 Good evening everyone. Today's topic is the mitral valve and regurgitation It's March 17th, St. Patrick's Day. So the talk today will have a celebration of Ireland running through it My home country. So I hope you enjoy it and let's proceed Today we're going to talk about the mitral valve anatomy first. We're going to discuss the etiology of mitral regurgitation I'm going to assess the mitral valve in 2D and 3D I'm going to talk about grading severity of mitral regurgitation Indications for surgery and factors that predict failed repairs Just some disclosures Neither of these two gentlemen or me. So I'll manage your expectations accordingly interesting facts the name of the mitral valve comes from its shape, which is the The bishops mitre Again Irish reference. We'll keep going So we're going to talk about mitral valve anatomy Mitral valve is a Pringle. The valve is saddle shaped like a Pringle The anterior posterior diameter is the front and back of the saddle The higher parts of the curve The lateral medial aspects are the lower parts of the valve You can imagine the horn of the saddle at the anterior aspect And this is where the aortic valve will be found When you look at the valve from the posterior aspect the chresenteric co-optation line Between the anterior leaflet anteriorly and near the aortic valve and the posterior leaflet Make a smiley face The annular height is from the surface of the valve to the top of the ap diameter I'll just point out to avoid any potential confusion in your minds about the geometry It's super helpful to think of this as a saddle, but recognize that the saddle is atypical If you're sitting in a real saddle, it's longest from front to back And narrow in width where it's whereas it's the opposite here. It would be a very difficult saddle to fit on So question number one What do the following structures are at risk of injury during routine mitral valve surgery? Is it one RCA, coronary sinus, non coronary cuspid aortic valve? Is it the SA node, AV node, left circumflex and the RCA? Coronary sinus, less circumflex, non coronary cuspid aortic valve Or is it right coronary cuspid aortic valve, AV node, RCA and the BZN name? Well to answer this you really need to know about the mitral valves relation to other structures The orientation of the valve and its relation to other structures are important to understand This will facilitate proper assessment of the valve and recognition of complications post mitral valve surgery So as you can see from the diagram the mitral valve is situated posterior and lateral to the aortic valve Remember the horn of the saddle near the aortic valve It's to the left of the tricuspid valve It's anterior to the coronary sinus It's posterior to the left circumflex artery The posterior portion is in close proximity to the bundle of his And the valve is slightly tilted with the anterior portion superior to the posterior portion So clinical implications include possible complications to consider post-surgery such as tear of the coronary sinus aortic valve injury Tricuspid valve problems conduction system abnormalities and circumflex artery injury Lastly, I'll draw attention to the area in the back between the aortic valve and the mitral valve Which is called the intervalvular fibrosis The intervalvular fibrosis is the common fibrous So the answer to question one Is the coronary sinus left circumflex and non-carnary cusp of the aortic valve? This diagram just illustrates The proximity of the left coronary cusps the aortic valve and the coronary sinus Especially when they're putting a ring in okay Moving on to the mitral apparatus The mitral valve itself is a complex apparatus that requires each individual component to function normally for optimal valvular function It includes the annulus the leaflets the papillary muscles The cordae and the left ventricular itself The annulus is a dynamic fibromuscular ring It's oval and saddle shaped as we've reviewed although it flattens in disease with anterior and posterior annular segments The anterior annulus Makes up one third of the annular circumference It forms part of the cardiac trigonal skeleton and it's relatively immobile and well supported It's mostly fibrous tissue with muscular portions As it approaches the posterior annulus and it forms part of the lvot The posterior annulus makes up the remaining two-thirds of annular circumference It's mostly membranous and muscular and blends into the muscular la and lv It's weaker and thinner than the anterior annulus especially posterior central annulus where it's almost devoid of collagen And mostly loose connective tissue. Thus, this is prone to dilatation annular motion during systole when the valve closes consists of translation away from the apex so up contraction posteriorly and then folding in the anterior plane In the diagram, this is illustrated by starting with the yellow circle The valve and diastole and seeing its position displaced up posteriorly and folded to get the red shape in systole which is the saddle shape These movements open up the lvot and optimize flow to assist in co-actation Annular dilatation is defined by an api diameter of greater than 35 millimeters. As we already know the valve is There are three main ways of naming the parts of the anterior and posterior leaflets Classically the nomenclature was based on anatomy the posterior leaflets scallops were named antrolateral by the laa middle and posterior medial The most common classification is the carpenter classification Which divides the leaflets into three segments each p1 closest to the laa i.e. antrolateral p2 p3 for each posterior scallop But corresponding a1 a2 a3 on the anterior leaflet The durian classification may sometimes be used in this system each leaflet has a 1 and 2 area The posterior leaflet is bigger so it also has a pm or post-middle designation in the middle There are two commissural areas c1 and c2 Everything is named according to their attachment to the papillaries So everything with a 1 as in c1 p1 a1 Attaches to the antrolateral papillary and everything with a 2 c2 p2 a2 attached to the posterior medial papillary So question number two A 65 year old male suffers an inferior st elevation mi two days later He has sudden onset of severe dyspnea. It's hypotensive and it's rushed to the cath lab A te is performed in the cath lab. What is the most likely cause of the symptoms? One ruptured p2 cordy and severe mr Two anterior lateral papillary muscle rupture and severe mr Three posterior medial papillary muscle rupture and severe mr Four leaflet tethering and severe functional mr Five annular dilatation and severe functional mr So let's talk about the subvalvular apparatus This is comprised of the papillary muscles of which there are two and the cordy tendinia of which there are more than a hundred This diagram shows the four main categories of cordy First order is primary. They attach to the ipsi lateral leaflet edge prevent Collapse of margins and are responsible for normal co-aptation Second order or secondary Attached to the body of the leaflet and relieve excess tension They're associated with the tethering effect of left ventricular remodeling And third order or tertiary and struts They attach to the base of the anterior and posterior leaflet respectively And this is by the maslow classification So the two papillary muscles are named for their location anterior lateral and posterior medial The anterior lateral papillary receives a dual blood supply from the lad and the circumflex While the posterior medial one receives a single blood supply from the rca and is more prone to ischemia The ischemia and papillary rupture can lead to acute severe mr and heart failure So the answer to question number two is number three posterior medial papillary muscle rupture and severe mr Because this was an inferior mi supplied by the rca Which is the territory of the posterior medial papillary muscle Moving on to the left ventricle The size shape and function of the left ventricle determine The systolic co-apting force the position of the papillary muscles and cordae And their effect on leaflet position and mobility i.e. it influences potentially all the components of the mitral valve This diagram shows an ischemic ventricle on the right Whose remodeling has changed the orientation of the posterior medial papillary causing valvular incompetence Coaptation is a function of the opposing tethering and closing forces Tethering pulls the leaflets down while the closing forces push up to help the valve close Increased tethering forces are due to lv dilatation spherical shape of the lv and papillary muscle displacement Impaired closing forces are generated by decreased lv contractility lv dyssynchrony papillary muscle dyssynchrony An altered mitral valve annulus systolic contraction Before moving on to our next segment I'm going to talk to you about the cliffs of Mohr which are Ireland's most visited natural attraction with over 1.5 million tourists visiting each year Located on the wild Atlantic Wages south of Doolin in County Clair, Ireland They ascend to over 200 meters and stretch south for eight kilometers to Haggs Head The oldest layers of base rock that form these cliffs are over 300 million years old Nature certainly took its time creating this one for us In the center of these cliffs you can see an enormous sea cave This cave was actually used to film scenes in the movie Harry Potter and the Half-Blood Prince Many other movies have also been filmed on these cliffs over the years Including one of my personal favorites, Princess Bride We're now going to talk about the etiology of mitral valve regurgitation The etiology of MR is varied and typically includes congenital abnormalities such as endocardial cushion defects or clefts Myxomatous degeneration Which is synonymous with Barlow's disease characterized by redundant leaflets Which are thick and hammock-like fibroelastic deficiency Which are basically thin leaflets and cordy rheumatic disease endocarditis cardiomyopathy which could be delayed or hypertrophic And others causes such as SLE, rheumatoid and ankylosing spondylitis Degenerative MR is the most common, which is classically Barlow's And others are acquired or functional This is a 3D view of the mitral valve It isn't a standard view but one can still appreciate the obvious cleft Without getting too much into the nitty-gritty you can further refine your diagnostic capabilities by appreciating The myxomatous disease exists as a spectrum This was well described by Adams in his 2007 paper in seminars in thoracic and cardiovascular surgery Without going over all the details, it's not just an academic distinction The clinical utility here is that due to fibroelastic deficiencies, it's actually harder to repair This slide just dissects the difference between fibroelastic deficiency and Barlow's disease It's worth teasing apart due to the fact that myxomatous degeneration is the most common cause of MR in countries From a clinical perspective, it's important to be able to differentiate these two to help with surgical decision making Fibroelastic deficiency is more a challenging repair due to the tendons of the tissue Although technically it's more simple because only a single effect a single segment is affected This is a typical myxomatous valve. You can see that it's the redundant thick and amyclic leaflets This is another myxomatous mitral valve with A2 to A3 prolapse and a p2 flail Here is an example of fibroelastic deficiency with very thin leaflets Here you can appreciate the fibroelastic deficiency in a 3d view of the mitral valve These pictures illustrate the gross difference between Valve leaflet appearance in Barlow's disease on the left and fibroelastic deficiency on the right You can see the marked redundancy of tissue in a myxomatous valve versus the thin tissue in fibroelastic deficiency This is a typical rheumatic valve. These valves are characterized by leaflet thickening and retraction, commissural infusion Leaflet tips have a rolled edge appearance giving it the hockey stick or golf club appearance to the anterior mitral leaflet and cordial shortening Of note, repair is a high failure rate. Thus replacement is often preferred This is a 3d image of a rheumatic valve Notice the moderate thickening of the anterior and posterior mitral valve leaflets and the decreased mobility of both So just to review some of those differentiating factors for you as you're evaluating patients in your own practice in terms of rheumatic versus degenerative So in terms of myxomatous as you can see on the slide mainly the posterior leaflet prolapse Versus rheumatic which is usually involves or always involves anterior leaflet and has secondary prolapse from a restricted posterior leaflet Myxomatous has an anteriorly directed jet versus rheumatic which is a posteriorly directed jet Myxomatous leaflets are thick and rheumatic leaflets are minimal thickening and they have a hockey stick appearance MR is often classified as primary or secondary Primary is equal to organic or degenerative or myxomatous It refers to the mitral valve being the problem which is amenable to correction Most chronic primary MR in the developed world is degenerative Mitral valve prolapse is the most common in the developed world This is classically myxomatous, fibrolactic deficiency or marfans Less commonly, infective endocarditis, CT disorders, i.e. connected tissue disorders, rheumatic heart disease, cleft mitral valve, radiation heart disease What I'm saying is MR is the disease and the surgery corrects the problem and you can divide this into degenerative, rheumatic or endocarditis Secondary MR is functional and may also be called ischemic which is technically a subtype The valve itself is noro, the problem is the abnormal ventricle causing imbalance between the tethering forces and the closing forces Restoring the valve is not curative It can be ischemic or cardiomyopathic and it's associated with the 20-30% failure repair Multiple words are used interchangeably to classify MR and perhaps not so accurately and sometimes confusingly So carpenture as mentioned before came up with a functional classification based on how the valve works So type one is normal leaflet motion It's usually from annular dilatation The annulus becomes flat which reduces the coaptation zone It also includes clefts, aneurysms, perforations and destruction from endocarditis The actual MR jet tends to be central And it's mostly posterior dilatation due to the weak and thin tissue Type two is excessive leaflet motion, most commonly P2 This is from leaflet or cordal or papillary problems The jet tends to be away from the diseased leaflet The hallmark of degenerative disease is excessive motion Some terms to know when describing type two lesions include billowing Or scalloping, which is mild prolapse The leaflet projects above the annulus and cistulae, but the coaptation remains below the plane of the annulus Prolapse, which the leaflet tip is above the annulus and cistulae, but still directed towards the left ventricle Or flail, where the leaflet edge flows freely into the LA in cistulae Usually due to a ruptured cordae and points to the LA Type three is restricted leaflet motion and there are two types here, there's 3a and 3b 3a is structural, so the leaflet is affected in cistulae and diastole And this is usually the case with rheumatic disease 3b is functional, so the leaflet is affected in cistulae only This is due to tethering in cistulae as a result of lv changes dilatation etc That happen with regional wall motion abnormalities Or annular or left ventricular dilatation There is distortion of the lv and the mitral apparatus relationship And this is particularly sensitive to loading conditions, so you'll see an ischemia lv dysfunction or remodeling So take a good look at this Echo clip and we will move on to Answering the question about it question number three Question number three the previous clip shows an example of biliflet prolapse anterior leaflet billowing A flail anterior mitral leaflet a flail posterior mitral leaflet Or cannot be determined in this view. Here is an illustration of carpenture's classification So normal is the coaptation of leaflets all below the annular plane Billowing is when part of the leaflet is above the annular plane Prolapse is where the leaflet tip is above the annular plane but still points in the right direction And flail is where the leaflet tip is above the annular plane but points into the array Note that all of these are determined from the long axis view where the highest point Of the annulus or saddle rests and this determines where the actual annular plane is This slide again illustrates what I've talked about in real echo images So prolapse versus billowing V versus flail an image to see So the answer to question three is number five cannot be determined in this view It looks like billowing but we don't know for sure if it projects above the annulus because we are not in a midisophageal long axis view Where the highest part of the annulus is found That was a four-chain review Here's an example of a flail posterior leaflet You can see the tip jutting into the elliptic and here's the 3d on fast view and some of you may appreciate The flail leaflet here Let's just show any example of prolapse. This looks like prolapse of p2 Here's a restricted posterior leaflet It appears that only one leaflet is moving while the other is stuck in the diastolic or open So to summarize this segment this slide just Captures the different classification of the current pentere system and highlights the Different causes for each type back to Ireland Skellig Michael is the site of a monastic settlement dating back to the 6th century However, one can find legendary accounts of Skellig Michael which date to pagan times back in 1400 BC Skellig Michael is the most westerly sacred site in Europe and it also finishes The line of ancient pilgrimage places in Europe This line runs from Ireland through to France Italy and Greece and on to Palestine This line is known as the Apollo slash Saint Michael axis as it is believed to be known thousands of years before christianity Skellig Michael was the home to the monks of Saint Phenom These Skellig monks led very simple lives out here in the wild atlantic living in stone beehive shaped huts Although the huts were round shaped on the outside They were rectangular on the inside You may recognize Skellig Michael from Star Wars movies This was the last known hiding place of Luke Skywalker assessment of the mitral valve Ideally the decision to surgically treat the patient should be made before surgery at baseline hemodynamics and conditions We all know that mr is subject to change under anesthesia due to preload afterload contractility and compliance changes Severity is known to decrease by at least one grade under anesthesia Once we're in the OR and assessing the mitral valve intraop There are a few key questions we need to answer What is the mechanism? What is the location of the mr? This is important that the valve may be deemed irreparable And replacement may be chosen I think it's fair to say that in many centers repair may be limited to isolated p2 disease And thus ruling out disease other than limited to a single scallop might be critical Here in the hands of our surgeons, it's not the case, but there is likely some bias here towards more complex repairs So keep that in mind How severe is the mr although as aforementioned this shouldn't ideally be influencing decisions Can the valve be repaired and will it be successful? And what measurement acquisition can we do? Such as the annulus and the leaflet size etc Are the leaflets thickened or calcified? Are they redundant? Are they intact? What's the leaflet motion like normal excessive or restrictive? What about the co-aptation point is it below at or above the annular plane? Is there a lack of co-aptation? What's the color Doppler look like off the jet? What about spectral Doppler and 3d interpretation the latest acc aha guidelines list indications for te as intraop to establish the anatomy and guide repair when tte fails or 3d for complex lesions And this is by the european guidelines Assessment in 2d in summary six views are used to assess the mitral valve midisophageal which would be four chamber mitral commissure view two chamber view and the long axis view for a mechanism and location of leaflet pathology And direction and location of the mr jet with color Doppler Then there's two trans gastric views which is basal short axis for leaflet pathology and location of the jet And the two chamber view which is especially useful for the subvalvular apparatus especially the core day The long axis view is used for most of the needed measurements such as for annular dimensions It's closest to the ap diameter. This is the part of the annulus that dilates leaflet length tenting area or height prolapse height the venocontractor width the PISA radius The continuous wave max mr jet velocity And system assessing for systolic anterior motion Just a quick note about jets The direction of the jet is important eccentric jets are almost always due to a structural abnormality So if you see an eccentric jet look for a structural problem Wall hugging jets are of concern. They have high energy They are subject to the coanda effect, which means the blood is sucked against the wall and appears smaller by color Doppler Central jets can be seen in isolated annular dilatation by leaflet disease tethering By leaflet mix omenous disease by leaflet excessive mobility eccentric jets like I said directed away from the excessively mobile leaflet Or towards the restricted one and the trans gastric two chamber like I said around 90 degrees is especially useful for subvalvular component The complex anatomy of the valve and patient variation makes it difficult to standardize the evaluation of the valve This map is just a guide to get you thinking about the anatomy of the leaflets and how you cut through them as the omni plane angle changes From my perspective it also requires some reflection to orient yourself and think about the 3d spatial orientation So i'm not going to spend a lot of time with it, but you can refer to the diagram Which comes from the ac 2013 recommendations for a comprehensive exam Manipulation of the probe includes not only the omni plane angle, but also inserting or withdrawing the probe Turning right or left to visualize all the parts of the leaflets This requires a good 3d understanding of the valve So for a systemic 2d exam Start with the me4 chamber at zero degrees with the mitral valve in the center of the screen The anterior leaflet is medial and the posterior leaflet is lateral Inserting and withdrawing the probe Visualize a1 p1 superior anteriorly at the level of the lvot You may need a bit of anti-flection And down to a2 p2 and then a3 p3 inferiorly slash posteriorly You may need to retroflex to get a good view You can assess the scallops and diastole and the jet or localization of the prolapse at systole From there you move to the mitral or the midisophageal mitral commissure view at 45 to 60 degrees This is an apparent double orifice as you cut through the crescentering opening p1 which is lateral and p3 which is medial With variable amounts of a But usually a2 in between You turn the probe to the right to see the anterior leaflet and to the left to see the posterior leaflet We then move on to the midisophageal 2 chamber view at around 90 degrees And turn the probe left and right Anteriorly to see the anterior leaflet posteriorly to see the posterior leaflet Expect to see p3 and a3 a2 and a1 Then the mitral the midisophageal long axis View at 120 to 125 degrees which shows you a2 and p2 Here you're cutting across the smallest diameter of the valve. It is the best view for assessing mitral valve prolapse We draw an advance to see all the leaks Turning left shows a1 p1 and right shows a3 and p3 Tram gastric basal short axis will show up any clefts and perforations Take a look at question number four Using t the diameter of the mitral valve annulus should be measured Now look at your options there one two three four or five Details about annular measurement are controversial in terms of one the best view to measure it in and two What point of the cardiac cycle i.e. valve open or closed? Classically the annulus have been measured at zero and 90 degrees with the valve open However, there is emerging recognition that using standardized omni plane angles and such that don't expect to capture the true AP diameter due to the orientation of the valve referred to the mitral valve map is suboptima Old guidelines used a single four chamber view to measure the annular diameter in mid diastole one frame after the maximum leaflet opening And calculating the area using the formula for a circle, but this is known to be an oversimplification Other resources propose using long axis and commissural views with an elliptical formula Maslow and side bottom two of the echo kings recommend using commissural and long axis views which are different degrees for everyone This slide demonstrates that using zero and 90 may not be cutting through the valve where you wish it to A long axis view will cut through the true AP diameter as demonstrated here Even maslow and side bottom can agree on the optimal time to measure Maslow says and diastole the valve open side bottom says and sisley the valve closed And then sisley the valve again is under the pressure The best way to size the annulus may be with 3d multi planar reconstruction The goal is to achieve the slice across the annulus. It gives the true AP dimension second best would probably be the long axis view most practically A surgeon would use a valve size or there's more to come on this topic I'm not going to spend time on this but just to remind you how we use three orthogonal planes to know exactly where the annulus is to get our dimensions for 3d and pure Why is measuring the annulus so important? annual plastic rings help improve coact tape coaptation The surgical results are far worse if the ring size is so optimal The business of measuring the annulus and sizing the valves for rings or annular plastic bands is confusing and not standardized It's very much surgeon and experience-based Most many surgeons use ring specific sizes Some bands like the simplicity band here are adjustable and don't require sizing per se annular plastic bands purportedly maintain the 3d integrity the valve better than rings They're applied to the posterior annulus only making them more flexible Band sizing is even more confusing and less standardized. Some types don't even need sizing conclusion It's really based on the surgeon and his experience and there's a lack of scientific justification This slide just illustrates How valve sizes work They give the option of using many different criteria including Inter commissurio distance, inter trigone distance anterior mitral leaflet area or anterior mitral leaflet height Notice that none of these are eco findings So mitral valve sizing for annual plastic is very surgeon dependent If you talk to our own surgeons, they likely will say that they use our measurements as a ballpark in conjunction with the use of sizers This slide illustrates that out of all the studies Used to measure mitral valve area only one study used te Therefore the answer to question number four is number five It does not matter how it is measured as long as the information is communicated to the surgeon Just a word on annular calcification The echo identification of mitral annular calcification is extremely important in patients coming from mitral valve surgery since It may not be evident pre-op Paraprosthetic leaks are technically unavoidable during valve replacement in patients with severe mitral annular calcification And it interferes with sutures and sewing rings. I'm not going to focus on 3d assessment I just want to point out the way we display the images and standardize views So it's on fast from the left atrium. You can see the aortic valve at 12 o'clock The tricuspid valve to the right The left atrial appendage to the left The coronary sinus is visible And the anterior leaflet is above the posterior leaflet and the line of co-aptation makes a smiley face Just a reminder that q-lab can create a 3d model of the mitral valve and give Measurements as illustrated by this paper by Maslow Before our final segment, let me introduce you to bush mills northern Ireland You may recognize this as the dark hedges Where you drive along the king's road, which led Ned Stark to his death and Arya Stark away from king's landing This is probably one of the most photographed landmarks on the game of thrones map And a hidden road on the way to bush mills Mitral regurgitation severity This slide Summarizes the ACC or AHA guidelines for 2020 on primary MR assessment Several valve hemodynamic criteria are provided for assessment of MR severity But not all criteria for each category will be present in each patient Categorization of MR severity as mild, moderate or severe depends on data quality And integration of these parameters in conjunction with other clinical evidence I thought it was more important to think about the mitral valve and understand it Than spend the time talking about numbers that you can look up on your own But the presentation wouldn't be complete without at least superficially reviewing the criteria for diagnosing MR And I have included the numbers for your reference As per these new guidelines Grade A is at risk of MR Grade B is progressive MR Grade C is severe asymptomatic MR And grade D is severe symptomatic MR The criteria you use include jet area to laa relationship Or ratio vena contractor regurgiton volume regurgiton fraction effective regurgiton orifice And angio This table shows the 2020 guidelines for assessment of secondary MR or functional MR The main differences are the criteria for ERO and RV are smaller They don't include regurgiton fraction Vena contractor other than stage A or angio for grading And this is due to underestimation of the ERO with the chresenteric shape of the RFS And baseline compromised LB function and higher filling pressures Otherwise, it's the same criteria as primary MR For your perosone These are the old ASC guidelines which are broken down into qualitative measures and quantitative measures They still use mild moderate and severe grading This chart represents the qualitative measures which is divided into structural and Doppler criteria The structural ones include LA and LV size What the leaflets and apparatus look like And the Doppler ones include what the jet looks like on continuous wave in terms of shape and density The mitral inflow pulse wave The jet area To laa ratio And the pattern of pomevane flow I thought discussion around each of the criteria is warranted. So let's start with pulse wave mitral inflow Pulse wave Doppler is used to measure the low flow velocities of blood through the left ventricular inflow tract producing the E and A waves E stands for early filling in diastole And it's a negative wave as it is away from the probe A is equal to HL contraction which will be in the same direction as E Both are away from the probe The E wave is dominant or bigger with MR because there's more volume going into the LV from the regurgitant volume When evaluating mitral regurgitation one must assess the pulmonary venous flow by pulse wave Doppler Normally normal pulmonary venous flow into the LA is pulsatile and laminar thus reddish With pulse wave you expect to see biphasic waves above the Doppler baseline i.e towards the transducer Therefore a forward flow during systole and diastole This creates the upright or big waves of the respective S and D waves The normal tracing here to the left on the slide There's also a small usually upright A wave that occurs due to HL contraction Occasionally this is a small reversed wave immediately after diastolic forward flow corresponding to mitral valve closure Blunting of the systolic flow i.e a small S wave or systolic reversal where the S wave is below the Doppler line Meaning the blood flows back into the pulmonary vein and away from the transducer appearing as a negative wave Can occur with MR, but their absence does not rule out severe MR, especially if chronic with time for adaptation of the left atrium Keep in mind that other things can be responsible for blunting and reversal of flow left atrial compliance LV systolic and diastolic function systolic blood pressure and systemic vascular resistance Reversal is mostly caused by MR When you measure this you want to put the pulse wave at least one to two centimeters into the pulmonary vein Check both the left and the right The MR jet direction may affect one pulmonary vein only When evaluating the valve with continuous wave Doppler, we look at the density and the contour A more dense jet means more severe MR Since density is a measure of how much blood is there The shape of the MR jet also gives us information on severity Mild MR has a parabolic shape While severe MR has a triangular shape When the regurgitant orifice is large The pressure equalizes very quickly so the flow happens right away steep up and steep down Creating the triangular shape Color flow Doppler remains the best screening method to diagnose much regurgitation It also allows a semi quantitative assessment of the severity of regurgitation And can provide clues to the mechanism of MR One pitfall is the appearance of MR by color Doppler is highly dependent on the gain and nyquist limit of the transducer Setting the gain too high Or the nyquist limit too low can make the MR appear more severe When taken as a percentage of the left atrial area The specificity of the jet surface area as an index of the severity of MR increases Wall-hunging jets should be considered hemodynamically significant until proven otherwise and they always warrant a careful examination It takes a high energy jet to follow the LA wall for some distance Owing to a physical phenomenon called the coanda effect which we mentioned before These jets appear smaller on color flow Doppler than they actually are. They're almost always due to a structural leaflet problem Question number five being a contractor should be measured in which view 1 me for c 2 me commissural view 3 me to chamber view 4 me lax or 5 none at the above Being a contractor width is the narrow central flow region of the jet at the orifice of the regurgitant valve It is measured in the midisophageal long axis view in late systole with the valve closed In the diagram the venocontractor is demarcated by the black line at the edges of the leaflets If one revisits the 3d anatomy of the valve and the axes of the line of coaptation One will appreciate that the long axis view is the view that will best give the narrows to width of the jet The other views slice the line of coaptation obliquely and can make the jet look very wide When in fact it may not be and thus it can be deceiving So just some important points about the venocontractor. It's The narrowest portion of the regurgitation jet It's high velocity laminar flow It's slightly smaller than the anatomic regurgitant orifice The cross-sectional area of the vc represents a measure of the effective regurgitant orifice area a true parameter of lesion severity It's independent of flow rate and driving pressure for a fixed orifice and it's Much less dependent on technical factors such as the pulse repetition frequency compared with the extent of the jet by color Doppler So it's reliable for central and eccentric jets, but not multiple jets Venocontractor with less than 0.3 millimeters is associated with mild MR and greater than 0.7 millimeters associated with severe MR And in between is a bit of a gray area Some tips and tricks on getting an accurate venocontractor So we want to keep your flow convergence Your vc in your jet area as linear as possible Take a zoomed view so the size and the position of the box should be adjusted to focus on the region of leaflet coaptation i.e not the entire regurgitant jet within the LA Use your color flow sector to and narrow it to maximize your lateral and temporal resolution Midisophageal long axis view only Set your scale to 40 to 60 centimeters per second And you know, there is no overestimation when the MR is not holo systolic And the venocontractor width is affected by the geometry the R of this so Whether it's circular or elliptical Just to note about venocontractor in 3d. It's useful for the venocontractor area More accurate for the er away than the 2d venocontractor width It's also useful for multiple jets of differing directions And it's important to measure all these jets individually and then add them to get the total venocontractor area It's measured offline by reorienting images and cropping the planes It can be difficult and tedious to find the smallest flow area Because I'm using this technology small errors and measurement can lead to large percentage errors So you have to be careful. This is just a summary of what I've explained from a very good paper by Zogby from 2017 Focusing here on the color flow Doppler and 3d venocontractor area The same paper highlights two cases showing Evaluation and quantification of the venocontractor area with 3d echo and multi planar reconstruction The upper panel showcase a primary mr with a circular vca and hemispheric pisa another uh with secondary mr and lower pounds with an elliptical vca and non hemispheric pisa 3d echo has shown that their regression are often crescent shaped in secondary mr In such cases the assumption of circular orifice geometry inherent to venocontractor width May result in underestimation of secondary mr In a recent study 3d vca greater than 0.4 centimeter squared denoted severe mr However, studies relating 3d vca to outcomes have not been performed yet I think it's safe to assume after that that everyone knows that the vc should be measured in minnesotheal long axis view There's a technical vignette slide which just summarizes what we talked about about jet area, which uh Depends on the orifice area, but also the orifice geometry and train flow the rate of flow the velocity the driving pressure pulse repetition frequency gain microst There's a bunch of stuff there that you know that makes that jet area quite, uh, not not very reliable For example high left atrial pressures might reduce the size of the mr jet despite severe prolapse This slide shows the jet area measured and highlights the need to use a proper nyquist limit On the right the jet appears much larger with a lower nyquist limit The jet area is compared to the left atrial area Which is no longer an adequate measure on its own i.e the jet area just without the la And it really depends on the recursion volume the recursion orifice and the velocity of flow This slide highlights what can happen when you mess with the color gain. So if you turn down the color gain Uh, you may get an underestimation of the jet area if you if you turn up the gain You can easily get an overestimation This slide illustrates what happens when You turn and down and up your nyquist limit. So if you look on the left They've turned the nyquist limit all the way down to 17 and you can see this huge severe jet Which is clearly inaccurate And overestimated Whereas a more normal jet is apparent on the right At a nyquist and a appropriately set like with limit around 69 This is an interesting point. I mean, we don't always think of this but transducer frequency does make a difference as well So if you look at the jet area with with a te pro, which is about seven megahertz It's always bigger than Measuring with the t te pro with two to four megahertz However, this is balanced by the fact that altered loading conditions around anesthesia often cause a decrease in the regurgiton jet area But I think it's still important to know I apologize for repeating myself, but I guess it'll reinforce certain points to you this Again a summary slide about jet area physics and limitations There is a poor correlation between jet area and MR severity due to technical and hemodynamic factors Which can be increased left atrial pressure left atrial size And underestimation of eccentric jets Question number six Which of the following are required to calculate the estimated regurgiton orifice area using pizza? I'll let you take a look at those Because my mouth's getting dry. I want to repeat the whole question. So just take a look at options one to five And I will talk a bit more about it before we get to the answer Effective regurgiton orifice area is calculated from the flow convergence method or Pisa which stands for proximal iso velocity surface area The principle as blood approaches an orifice blood cells accelerate along a series of concentric hemispheres seen by color Doppler So the velocity increases as it approaches the valve When it reaches the nyquist limit, which is a velocity Aliasing occurs and the color turns from red to blue At this point, you know the velocity You know the radius of the hemisphere so you can calculate the area And then you can calculate volumetric flow at that radius I want to try to make this simple for those of you not familiar with the concept So what we know is the law of continuity says flow area times spatial velocity Is constant within the flow stream That the velocity increases as the flow converges on the mitral orifice The smallest hemisphere and we can measure the velocity before and at the valve We want to know the area of the orifice of the valve Therefore if we can find the area of the flow coming into the valve We can find the effective or regurgent orifice area Here we see the three components you need to calculate it number one the color Doppler and late Cicely and The midisophageal long axis view to show flow convergence number two Pisa measured from the Tip of the mitral leafless to the point of first aliasing Note your nycos limit seven millimeters at 72.8 centimeters per second Gives us the velocity and area before the valve Then you shoot a continuous wave Doppler through the mitral valve to find the peak regurgent velocity of the mr jet Which as you can see here in the top right is 6.12 meters per second Leaving the only unknown the area of the valve orifice For simplification if the nycos limit is set to 40 centimeters per second And the gradient across the mr jet is 100 millimeters in mercury As produced by a 5 meter per second regurgent jet The ero a is r squared over 2 where r is the distance of the aliasing contour Just a reminder the area of the hemisphere is what interests us here The area of a circle is pi r squared sphere is 4 pi r squared and hemisphere is 2 pi r squared The volumetric flow is the area times velocity, which is 2 pi r squared times the nycos limit And the ero a is the volumetric flow divided by the mr velocity By continuous wave Doppler and this is illustrated here on this slide so 2 pi times 0.7 v squared times The nycos limit for the 72.8 centimeters per second gives you a volumetric flow of 224 centimeters cubed per second So the next step is to take that volumetric flow calculation and divide it by your measured peak mr velocity Which was 6.12 meters per second You've changed it to 612 centimeters per second to get the units the same So 224 divided by 612 Gives you an ero a of 0.37 centimeters squared So the answer to question number six is number four we use Pisa radius nycos limit and maximum velocity through the regurgent jet to calculate our ero a Using pizza now we're going to talk about quantification of regurgent volume Or rv This is simply blood entering the left ventricle Minus blood exiting the left ventricle into the orda, but how do we calculate the volume? We calculate the stroke volume You can imagine that the stroke volume is a cylinder. So we need to calculate the volume of a cylinder This would be the area of a circle, which is the valve area times the length or distance of the cylinder Which is vti or with pulse wave If you're like me, you might be missing the step to get from pulse wave to distance Basic physics tells us that the delta distance over time Is equal to velocity So if we integrate our velocity times time tracing of the pulse wave Doppler we get distance And summary vti is giving you distance The sv is vti Our distance times your area of a circle using the annulus measurements Again, we're assuming the mitral valve and the aortic valve are circular So the stroke volume across the mitral valve, which is vti of mitral valve Using your pulse wave at the annulus times the area of the mitral valve elliptical Minus the stroke volume across the alveo t Which is the vti of the alveo t times the area of the alveo t The area of the alveo t or aortic annulus is 2 pi r squared. This assumes the r is circular This is hard and cumbersome. So nobody does it You might also be able to take an er away from pizza and multiply by the vti of the mrjet Regurgitation fraction Is simply the regurgitation volume expressed as a percentage of the lv volume So it's the percentage of lv blood flowing back into the la during systole Here's question number seven The calculated er away and rv based on the data from the next picture is 0.59 centimeters squared and 79.8 centimeters cubed 0.15 centimeters squared and 79.8 centimeters cubed 0.59 centimeters squared and 37.4 centimeters cubed Or 0.15 centimeters squared and 37.4 centimeters cubed Or finally more data is needed So let's take a look at what we're seeing here. We're seeing a pizza radius in the middle of one centimeter We've got a nyquist of 44.7 centimeters per second and we're getting a regurgitant Sorry, a vmax of 4.7 meters per second or 470 centimeters per second So here's what we need to calculate our er away is going to be 2 pi r squared times your nyquist limit over your mr velocity And your regurgitant volume is going to be your er away times your vti Which was also present in that last side at 133.7 centimeters So let's quickly run through the calculation. So er away is twice two times pi with 3.142 times the radius one squared and applied by the nyquist limit 44.7 divided by the mr velocity it's 470 which gets you 280.89 over 470 which gives you 0.59 centimeters squared Then your regurgitant volume is That er away which is 0.59 multiplied by your vti 133.7 which gives you 79.8 centimeters cubed So the answer to question seven is a 0.59 centimeters squared and 79.8 centimeters cubed The story of kylemore abbey is a truly remarkable one that spans over 150 years of tragedy romance innovation education and spirituality Built as a breathtaking castle in 1868. It is now the abbey and home of the benedictine community of nuns The benedictine nuns arrived at kylemore in 1920 after their abbey in Ypres, belgium was destroyed in the early months of world war one Settling at kylemore the benedictine community opened a world-renowned boarding school for girls and began restoring the abbey gothic church and victorian walled garden to their former glory This is one of my favorite drives along the west coast of ireland kanabara Finally predictors of failed repairs Predictors of failed repair must be divided into primary mr and secondary mr Because the risk of repair failure is so much bigger so much higher in secondary mr For primary the things you're looking out for are as an annulus bigger than 50 millimeters There's more than three segments affected in terms of leaflets disease of the anterior leaflet severe calcification or not much tissue Or if there's a severe central jet for secondary mr large ventricle Tenting area greater than two and a half centimeters squared Or a co-optation distance greater than or equal to one centimeter Castillo Adele showed in this paper about or a repair failure in For a degenerative valve if there was severe annular dilatation greater than five centimeters Or for functional mr if the annular dilatation was greater than four centimeters difficult repair or mr recurrence or re-operation Is associated with things like prolapse or flail of three or more segments by leaflet pathology atrialization of the posterior leaflet insertion a large central jet or extensive valve calcification Reduced ability to repair it can be seen with restricted leaflets Or small leaflets so a posterior leaflet less than 17 millimeters pre-op An anterior leaflet less than 25 millimeters A small annulus diameter less than 35 millimeters or short core day less than 29 millimeters In functional ischemic mr And there's failure failure to uh failed repair in In areas with systolic tenting area of greater than or equal to once point six centimeters squared severe functional ischemic mr Or a diastolic annular diameter greater than or equal to 37 millimeters Indications for surgery i've included the acca aj guidelines summarized for you on the indications of surgery I will let you review them on your own for the sake of time Here's the algorithm for indications for surgery and primary mitral recurrence from the 2020 acca aj guidelines In summary mitral valve surgery class 1 recommendations recommended for Symptoms due to stage d regardless of lv function No symptoms, but stage c2 plus lv impairment So e f of less than or equal to 60 percent and or an lv and systolic diameter of greater than or equal to 40 millimeters Or stage c and d with degenerative mitral valve disease and successful repair possible Repair is preferred over replacement for severe mr limited to the posterior leaflet severe mr that involves the anterior leaflet If successful repair it's expected moving on to class 2a recommendations for repair. So it's reasonable if We're stage c with lv preservation If expected success is greater than 95 percent and mortality is less than 1 percent at a center of excellence Or stage c with lv preservation And it's non-romatic and there's expected success If there's new a fib or the resting home the artery pressure is greater than 50 Class 2b recommendations. So consider mv surgery if We're at stage d with an ejection fraction less than or equal to 30 percent consider Repair if it's romantic disease when other conditions indicate surgery And expected success or if long-term anticoagulation is going to be problematic Also consider trans catheter mitral valve repair if at stage d with New york heart association 3 class 3 or 4 symptoms if there's a reasonable light expectancy and they can't have surgery And class 3 recommendations avoid mv replacement in isolated severe mr with less than 1 or 2 of the posterior leaflet unless repair is attempted and has failed Here's the 2020 guidelines for surgery for secondary mr On the same paper In summary mitral valve surgery is reasonable class 2a for stages c or d Plus a cabbage or an avr You consider mitral valve surgery for stage d with nyha class 3 or 4 symptoms Or consider mv repair For stage b and other cardiac surgery Thank you very much for bearing with me for this needlessly overlong talk I'm available for questions by email. Thank you