Mitral Regurgitation

Fig. 29. Pulmonary vein systolic flow reversal. Pulsed Doppler examination right upper pulmonary vein flow in severe mitral regurgitation shows reversal of pulmonary vein systolic flow, as depicted by the negative S-wave.

Pulse Doppler Mitral Regurgitation

Fig. 30. Mitral E-point velocity. (A) Pulsed Doppler of normal mitral inflow characteristically shows an early diastolic E-wave followed by the atrial A wave. (B) In severe mitral regurgitation (MR), marked E-wave dominance is seen (>1.2 m/s), reflecting a marked increased in early diastolic flow—typical of severe MR.

Fig. 30. Mitral E-point velocity. (A) Pulsed Doppler of normal mitral inflow characteristically shows an early diastolic E-wave followed by the atrial A wave. (B) In severe mitral regurgitation (MR), marked E-wave dominance is seen (>1.2 m/s), reflecting a marked increased in early diastolic flow—typical of severe MR.

in cardiomyopathy. With cardiomyopathy, the annulus becomes dilated and the exoskeleton of the LV becomes stretched. Despite preserved leaflet motion, the leaflets are unable to coapt because of the incompetent architecture of the LV and annulus. This often results in a central jet of MR (Figs. 8 and 9). Another etiology of MR despite preserved leaflet motion is leaflet perforation, as a sequelae of endocarditis.

Functional Classification: Type II

Type II regurgitation refers to MR that occurs because of leaflet prolapse. This may be owing to simple elongation of the leaflets, with prolapse into the left atrium. This may be owing to chordal rupture or papillary muscle rupture. An example of chordal rupture is shown in Fig. 35.

Functional Classification: Type IIIa Restricted Leaflet Motion

Valvular and subvalvular thickening can restrict mitral leaflet motion. Mitral annular calcification and thickening of the subvalvular apparatus are seen with increasing age, or as the sequelae of rheumatic heart disease. The resulting poor coaptation results in MR.

Acute Mitral Regurgitation Mild Doppler
Fig. 31. Continuous-wave (CW) Doppler intensity. CW Doppler envelopes showing a higher intensity signal in moderate-to-severe regurgitation (A) compared to mild mitral regurgitation (B). Compare these densities to the antegrade (mitral inflow) signals above the baseline.
Doppler Mitral Regurgitation
Fig. 32. Continuous-wave (CW) Jet with V-wave. Notching of the CW envelope can occur in severe mitral regurgitation, a reflection of the large atrial V-wave (insert). Left ventricular systolic performance (dP/dT).

Fig. 35 shows an example of such thickening of the valvular and subvalvular apparatus.

Functional Classification: Type IIIb Restricted Leaflet Motion

When leaflet motion is restricted, with displacement of the papillary muscles, this is referred to as type IIIb MR. The most common culprit is a dilated cardiomyopathy, where enlargement of LV chambers are accompanied by elongation of the papillary muscles and displacement of such muscles to the apex, relative to the mitral valve leaflets. Figure 35 shows such a schema and still frame of an enlarged LV and downwardly displaced papillary muscles. The resulting mitral valve incompetence often results in a centrally directed jet of MR.

MR dP/dt = 1785 mmHg/sec Vmax t = 0.09 m/sec Vmax 2 = 5.46 m/sec At = 67 msec f\ J.I \

HR=100bptn Sweep=100rt

HR=100bptn Sweep=100rt

Mitral Regurgitation
Fig. 33. Left ventricular systolic performance (dP/dT). During isovolumetric contraction, the rate of rise of left ventricular pressure (dP/dT) is a useful index of ventricular contractility. It may predict postoperative left ventricle function in patients with severe mitral regurgitation.

interatrial groove, and left atriotomy; in difficult cases, a transseptal approach through the right atrium into the LA is taken. The valve is visualized looking down from the left atrium toward the LV during surgery, as shown in Figs. 1 and 2. Because this is the visual field in which any surgical repair will take place, it is helpful for the surgeon to map out mitral valve pathology from this view (Fig. 36). Looking down from the LA toward the LV, there are three scallops to each mitral valve leaflet. For orientation, one notes that the anterior leaflet faces the aorta. A commonly used nomenclature divides the anterior leaflet into A1, A2, A3 and the posterior leaflet into P1, P2, P3, with the numbering beginning at the anterolateral commissure and progressing toward the posteromedial commissure (Fig. 1B).

A great advance in mitral valve mapping has been the use of multiplanar TEE—both before referring patients to surgery and intra-operatively (see Chapter 23).

Mitral Valve Scallops Anatomy
Fig. 34. Three-dimensional image acquisition of eccentric mitral regurgitant jet on transesophageal echocardiography. (Image courtesy of Michael D'Ambra, MD, Cardiothoracic Anesthesia, Brigham and Women's Hospital.) (Please see companion DVD for corresponding video.)

Valve Analysis

In patients with severe MR who are referred for surgical repair, it is important to delineate the anatomy of the anterior and posterior leaflets. During surgery, valve exposure is often performed by dissection of the

CASE PRESENTATION 6: POST-MITRAL VALVE SURGERY

This 84-yr-old woman presented with heart failure 14 yr after coronary artery bypass surgery and mitral valve replacement with a porcine biopros-thesis (Fig. 37; please see companion DVD for corresponding video).

Carpentier Mitral Valve
Fig. 35. Functional classification of mitral regurgitation (by Carpentier). (Figure courtesy of Dr. David Adams, Mount Sinai Medical Center, New York, NY.)
Tee Views Mitral Valve Scallops

Fig. 36. Orientation of mitral valve leaflets and scallops (Carpentier's nomenclature) during intra-operative (TEE) echocardiography. The aorta is assigned the 12 o'clock position, the commissures—at the 3 o'clock and 9 o'clock positions as shown. The left atrial appendage (LAA) at the 9 o'clock/antero-lateral commissure position. The TEE operator's view is the mirror-image of the surgeon's view.

Fig. 36. Orientation of mitral valve leaflets and scallops (Carpentier's nomenclature) during intra-operative (TEE) echocardiography. The aorta is assigned the 12 o'clock position, the commissures—at the 3 o'clock and 9 o'clock positions as shown. The left atrial appendage (LAA) at the 9 o'clock/antero-lateral commissure position. The TEE operator's view is the mirror-image of the surgeon's view.

Porcine Mitral Valve Echo

Fig. 37. A 84-yr-old woman after coronary artery bypass grafting and 14 yr status after porcine mitral valve replacement with congestive heart failure. (Please see companion DVD for corresponding video.)

Porcine Women

Fig. 37. A 84-yr-old woman after coronary artery bypass grafting and 14 yr status after porcine mitral valve replacement with congestive heart failure. (Please see companion DVD for corresponding video.)

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