Carpentier Mitral Valve Regurgitation Clasif

UCSF

Mitral Mitral Regurgitation:Regurgitation:Emerging Concepts

Elyse Foster, MDElyse Foster, MDProfessor of MedicineProfessor of Medicine

UCSFUCSF

UCSF

Disclosure:Disclosure:Grants from Grants from EvalveEvalve, Inc, Inc

Guidant Guidant -- Boston Scientific Boston Scientific CorporationCorporation

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Classification ofClassification of Mitral Mitral regurgitation:regurgitation:

•• Organic Organic -- Primary pathology of the leafletsPrimary pathology of the leaflets•• DegenerativeDegenerative•• RheumaticRheumatic•• EndocarditisEndocarditis•• Congenital (Congenital (egeg. cleft). cleft)

•• Functional Functional -- Malcoaptation Malcoaptation 22°° to myocardial to myocardial processprocess•• IschemicIschemic•• Dilated Dilated cardiomyopathycardiomyopathy•• Hypertrophic cardiomyopathyHypertrophic cardiomyopathy

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Anatomy of the Anatomy of the Mitral Mitral ApparatusApparatus

•• LeafletsLeaflets•• AnnulusAnnulus•• Chordae tendinaeChordae tendinae•• Papillary musclesPapillary muscles•• Left ventricleLeft ventricle

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Mitral Mitral Valve Valve ProlapseProlapse

Mitral Mitral Valve Valve EndocarditisEndocarditis

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Physiology of Primary Physiology of Primary Mitral Mitral RegurgitationRegurgitation

•• Left ventricular volume overloadLeft ventricular volume overload•• LA enlargementLA enlargement•• Eccentric hypertrophyEccentric hypertrophy•• LVEF normal to LVEF normal to hyperdynamichyperdynamic•• Pulmonary hypertensionPulmonary hypertension•• Acute Acute vsvs. Chronic. Chronic

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Acute MRAcute MR

EDV 170 mlEDV 170 ml

ESV 30 mlESV 30 ml

SV 70 mlSV 70 ml

RV 70 mlRV 70 ml

LAp LAp 25 mmHg25 mmHg

EF 82%EF 82%RF 50%RF 50%

Chronic compensatedChronic compensated


ESV 50 mlESV 50 ml

SV 95 mlSV 95 ml

RV 95 mlRV 95 ml


EF 79%EF 79%RF 50%RF 50%

Adapted From Adapted From CarabelloCarabello, NEJM 1997, NEJM 1997

Chronic Chronic decompensateddecompensated


ESV 110 mlESV 110 ml

SV 65 mlSV 65 ml

RV 85 mlRV 85 ml

EF 58%EF 58%RF 57%RF 57%


NormalNormal


ESV 50 mlESV 50 ml

SV 100 mlSV 100 mlEF 66%EF 66%


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The Roles of EchocardiographyThe Roles of Echocardiography

•• How severe is the MR?How severe is the MR?•• What is the mechanism for MR?What is the mechanism for MR?•• How well compensated is the LV?How well compensated is the LV?•• What is the best way to reduce the MR?What is the best way to reduce the MR?

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Mitral Mitral Regurgitation by Regurgitation by EchocardiographyEchocardiography

•• Extremely commonExtremely common•• Increases with ageIncreases with age•• Severity exaggerated due to an Severity exaggerated due to an

overreliance overreliance on qualitative rather than on qualitative rather than quantitative parametersquantitative parameters

•• If there is no apparent leaflet pathology, LV If there is no apparent leaflet pathology, LV and LA size are normal, probably not and LA size are normal, probably not severe.severe.

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How severe?How severe?

•• The severity of The severity of mitral mitral regurgitation regurgitation should be evaluated based on a should be evaluated based on a constellation of 2constellation of 2--dimensional and dimensional and Doppler Doppler echocardiographic echocardiographic findings.findings.

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Journal of the American Society of EchocardiographyJournal of the American Society of EchocardiographyJuly 2003July 2003

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MR: Color Flow EvaluationMR: Color Flow Evaluation

Mild central jetMild central jet Severe eccentricSevere eccentricencircling jetencircling jet

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MildMildCentral MRCentral MR

SevereSevereCentral MRCentral MR

SevereSevereEccentric MREccentric MR

Adapted from Adapted from Zoghbi Zoghbi et al. ASE valve et al. ASE valve regurg regurg document (JASE 03)document (JASE 03)

< 4 cm< 4 cm22

< 10% LA Area< 10% LA Area> 8 cm> 8 cm22

> 40% LA Area> 40% LA Area

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““Spatial MappingSpatial Mapping””Color Jet Area in MRColor Jet Area in MR

•• Most widely used, most helpful at extremesMost widely used, most helpful at extremes•• Regurgitant Regurgitant volume only weakly related to area (r = 0.64)*volume only weakly related to area (r = 0.64)*•• More severe, eccentric jets have smaller areaMore severe, eccentric jets have smaller area•• Significantly affected by instrument settingsSignificantly affected by instrument settings

•• Nyquist Nyquist limit optimal at 50 limit optimal at 50 -- 60 cm/sec60 cm/sec•• Gain should be adjusted for Gain should be adjusted for ““slight speckleslight speckle””•• Optimize frame rate by reducing depth and usingOptimize frame rate by reducing depth and using narrow sector narrow sector

angle to minimum of 16 angle to minimum of 16 -- 18 Hz18 Hz•• Driving pressure important Driving pressure important -- record BP on screenrecord BP on screen

•• LowLow blood pressure blood pressure ⇒⇒ smaller jetsmaller jet•• High blood pressure High blood pressure ⇒⇒ larger jetlarger jet

*From Hall, Circ *From Hall, Circ ‘‘9797

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Color Flow Jet in MRColor Flow Jet in MR

•• Jet Penetration:Jet Penetration:•• Mild Mild -- centralcentral•• Moderate Moderate -- eccentric to 1st PVeccentric to 1st PV•• Severe Severe -- eccentric and extends past 1st PVeccentric and extends past 1st PV

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The limitations of color flow The limitations of color flow Doppler necessitate an Doppler necessitate an integrative approach tointegrative approach to

assessment of MRassessment of MR severityseverity

Qualitative and quantitative Qualitative and quantitative parametersparameters

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MR MR Quantitation Quantitation based on based on Doppler and 2Doppler and 2--D measurementsD measurements

MILDMILD MODMOD MODMOD--SEVSEV

SEVSEV

VC width VC width (cm)(cm)

< 0.3< 0.3 0.3 0.3 -- 0.69 0.69 >> 0.70.7

ROA(cmROA(cm22)) < 0.2< 0.2 0.2 0.2 -- 0.290.29 0.3 0.3 --0.390.39 >> 0.40.4

RV (ml)RV (ml) < 30< 30 30 30 -- 4444 45 45 -- 5959 >> 6060

RF (%)RF (%) < 30< 30 30 30 -- 3939 40 40 -- 4949 >> 5050

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Vena contractaPISA

Adapted from Adapted from Zoghbi Zoghbi et al. ASE valve et al. ASE valve regurg regurg document (JASE 03)document (JASE 03)

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Color Flow Jet Width in MRColor Flow Jet Width in MR

•• Vena Vena Contracta Contracta WidthWidth•• Parasternal Parasternal LAX most accurateLAX most accurate•• > 0.5 cm:> 0.5 cm: RV > 60 ml RV > 60 ml

ROA > 0.4 cmROA > 0.4 cm22

•• << 0.3 cm:0.3 cm: RV < 60 ml RV < 60 ml ROA < 0.4 cmROA < 0.4 cm22

*From Hall, Circ *From Hall, Circ ‘‘9797

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•• Regurgitant Regurgitant volume (RV) = TSV volume (RV) = TSV -- FSVFSV= 190 = 190 -- 95 = 95 ml95 = 95 ml

•• Regurgitant Regurgitant Fraction (RF) = Fraction (RF) = RV/TSV = 95/190 = 50%RV/TSV = 95/190 = 50%

Regurgitant Regurgitant Volume Volume and Fractionand Fraction


ESV 50 mlESV 50 ml

SV 95 mlSV 95 ml

RV 95 mlRV 95 ml

EF 79%EF 79%RF 50%RF 50%

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Total SV = EDV Total SV = EDV -- ESV = 56 mlESV = 56 ml

EDV = 114 mlEDV = 114 ml

ESV = 58 mlESV = 58 ml

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LVOTd LVOTd = 2.0 cm= 2.0 cm LVOTLVOTVTI VTI = 15 cm= 15 cm

FSV = 45 mlFSV = 45 mlRV = 11 mlRV = 11 mlRF = 11/56 = 20%RF = 11/56 = 20%

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Regurgitant Regurgitant Orifice Area Orifice Area (PISA Method)(PISA Method)

•• Quantitative Quantitative measurement of:measurement of:•• ROA (cmROA (cm22))•• Regurgitant Regurgitant VolumeVolume

rr va- 40

v2

Regurgitant flow = 2πr2 X VaROA = 2πr2 X Va/V2

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PISA radius = 1.1 cmPISA radius = 1.1 cmAlias vel = 0.4 m/secAlias vel = 0.4 m/sec

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PISA CalculationPISA Calculation

ROA = 2πr2 X V/V2 = 6.28(1.1cm)2 X .40/5 = .60 cm 2Regurgitant Volume = ROA X VTIMR = .60 X 150 = 91 ml

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Pulmonary Vein FlowPulmonary Vein Flow

SD

S

D

44--Systolic FlowSystolic FlowReversalReversal

11--NormalNormal

S D

22--Systolic bluntingSystolic blunting

33--Diastolic dominantDiastolic dominant

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Pitfalls:Pitfalls:Pulmonary venous flow patterns in MRPulmonary venous flow patterns in MR

•• PV flow pattern reflects LA pressure and PV flow pattern reflects LA pressure and loading conditionsloading conditions

•• Influenced by factors other than MR Influenced by factors other than MR severityseverity•• Diastolic functionDiastolic function•• LA sizeLA size•• Atrial Atrial fibrillationfibrillation

•• Systolic flow reversal maySystolic flow reversal may present inpresent in only only one PV especially when jet is eccentricone PV especially when jet is eccentric

•• Most useful when systolic dominant or Most useful when systolic dominant or clear systolic flow reversal is presentclear systolic flow reversal is present

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What is the mechanism underlying MR?What is the mechanism underlying MR?Carpentier Carpentier Leaflet Motion Classification Leaflet Motion Classification

•• Normal (I) motionNormal (I) motion•• Primary annular diseasePrimary annular disease

•• Excessive (II) motionExcessive (II) motion•• (Non(Non--rheumatic) Degenerative valve diseaserheumatic) Degenerative valve disease

•• Restricted (III) motionRestricted (III) motion•• Systolic (III a): Functional MRSystolic (III a): Functional MR•• Diastolic (III b): Mitral stenosis; Dystrophic leaflet calcificaDiastolic (III b): Mitral stenosis; Dystrophic leaflet calcificationtion

•• CombinationCombination

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Carpentier ClassificationCarpentier Classification

•• Type I Normal leaflet and chordal motionType I Normal leaflet and chordal motion•• Type II Prolapse or excessive motionType II Prolapse or excessive motion•• Type III Restricted motionType III Restricted motion

I II III

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Degenerative MR:Degenerative MR:Prolapse vsProlapse vs. Flail. Flail

•• ProlapseProlapse -- leaflet leaflet displacement above the displacement above the annulus by 2 annulus by 2 -- 4 mm in 4 mm in which the free edges of the which the free edges of the leaflets remain supportedleaflets remain supported

•• Flail leafletFlail leaflet has both has both ruptured chordae and an ruptured chordae and an unsupported free edge that unsupported free edge that extends above the extends above the opposing leaflet during opposing leaflet during systolesystole

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Role of TEERole of TEE

•• Mapping of anatomic defectMapping of anatomic defect•• Inadequate TTEInadequate TTE

•• Acoustic shadowing due to prosthetic Acoustic shadowing due to prosthetic valve or dense annular calcificationvalve or dense annular calcification

•• EndocarditisEndocarditis•• Annular abscessAnnular abscess

•• Intraoperative Intraoperative evaluation of MV repairevaluation of MV repair

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Mitral Mitral Valve ScallopsValve Scallops

•• A1 A1 –– A3A3•• P1 P1 –– P3P3•• A1, P1 A1, P1 –– anterolateralanterolateral•• A2, P2 A2, P2 –– centralcentral•• A3, P3 A3, P3 -- posteromedialposteromedial

Adapted from Foster et.al.Adapted from Foster et.al.Ann Ann Thorac Surg Thorac Surg 19981998

Ao

A3A2

A1

P3P2

P1

LAA

Inf/post

Medial Lateral

Sup/Ant

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How to fix it:How to fix it:Anatomic definition criticalAnatomic definition critical

•• Surgical ApproachSurgical Approach•• Posterior leafletPosterior leaflet

•• Quadrangular resectionQuadrangular resection•• Higher shortHigher short--term and longterm and long--term successterm success

•• Anterior leafletAnterior leaflet•• May require May require chordal chordal switchswitch•• Less successfulLess successful

•• Percutaneous Percutaneous approachesapproaches

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Complex mapping for leaflet Complex mapping for leaflet localizationlocalization

0 degrees0 degrees

60 degrees60 degrees

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33--Dimensional Dimensional EchocardiographyEchocardiography

Courtesty Courtesty of of TomTec TomTec CorporationCorporation

Prolapsed segmentProlapsed segment

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How well is the LV compensated?How well is the LV compensated?

•• Echo evaluation of LV dimensions and Echo evaluation of LV dimensions and LVEFLVEF

•• Basis for ACC/AHA recommendations Basis for ACC/AHA recommendations for valve replacementfor valve replacement

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Mitral Mitral regurgitation: Indications for surgery regurgitation: Indications for surgery in nonin non--ischemic MRischemic MRBonow Bonow et al JACC 2006et al JACC 2006

IndicationIndication ClassClassAcute Acute syx syx severe MRsevere MR IISymptomatic chronic severe MR with EF > 30% Symptomatic chronic severe MR with EF > 30% and/or and/or ESD < 55 mmESD < 55 mm

II

Asyx Asyx MR with LVEF <55% and/or LVESD MR with LVEF <55% and/or LVESD > 40 mm> 40 mm IIRepair recommended over replacementRepair recommended over replacement IIAsyx Asyx pt with preserved LVEF when repair likelihood > pt with preserved LVEF when repair likelihood > 90%90%

IIaIIa

Asyx Asyx with preserved EF and with preserved EF and Afib Afib or PHTor PHT IIaIIaSevere LV Severe LV dysfxn dysfxn with EF< 30%, ESD >55 with EF< 30%, ESD >55 with primary with primary MR when repair likelihood is highMR when repair likelihood is high

IIaIIa

Severe LV Severe LV dysfxn dysfxn with EF< 30%, ESD >55with EF< 30%, ESD >55 with with functional MR unresponsive to med Rx + CRTfunctional MR unresponsive to med Rx + CRT

IIbIIb

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Mitral Mitral regurgitation: Indications for surgery regurgitation: Indications for surgery in nonin non--ischemic MRischemic MRBonow Bonow et al JACC 2006et al JACC 2006

IndicationIndication ClassClassMVP and preserved LVEF with recurrent ventricular MVP and preserved LVEF with recurrent ventricular arryhthmias arryhthmias despite med Rxdespite med Rx

IIbIIb

Asyx Asyx pts with preserved LVEF when repair unlikelypts with preserved LVEF when repair unlikely IIIIIIMild or moderate MRMild or moderate MR IIIIII

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Functional Functional mitral mitral regurgitationregurgitation

•• Symmetric leaflet tetheringSymmetric leaflet tethering•• Central MR jetCentral MR jet•• Severity dependent on:Severity dependent on:

•• Coaptation Coaptation depthdepth•• Tenting angleTenting angle

•• Asymmetric leaflet tetheringAsymmetric leaflet tethering•• Eccentric jetEccentric jet•• Ipsilateral Ipsilateral to tethered leafletto tethered leaflet

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• Left Ventricular dilation

• Papillary muscle splaying

• Mitral annular dilation

Causes of Functional MRin Dilated cardiomyopathyCauses of Functional MRCauses of Functional MR

in Dilated in Dilated cardiomyopathycardiomyopathy

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MR

CHF

Functional MRFunctional MRFunctional MR

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Coaptation DepthCoaptation Depth(Leaflet tenting)(Leaflet tenting)

2.0 cm2.0 cm

SymmetricSymmetric tethering due to splaying tethering due to splaying of papillary muscles in DCMof papillary muscles in DCM

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Inferior infarct with remodelingInferior infarct with remodeling

Posterior MR jetPosterior MR jet

•• Asymmetic Asymmetic tetheringtethering•• Restricted posterior Restricted posterior

leafletleaflet motionmotion•• Usually in setting of Usually in setting of

IMI with remodelingIMI with remodeling

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Functional MRFunctional MR

•• More likely respond to medical therapy and More likely respond to medical therapy and CRTCRT

•• More difficult to address surgicallyMore difficult to address surgically•• Annuloplasty Annuloplasty ring for symmetric leaflet ring for symmetric leaflet

tetheringtethering•• Ischemic MR with asymmetric tethering Ischemic MR with asymmetric tethering

technically challengingtechnically challenging•• Lesser degrees of MR may be clinically Lesser degrees of MR may be clinically

important important ieie. EROA of 0.2 cm. EROA of 0.2 cm22

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Conclusions:Conclusions:

•• Echocardiography currently provides the Echocardiography currently provides the best qualitative and quantitative best qualitative and quantitative assessment of mitral regurgitationassessment of mitral regurgitation

•• Directed imaging provides important Directed imaging provides important anatomic information vital to MV repairanatomic information vital to MV repair

•• Indications for intervention in Indications for intervention in hemodynamicallyhemodynamically significant MR still significant MR still evolvingevolving

•• PercutaneousPercutaneous repair likely to become a repair likely to become a viable optionviable option

Carpentier Mitral Valve Regurgitation Clasif

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