't there 12 days ago.

And you can see it here in the short axis.

The thickening here, this area, this is where the, uh,

vegetation is With color.

We'll see color flow that's actually

outside of the leaflets.

That's why I wasn't really seeing it in the peroneal lawn,

'cause I didn't, you know, angle over enough to bring it in.

Here's the four chamber.

You see, we're seeing, uh, flow reversal, uh,

perforated area in the vegetation.

And with color, we're seeing again, exactly

where it's coming from in the area of, uh, this is P one,

nice flow convergence.

So I did my PISA measurement, got a regurg of volume of 79,

which is severe regurg orifice, which is 0.6,

which is, uh, severe.

And, uh, use the, uh, continuity

of flow principle using the stroke volume

of the mitral valve and the LVLT.

And it gave me a regurg volume of 90

and a regurg and fraction of 69.

I got 79 with the, uh, PISA as far as regurg and volume.

And when I did my regurg orifice, I got 0.7.

And here's some more views of the vegetation in 3D.

There's the, uh, MR and the per perforated area.

And then I did my, uh, vena contract use utilizing 3D,

which gave me Avena contract of 0.6.

And I got with vaa, we'll quickly go back again,

I got 0.6, uh, with, uh, aisa.

So it all lines up very well there, showing consistency.

So again, uh, Whenever you, uh,

whenever you're assessing a patient from mitral

regurgitation, it's a lot of things to consider.

We have to consider the anatomy of the valve.

So it's, uh,

and we have to understand that the valve consists

of more than just the leaflets.

So you have to look at the ventricle, the papillary muscles,

the chord a, the annulus, uh, all of those have

to be, uh, assessed.

And whenever you quantify, you wanna make sure

that it utilize a at least two method,

two different methods, uh, when appropriate to, uh, assess

to best assess the mitral regurgitation.

So this, uh, concludes my talk for tonight.

Uh, if anyone has any questions

or comments, we'll give you a few moment moments to do that

before we end tonight.

Hey, Billy. Hi. Hi.

Great talk. Um, I wanted to know,

and maybe some of the present

or uh, some of the, uh,

people participating would probably like to know in,

in your institution, do you routinely, um, have access

to the report or do the images from the Mr.

Cardiography? And is that part of the ordering protocol

whenever people put that in, that they, you know, say, Hey,

we've got, we already have MR of this, um,

and you guys will, you know, have access

to read those reports?

Uh, yes.

Whenever a patient has, uh, we have access

to history on their records.

So previous exams

and tests that have been done, uh, we can pull it up.

So that's normally what I do

whenever I do patients anyway, I try to look at the history

'cause it kind of helps me, you know,

to know what to focus on.

And, uh, so I'll, I'll look at that

and to see, you know, if it was severe before

or if they had MR before.

Uh, not only that, I also like to compare.

Uh, 'cause oftentimes, especially with mitral regurgitation,

they'll do a trans esophageal echo, uh, afterwards.

And I always like to compare the trans esophageal images

to the images, uh, that I get to, to see, you know,

how, how they compare.

And oftentimes they do.

And I also notice that a lot of times, especially being

that I, I utilize the three DA lot, they'll, um,

they'll, they'll try to reproduce the images, uh,

that I was getting on my 3D images, uh, on the transthoracic

with the TEE.

Uh, that's a lot of times they'll focus in on,

I was focusing on, uh, which is,

which gives me more confident confidence, you know,

what I'm doing and what I've, you know, the measurements

that I've made and the images, the

information that I've provided.

Okay, great.

Mitral Regurgitation Mechanisms and Quantification

Quiz 1