TEKNIK PEMERIKSAAN

TRANSTHORACIC
ECHOCARDIOGRAPHY (TTE) PADA
PENYAKIT KATUP JANTUNG
MUHAMMAD ASRUL APRIS
MITRAL REGURGITATION (MR)
DEFINITION

• Backflow of blood from left ventricle (LV) to left atrium (LA)

• Typically MR occurs during systole, but in rare conditions (i.e. AV block) it
may occur also during diastole
CLINICAL FEATURES

Acute
• Dyspnoea, orthopnoea
• No cardiomegaly, short murmur, S3

Chronic
• Variable symptoms
• Cardiomegaly, murmur, P2 loud, S3
AETIOLOGY

Primary MR (organic/structural): Primary pathology of the valve

• Non-ischaemic: degenerative disease (Barlow, fibroelastic degeneration, Marfan, Ehler–

Danlos, annular calcification), rheumatic disease, toxic valvulopathy, infective endocarditis
• Ischaemic: ruptured (complete/partial) papillary, scarred/retracted papillary muscle

• Annulus : annular calcification

• Leaflet : myxomatous degeneration, rheumatic deformity, infectious perforation
• Chordae : myxomatous degeneration, spontaneous rupture, rheumatic shortening, infectious
destruction
• Papillary : infarction, ischemic lengthening

Secondary MR (functional/non-structural): malcoaptation related to LV

(LA) remodelling with no structural abnormalities of the valve → non-
ischaemic and ischaemic
• LV dilatation
• PM displacement
ROLE OF ECHO

Imaging of AS patients should evaluate the aetiology :

• Mechanism
• Dysfunction
• Severity of regurgitation
• Consequences
• Possibility of repair
MITRAL VALVE ANATOMY/IMAGING

• Two leaflets (each with a thickness about 1 mm)

• Posterior leaflet
◆ quadrangular shape
◆ two well-defined indentations
◆ three individual scallops (P1–P2–P3)
◆ two-thirds of the annular circumference
• Anterior leaflet
◆ semi-circular shape
◆ in continuity with the non-coronary cusp of the aortic valve (intervalvular
fibrosa)
◆ artificially divided into three portions (A1–A2–A3)
MITRAL VALVE ANALYSIS: TRANSTHORACIC
ECHO (TTE)
MITRAL VALVE IMAGING (TTE)
MITRAL VALVE ANALYSIS:
TRANSOESOPHAGEAL ECHO (TOE)
MITRAL VALVE IMAGING (TOE)
MECHANISM: LESION/DEFORMATION
RESULTING IN VALVE DYSFUNCTION
Degenerative disease (primary MR)
• The most common surgical MR cause
• Covers a large spectrum of lesions
• isolated scallop to multi-segment (or generalized) prolapse
• thin/non-redundant leaflets to thick (> 5 mm)/excess-tissue
Phenotypes
• Barlow (diffuse leaflet thickening)
• Fibroelastic degeneration (thickening of the prolapsed area)
Morphotypes (Fig. 7.6.1)
• Isolated billowing: leaflets tips remaining intraventricular
• Prolapse: leaflet tip below the mitral annulus plane and directed
towards the LV
• Flail leaflet: leaflet eversion (leaflet tip is directed towards the
LA)
MECHANISM: LESION/DEFORMATION
RESULTING IN VALVE DYSFUNCTION
Secondary (functional) MR
• Structurally normal mitral valve
• Mitral tethering secondary to:
• ventricular deformation/remodelling
• annular dilatation/dysfunction
• insufficient LV-generated closing forces
• Echo-morphological parameters
• global LV remodelling: LV sizes, volumes, function, sphericity
index (SI) (Fig 7.6.2A)
• local LV remodelling: papillary muscles displacement, regional
wall motion abnormality
• mitral valve (MV) deformation: tenting area (TA), coaptation
distance (CD), posterolateral angle (PLA) (Fig 7.6.2B, Box 7.6.1)
DYSFUNCTION (CARPENTIER'S CLASSIFICATION):

LEAFLET MOTION ABNORMALITY

Type I : Normal leaflet motion
• Annular dilatation (rarely isolated)
• Leaflet perforation (infective endocarditis)
• Cleft MV (Fig. 7.6.3A)
Type II : excessive leaflet mobility
• Prolapse
• Flail leaflet (Fig. 7.6.3B)
Type III : Reduced leaflet mobility or motion
• IIIa: systolic+diastolic restriction due to chordae shortening,
leaflet thickening (rheumatic disease, toxic valvulopathy,
radiation-induced mitral valve disease) (Fig. 7.6.3C)
• IIIb: systolic restriction: secondary MR (Fig. 7.6.3D)
 ASSESSMENT OF MR SEVERITY
Mitral valve morphology
• Visual assessment
Technique • Multiple views

Usefulness/
• Flail valve (Fig. 7.6.12) or ruptured PMs are specific for significant MR
Advantages

Limitations • Other abnormalities are non-specific of significant MR

Colour-flow imaging in MR
• Optimize colour gain/scale
Technique • Evaluate in two views
• Need blood pressure evaluation

Usefulness/ • Ease of use

• Evaluates the spatial orientation of MR jet
Advantages • Good screening test for mild vs severe MR

• Can be inaccurate for estimation of MR severity

Limitations • Influenced by technical and haemodynamic factors
• Underestimates eccentric jet adhering the LA wall (Coanda effect) (Fig. 7.6.13)
 ASSESSMENT OF MR SEVERITY
Vena contracta width in MR
• Two orthogonal planes: PTLAX (Fig. 7.6.14) and AP-4CV (Fig. 7.6.15)
• Optimize colour gain/scale (40–70 cm/s)
• Identify the three components of the regurgitant jet (VC, PISA, jet into LA)
• Reduce the colour sector size and imaging depth to maximize frame rate
Technique • Expand the selected zone (zoom)
• Use the cine-loop to find the best frame for measurement
• Measure the smallest VC (immediately distal to the regurgitant orifice, perpendicular to the direction of the jet)
• The VC is the area of the jet as it leaves the regurgitant orifice; it reflects thus the regurgitant orifice area

• Relatively quick and easy

• Relatively independent of haemodynamic and instrumentation factors
Usefulness/
• Not affected by other valve leak
Advantages • Good for extreme MR: mild vs severe
• Can be used in eccentric jet

• Not valid for multiple jets

• Small values; small measurement errors leads to large % error
Limitations • Intermediate values need confirmation
• Affected by systolic changes in regurgitant flow

• Mild MR VC < 3 mm
Interpretation •
Severe MR VC > 7 mm
 ASSESSMENT OF MR SEVERITY
Proximal isovelocity surface area
(PISA)
• Flow converges toward a restrictive orifice remaining laminar and forming isovelocity
Definition surfaces that approximate hemispheres (Fig. 7.6.16)

Conservation of • Flow across any isovelocity surface = flow through orifice

mass principle

• Apical 4CV (Fig. 7.6.17ABCDEF)

• Optimize colour-flow imaging of MR
• Zoom the image of the regurgitant mitral valve
• Decrease the Nyquist limit (colour-flow zero baseline)
PISA method in • With the cine mode select the best PISA
MR: recordings • Display the colour off and on to visualize the MR orifice
• Measure the PISA radius at mid-systole using the first aliasing and along the direction of
the ultrasound beam
• Measure MR peak velocity and TVI (CW)
• Calculate flow rate, EROA, R Vol (Box 7.6.3)
 ASSESSMENT OF MR SEVERITY
Proximal isovelocity surface area
(PISA)
• Can be used in eccentric jet
• Not affected by the aetiology of MR or other valve leak
Usefulness/Advantages
• Quantitative: estimate lesion severity (EROA) and volume overload (R Vol)
• Flow convergence at 50 cm/s alerts to significant MR

• PISA shape affected

• by the aliasing velocity
• in case of non-circular orifice
• by systolic changes in regurgitant flow (Fig. 7.6.18EF)
Limitations • by adjacent structures (flow constrainment) (Fig. 7.6.18AD)
• PISA is more a hemi-ellipse (Fig. 7.6.18B)
• Errors in PISA radius measurement are squared
• Inter-observer variability
• Not valid for multiple jets (Fig. 7.6.18C)

• Mild MR EROA < 20 mm2

Interpretation
• Severe MR EROA ≥ 40 mm2
ASSESSMENT OF MR SEVERITY
Haemodynamics of MR
Under basal conditions, regurgitant volume (RV) is
determined by :
• the MR orifice area,
• the systolic pressure gradient across the orifice, and
• the duration of the systole (Box 7.6.4)
ASSESSMENT OF MR SEVERITY
3D vena contracta (VC)—PISA in
MR
• Calculations of VC area and flow convergence zone from 2DE are based on
the geometric assumption that the VC area is either circular or elliptical
• So the geometry can be variable depending on the shape of the orifice and
mitral valve leaflets surrounding the orifice
◆ Secondary MR looks like an ellipsoidal shape and two separate MR jets
originating from the medial and lateral sides of the coaptation line can be
observed on 2D echo (Fig. 7.6.20)
◆ In primary MR, the shape of the PISA is often rounder, which minimizes
the risk of EROA underestimation (Fig. 7.6.21)
• Careful consideration of the 3D geometry of VC/PISA may be of interest in
evaluating the severity of MR. The best 3D echo method to quantitate MR
severity is still not defined
ASSESSMENT OF MR SEVERITY
Doppler quantitation from two valves flow (Box 7.6.5)

• Not applicable in case of significant aortic regurgitation

• This approach is time-consuming and is associated with several
drawbacks
• Interpretation
Severe AR: RF > 50%
ASSESSMENT OF MR SEVERITY
Complementary findings
 CONSEQUENCES OF MR
LV size and function (Fig. 7.6.24ABC)
• LV enlargement is measured by LV diameters (2D diameters) and/or volumes (2D method of discs
or 3D echo when imaging is of high quality)
• dilatation sensitive for chronic significant MR
• normal size almost excludes significant chronic MR unless it is acute
• LV dysfunction is evaluated by either ejection fraction or endsystolic LV size
• LV ejection fraction is load-dependent, often overestimates LV systolic performance
• Other parameters of LV dysfunction
• global longitudinal strain < 18.1% or strain rate value < 1.07/s
• peak tissue Doppler lateral annulus systolic velocity < 10.5 cm/s
LA size (Figs. 7.6.24D)
• LA volume can be reliably measured by 2D method of discs
• a normal sized LA is inconsistent with severe MR unless it is acute
• significant enlargement: LA volume index > 40 mL/m2
Pulmonary systolic arterial pressure
• Significant increase: PSAP > 50 mmHg at rest

Tricuspid annular dilatation

• Significant: ≥ 40 mm or > 21 mm/m2

Specificities in secondary MR
• LV and LA dilatation are in excess to the degree of MR
• LA pressure is often elevated despite lower R Vol than in primary MR
INTEGRATING INDICES OF MR SEVERITY
CHRONIC/ACUTE MR: DIFFERENTIAL
DIAGNOSIS
MONITORING OF ASYMPTOMATIC PATIENTS
WITH PRIMARY MR
When?
• Moderate MR → clinical examination every year + echo every two years
• Severe MR → clinical examination every six months + echo every year
• Severe MR → clinical examination every six months + echo every six months if LV ejection fraction 60–65% or end-
systolic diameter close to 40 mm (22 mm/m2)
What for?
• Progression of MR: marked individual differences
• Progression of the lesion: new flail leaflet, increase of annulus size
• Evolution of LV end-systolic dimension or volume
• LV ejection fraction
• LA size and area
• pulmonary systolic pressure
• exercise capacity
• occurrence of atrial arrhythmias
Surgical class I indications for mitral valve surgery (repair preferred) in primary MR
• Severe MR +
• symptoms and LV ejection > 30% and ESD < 55 mm
• no symptoms but LV ejection fraction ≤ 60% and/or ESD ≥ 45 mm
EXERCISE ECHOCARDIOGRAPHY IN MR
Asymptomatic patients with moderate to severe primary MR
• Symptom onset
• Contractile reserve
• LVEF increases by > 4%
• global longitudinal strain increases > 1.9%
• Worsening of MR severity
• Pulmonary arterial systolic pressure (PSAP) > 60 mmHg
Heart failure patients with moderate secondary MR
• Exercise-induced dyspnoea
• Viability/ischaemia
• Global/regional contractile reserve
• Increase in MR (EROA ≥ 13 mm2)
• Significant increase in PSAP
PROBABILITY OF SUCCESSFUL MITRAL VALVE
REPAIR IN MR
Factors affecting the possibility of repair: prolapse location, valvular/annular calcifications
and severity of annulus dilatation