An Integrative, Multiparametric Approach to Mitral Regurgitation Evaluation

Figures

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  Figure 1. Multiparametric Integrative Algorithm for MR Evaluation This algorithm was proposed by the American Society of Echocardiography and the Society of Cardiovascular Magnetic Resonance for evaluation of mitral regurgitation (MR).1 CMR = cardiac magnetic resonance; CW = continuous wave; EROA = effective regurgitant orifice area; LA = left atrial; LV= left ventricle/ventricular; PISA = proximal isovelocity surface area; RF = regurgitant fraction; RVol = regurgitant volume; TEE = transesophageal echocardiography; TTE = transthoracic echocardiography; VCW = vena contracta width.

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  Figure 2. Case 1: Transthoracic Echocardiography (A, B) Parasternal and (C, D) apical views of a posterior mitral valve leaflet flail resulting in an eccentric, anteriorly directed mitral regurgitation jet.

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  Figure 3. Case 1: Quantification of Mitral Regurgitation Severity by Using 2 Methods Both methods demonstrate hemodynamically significant mitral regurgitation. LV = left ventricular; LVEDV = left ventricular end-diastolic volume; LVESV = left ventricular end-systolic volume; LVOT = left ventricular outflow tract; MRF = mitral regurgitant fraction; MRV = mitral regurgitant volume; MV = mitral valve; PW = pulsed wave; SV = stroke volume; VTI = velocity time integral; 2D = 2-dimensional.

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  Figure 4. Case 1: Cardiac Magnetic Resonance Quantification of Mitral Regurgitation Severity Sequential short-axis slices are acquired from the mitral valve annulus to the left ventricular (LV) apex. Left ventricular end-diastolic volume (LVEDV) is calculated by adding the volume (area × thickness) of each short-axis slice during diastole. Left ventricular end-systolic volume (LVESV) is calculated by adding the volume of each short-axis slice during systole. Subtracting left ventricular end-systolic volume from left ventricular end-diastolic volume yields left ventricular LV stroke volume (SV). Subsequently, left ventricular outflow tract (LVOT) stroke volume obtained by phase contrast imaging is subtracted from the left ventricular stroke volume to yield the mitral regurgitant volume (MRV). MRF = mitral regurgitant fraction.

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  Figure 5. Case 1: Baseline and Postprocedural Images (A) A P3 flail resulting in (B) a severe laterally directed mitral regurgitation jet. (C) The 3-dimensional imaging of the valve shows the P3 flail with a ruptured chord in the left atrium. (D) Baseline systolic flow reversal in the left upper pulmonary vein. (E) Deep transgastric views reveal a left ventricular outflow tract (LVOT) stroke volume (SV) of 42 mL. (F, G) Post–transcatheter edge-to-edge repair (TEER) images show successful implantation of a MitraClip device (Abbott) at A3 to P3 resulting in mild residual mitral regurgitation. (H, I) Follow-up interrogation reveals a forward pulmonary vein systolic wave and an increase in left ventricular outflow tract stroke volume, both suggestive of significant mitral regurgitation reduction. AV = aortic valve; D = diastolic wave; IAS = interatrial septum; S = systolic wave; VTI = velocity time integral.

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  Figure 6. Case 2: Mitral Valve Prolapse With MR (A to C) Parasternal views of bileaflet mitral valve prolapse resulting in late systolic mitral regurgitation (MR). (D, E) Apical views demonstrating the presence of late systolic mitral regurgitation. (F) Note the discrepancy in mitral regurgitation severity between the proximal isovelocity surface area (PISA)–derived effective regurgitant orifice area (EROA) method and the volumetric method given the timing of the mitral regurgitation jet. MRV = mitral regurgitant volume; PkVreg = peak regurgitation velocity; Va = aliasing velocity; VTIreg = velocity time integral of the regurgitant mitral regurgitation jet.

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  Figure 7. Case 3: Transthoracic Echocardiography and Doppler Imaging on Presentation (A to C) Transthoracic echocardiography demonstrating significant residual mitral regurgitation post transcatheter edge-to-edge repair. (D) Continuous wave (CW) Doppler tracings demonstrating a complete mitral regurgitation jet. Other markers of significant mitral regurgitation include (E) a high E-wave velocity, (F) systolic flow reversal in the pulmonary vein, and (G) pulmonary hypertension. PASP = pulmonary artery systolic pressure; other abbreviations as in Figure 3.

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  Figure 8. Case 3: Transesophageal Echocardiography (A) Severe mitral regurgitation with (B) systolic flow reversal in the pulmonary vein. (C) Biplane imaging of the lattermost clip reveals single leaflet device attachment with the clip attached to the anterior leaflet. Abbreviations as in Figure 5.

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  Figure 9. Case 4: Transesophageal Echocardiography (A, B) 2-Dimensional transesophageal echocardiography images demonstrating left atrial (LA) dilation with mitral annular dilation resulting in significant central mitral regurgitation. (C, D) 3-Dimensional and 3-dimensional color transesophageal echocardiography images revealing the presence of multiple mitral valve indentations resulting in significant mitral regurgitation. LV = left ventricular; other abbreviations as in Figure 5.

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  Figure 10. Case 5: Transthoracic Echocardiography Parasternal long-axis views demonstrating mitral annular dilation and apical leaflet tethering resulting in (A) a central malcoaptation gap with (B) significant mitral regurgitation. (C) This is also demonstrated by apical views. (D, E) In cases of functional mitral regurgitation, effective regurgitant orifice area (EROA) estimation by proximal isovelocity surface area (PISA) may underestimate mitral regurgitation severity because the effective regurgitant orifice area may be elliptical rather than hemispheric in shape. (F) The patient additionally had severe pulmonary hypertension. Abbreviations as in Figures 6 and 7.

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  Figure 11. Case 5: Intraprocedural Transesophageal Echocardiography (A, B) Baseline 2-dimensional intraprocedural transesophageal echocardiography images demonstrates severe functional mitral regurgitation. (C) 3-Dimensional imaging of the valve reveals the presence of a central coaptation gap in systole resulting from annular dilation and leaflet tethering. (D) Deep transgastric views are used to evaluate left ventricular outflow tract (LVOT) stroke volume (SV) at baseline and the end of the procedure. (E) The patient underwent implantation of 2 MitraClip devices (Abbott) at A2 to P2 (arrows) with (F) reduction in mitral regurgitation to mild. (G) The double-orifice mitral valve and 2 MitraClip devices are demonstrated by 3-dimensional transesophageal echocardiography imaging. (H) At the end of the procedure, the left ventricular outflow tract stroke volume increased from 28 to 44 mL. TVI = time velocity integral; other abbreviations as in Figure 5.