Mitral Regurgitation:

Emerging Concepts

Elyse Foster, MD
Professor of Medicine
UCSF

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 Disclosure:
Grants from Evalve, Inc
Guidant - Boston Scientific
Corporation

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 Classification of Mitral regurgitation:

Organic - Primary pathology of the leaflets

Degenerative
Rheumatic
Endocarditis
Congenital (eg. cleft)
Functional - Malcoaptation 2 to myocardial
process
Ischemic
Dilated cardiomyopathy
Hypertrophic cardiomyopathy

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 Anatomy of the Mitral Apparatus

Leaflets
Annulus
Chordae tendinae
Papillary muscles
Left ventricle

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Mitral Valve Prolapse

Mitral Valve Endocarditis

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Physiology of Primary
Mitral Regurgitation

Left ventricular volume overload

LA enlargement
Eccentric hypertrophy
LVEF normal to hyperdynamic
Pulmonary hypertension
Acute vs. Chronic

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 Normal Acute MR
SV 100 ml SV 70 ml
EF 66% EF 82%
EDV 150 ml EDV 170 ml RF 50%
LAp 10 mmHg RV 70 ml
ESV 50 ml LAp 25 mmHg ESV 30 ml

Chronic compensated Chronic decompensated

SV 95 ml EF 58%
EF 79% SV 65 ml
RF 57%
RF 50% EDV 240 ml
EDV 260 ml
RV 95 ml ESV 50 ml RV 85 ml ESV 110 ml
LAp 15 mmHg
LAp 25 mmHg

Adapted From Carabello, NEJM 1997 UC SF

 The Roles of Echocardiography

How severe is the MR?

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

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 Mitral Regurgitation by
Echocardiography

Extremely common
Increases with age
Severity exaggerated due to an
overreliance on qualitative rather than
quantitative parameters
If there is no apparent leaflet pathology, LV
and LA size are normal, probably not
severe.

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 How severe?

The severity of mitral regurgitation

should be evaluated based on a
constellation of 2-dimensional and
Doppler echocardiographic findings.

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Journal of the American Society of Echocardiography
July 2003
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MR: Color Flow Evaluation

Mild central jet Severe eccentric

encircling jet
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 Mild Severe Severe
Central MR Central MR Eccentric MR

< 4 cm2 > 8 cm2

< 10% LA Area > 40% LA Area

Adapted from Zoghbi et al. ASE valve regurg document (JASE 03) UC SF
 Spatial Mapping
Color Jet Area in MR

Most widely used, most helpful at extremes

Regurgitant volume only weakly related to area (r = 0.64)*
More severe, eccentric jets have smaller area
Significantly affected by instrument settings
Nyquist limit optimal at 50 - 60 cm/sec
Gain should be adjusted for slight speckle
Optimize frame rate by reducing depth and using narrow sector
angle to minimum of 16 - 18 Hz
Driving pressure important - record BP on screen
Low blood pressure smaller jet
High blood pressure larger jet

*From Hall, Circ 97 UC SF

 Color Flow Jet in MR

Jet Penetration:
Mild - central
Moderate - eccentric to 1st PV
Severe - eccentric and extends past 1st PV

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The limitations of color flow
Doppler necessitate an
integrative approach to
assessment of MR severity

Qualitative and quantitative

parameters

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 MR Quantitation based on
Doppler and 2-D measurements

MILD MOD MOD- SEV

SEV
VC width < 0.3 0.3 - 0.69 > 0.7
(cm)
ROA(cm2) < 0.2 0.2 - 0.29 0.3 -0.39 > 0.4

RV (ml) < 30 30 - 44 45 - 59 > 60

RF (%) < 30 30 - 39 40 - 49 > 50

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 Vena contracta
PISA

Adapted from Zoghbi et al. ASE valve regurg document (JASE 03) UC SF
 Color Flow Jet Width in MR

Vena Contracta Width

Parasternal LAX most accurate
> 0.5 cm: RV > 60 ml
ROA > 0.4 cm2

< 0.3 cm: RV < 60 ml

ROA < 0.4 cm2

*From Hall, Circ 97 UC SF

 Regurgitant Volume
and Fraction
SV 95 ml
EF 79%
RF 50% EDV 240 ml

RV 95 ml ESV 50 ml

Regurgitant volume (RV) = TSV - FSV

= 190 - 95 = 95 ml

Regurgitant Fraction (RF) =

RV/TSV = 95/190 = 50%

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Total SV = EDV - ESV = 56 ml

EDV = 114 ml

ESV = 58 ml
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LVOTd = 2.0 cm LVOTVTI = 15 cm

FSV = 45 ml
RV = 11 ml
RF = 11/56 = 20%
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 Regurgitant Orifice Area
(PISA Method)

Regurgitant flow = 2r2 X Va

ROA = 2r2 X Va/V2
Quantitative
- 40 measurement of:
r va ROA (cm2)
Regurgitant Volume

v2 UC SF
PISA radius = 1.1 cm
Alias vel = 0.4 m/sec

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 PISA Calculation

ROA = 2r2 X V/V2 = 6.28(1.1cm)2 X .40/5 = .60 cm 2

Regurgitant Volume = ROA X VTIMR = .60 X 150 = 91 ml
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 Pulmonary Vein Flow

S
D
S D

1-Normal 2-Systolic blunting

4-Systolic Flow
S Reversal
3-Diastolic dominant UC SF
 Pitfalls:
Pulmonary venous flow patterns in MR
PV flow pattern reflects LA pressure and
loading conditions
Influenced by factors other than MR
severity
Diastolic function
LA size
Atrial fibrillation
Systolic flow reversal may present in only
one PV especially when jet is eccentric
Most useful when systolic dominant or
clear systolic flow reversal is present
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What is the mechanism underlying MR?
Carpentier Leaflet Motion Classification

Normal (I) motion

Primary annular disease

Excessive (II) motion

(Non-rheumatic) Degenerative valve disease

Restricted (III) motion

Systolic (III a): Functional MR
Diastolic (III b): Mitral stenosis; Dystrophic leaflet calcification

Combination

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 Carpentier Classification
I II III

Type I Normal leaflet and chordal motion

Type II Prolapse or excessive motion
Type III Restricted motion

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 Degenerative MR:
Prolapse vs. Flail

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

Flail leaflet has both

ruptured chordae and an
unsupported free edge that
extends above the
opposing leaflet during
systole

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 Role of TEE

Mapping of anatomic defect

Inadequate TTE
Acoustic shadowing due to prosthetic
valve or dense annular calcification
Endocarditis
Annular abscess
Intraoperative evaluation of MV repair
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 Mitral Valve Scallops
Sup/Ant
Ao LA
A
A1 A3 A1
P1
P1 P3 Medial A2 Lateral
A1, P1 anterolateral A3
P2
A2, P2 central P3
A3, P3 - posteromedial
Inf/post

Adapted from Foster et.al.

Ann Thorac Surg 1998
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 How to fix it:
Anatomic definition critical

Surgical Approach
Posterior leaflet
Quadrangular resection
Higher short-term and long-term success
Anterior leaflet
May require chordal switch
Less successful
Percutaneous approaches
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Complex mapping for leaflet
localization
0 degrees

60 degrees
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 3-Dimensional
Echocardiography

Prolapsed segment

Courtesty of TomTec Corporation UC SF

 How well is the LV compensated?

Echo evaluation of LV dimensions and

LVEF
Basis for ACC/AHA recommendations
for valve replacement

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 Mitral regurgitation: Indications for surgery
in non-ischemic MR
Bonow et al JACC 2006

Indication Class
Acute syx severe MR I
Symptomatic chronic severe MR with EF > 30% and/or I
ESD < 55 mm
Asyx MR with LVEF <55% and/or LVESD > 40 mm I
Repair recommended over replacement I
Asyx pt with preserved LVEF when repair likelihood > IIa
90%
Asyx with preserved EF and Afib or PHT IIa
Severe LV dysfxn with EF< 30%, ESD >55 with primary IIa
MR when repair likelihood is high
Severe LV dysfxn with EF< 30%, ESD >55 with IIb
functional MR unresponsive to med Rx + CRT
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 Mitral regurgitation: Indications for surgery
in non-ischemic MR
Bonow et al JACC 2006

Indication Class
MVP and preserved LVEF with recurrent ventricular IIb
arryhthmias despite med Rx
Asyx pts with preserved LVEF when repair unlikely III
Mild or moderate MR III

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Functional mitral regurgitation

Symmetric leaflet tethering

Central MR jet
Severity dependent on:
Coaptation depth
Tenting angle
Asymmetric leaflet tethering
Eccentric jet
Ipsilateral to tethered leaflet
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 Causes of Functional MR
in Dilated cardiomyopathy

Left Ventricular dilation

Papillary muscle splaying

Mitral annular dilation

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Functional MR

MR

CHF

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Coaptation Depth
(Leaflet tenting)

2.0 cm

Symmetric tethering due to splaying

of papillary muscles in DCM
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 Asymmetic tethering Inferior infarct with remodeling
Restricted posterior
leaflet motion
Usually in setting of
IMI with remodeling

Posterior MR jet

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 Functional MR

More likely respond to medical therapy and

CRT
More difficult to address surgically
Annuloplasty ring for symmetric leaflet
tethering
Ischemic MR with asymmetric tethering
technically challenging
Lesser degrees of MR may be clinically
important ie. EROA of 0.2 cm2

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 Conclusions:

Echocardiography currently provides the

best qualitative and quantitative
assessment of mitral regurgitation
Directed imaging provides important
anatomic information vital to MV repair
Indications for intervention in
hemodynamically significant MR still
evolving
Percutaneous repair likely to become a
viable option
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