Page 15 - Advanced echocardiography in characterization and management of patients with secondary mitral regurgitation

tether system; panel g = annular winglets system; panel h = native leaflet engagement system (reproduced with permission from Regueiro et al. [30]).
Primary MR
Secondary MR
MR mechanism according to Carpentier classification
Type I
Normal leaflet motion (i.e. leaflet perforation)
Type II
Excessive leaflet motion (i.e. mitral valve prolapse or flail)
Type IIIa
Restricted opening during systole and diastole (i.e. rheumatic heart disease)
Type I
Normal leaflet motion (i.e. annular dilation)
Type IIIb
Restricted closure during systole (i.e. due to tethering of the leaflets secondary to LV dysfunction and dilation)
Qualitative
Quantitative measurements
Flail leaflet, ruptured papillary muscle, large perforation
Large coaptation defect
Very large central jet or eccentric jet adhering, swirling and reaching the posterior wall of the left atrium
Very large central jet or eccentric jet adhering, swirling and reaching the posterior wall of the left atrium
Semiquantitative measurements
Vena contracta width ≥7mm (>8 mm for biplane)
Vena contracta width ≥7mm (>8 mm for biplane)
Systolic pulmonary vein flow reversal
Systolic pulmonary vein flow reversal
E-wave dominant ≥1.5 m/s
(according to AHA/ACC guidelines >1.2m/s)
EROA ≥40 mm2
E-wave dominant ≥1.5 m/s
(according to AHA/ACC guidelines >1.2m/s)
EROA ≥20 mm2
(according to AHA/ACC guidelines EROA ≥40 mm2)
Regurgitant volume ≥60 mL/beat
Regurgitant volume ≥30 mL/beat (according to AHA/ACC guidelines RVol ≥60 mL/beat)
Regurgitant fraction ≥50%
Regurgitant fraction ≥50%
Figure 2: Mechanisms of and criteria for the definition of severe mitral regurgitation [2,5,7,23]. EROA, Effective regurgitant orifice area; MR = mitral regurgitation RVol, regurgitant volume.
Three-dimensional transesophageal echocardiography has been shown to provide better information on valve morphology and function [3▪▪,4–7]. Morphological assessment of the mitral valve is key in the evaluation of patients with severe mitral regurgitation who may be candidates for transcatheter therapies (Fig. 3). For transcatheter edge- to-edge repair therapies, the leaflet coaptation depth and length (in secondary mitral regurgitation) and the width and height of the flail (in primary mitral regurgitation) need to be measured. The Neochord device is an appropriate therapy for primary mitral regurgitation preferably because of prolapse of the central scallop of the posterior mitral leaflet and with enough length of the leaflets relative to the mitral annulus dimensions to ensure proper coaptation. When evaluating patients for transcatheter mitral annuloplasty, the dimensions of the mitral annulus should be assessed. Three- dimensional transesophageal echocardiography is superior to two-dimensional transthoracic echocardiography to assess the mitral annulus perimeter and area.
13
Ch 1
Severe MR