Gold Standard to Measure What Is the Echo Gold Standard to Measure Mitral Regurgitation ? Steven A. Goldstein MD FACC, FASE Director, Noninvasive Cardiology Medstar Heart Institute Washington Hospital Center Sunday, February 21, 2016

financial relationships DISCLOSURE I have N O relevant financial relationships

Quantitation of Mitral Regurgitation Echocardiography Left ventriculography CT-scan (CTA) Cardiac MR (MRA)

Recommendations for Evaluation of the American Society of Echocardiography Report Recommendations for Evaluation of the Severity of Native Valvular Regurgitation with Two-dimensional and Doppler Echocardiography Zoghbi, et al J Am Soc Echocardiogr 16:777(2003)

Quantitation of MR

Severity of Mitral Regurgitation Integrated Echo Assessment Semiquantitation/qualitative Quantitation: vena contracta width, PISA Volumetric method (Regurg volume/fraction) Indirect: LA and LV size Color jet area Signal intensity Antegrade flow (mitral E-wave) Pulmonary venous flow V-wave cutoff sign

Mitral Regurgitation Qualitative Assessment courtesy of Jamil Tajik

Mitral Regurgitation Do Not Fall into Trap ! Color flow mapping is not an "ultrasonic angiogram" Color flow mapping is a velocity display and does not directly show volume information

Visualized Regurgitant = / Regurgitant Jet Volume

1. Regurgitant volume Mitral Regurgitation Color Doppler Assessment Factors Affecting Regurgitant Jet Area 1. Regurgitant volume 2. Velocity of regurgitation (driving pressure) 3. Size and compliance of left atrium 4. Central vs wall impinging jets Orifice size and shape 6. Influence of coexisting jets or flowstreams 7. Heart rate 8. Technical factors

Technical Factors Affect Size, Shape, and Appearance Regurgitant Jets Technical Factors Affect Size, Shape, and Appearance Gain settings, scale Frame rate, sector size Transducer Color flow algorithms Machine

Case

Correct settings Mild (1+) or mild-to-moderate (1-2+)

Scale decreased Scale increased

Severity of Mitral Regurgitation Integrated Echo Assessment Semiquantitation Quantitation: vena contracta width, PISA Indirect: LA and LV size Color jet area Signal intensity Antegrade flow Pulmonary venous flow V-wave cutoff sign

Severity of Mitral Regurgitation Indirect Clues 2.0 m/s Severe: E > 1.2 - 1.5 m/s

Mitral Regurgitation Peak E-wave Velocity Retrospective study - Thomas JACC 31:174(1998) Modest positive predictive value (75%) for an E-velocity >1.2 m/s identifying patients with chronic severe MR E/A < 1 excludes severe MR

Severity of Mitral Regurgitation Integrated Echo Assessment Semiquantitation Quantitation: vena contracta width, PISA Indirect: LA and LV size Color jet area Signal intensity Antegrade flow Pulmonary venous flow V-wave cutoff sign

Pulmonary Venous Flow Pattern Mitral Regurgitation Pulmonary Venous Flow Pattern Systolic Flow Reversal Normal Pattern Systolic blunting < Severe MR Severe MR Less predictive (trivial to severe)

Pulmonary Venous Flow Patterns Mitral Regurgitation Pulmonary Venous Flow Patterns 1.8 1.5 1.2 Regurgitant Orifice Area (cm2) 0.9 0.6 0.3 Normal Blunted Reversed Pu et al (Cleve Clinic) J Am Soc Echo 12:736(1999)

Severity of Mitral Regurgitation Integrated Echo Assessment Semiquantitation Quantitation: vena contracta width, PISA Indirect: LA and LV size Color jet area Signal intensity Antegrade flow Pulmonary venous flow V-wave cutoff sign

Quantitation of MR - PISA Method

Proximal Isovelocity Surface Area (Flow Convergence) Hydrodynamic Principle As blood approaches a regurgitant orifice, its velocity increases forming concentric, roughly hemispheric shells of increasing velocity and decreasing surface area.

= PISA Method Another form of the continuity equation Flow entering the proximal convergence zone V = 20 cm/sec V = 40 cm/sec V = 80 cm/sec = Flow exiting the regurgitant orifice V = 430 cm/sec Another form of the continuity equation

Conservation of Mass/Volume VTR R Flowinto RA = Flowfrom RV A x Va = 2 x R2 x Va FlowTR = 6.28 x R2 x Valias

Quantitation of Regurgitation Criteria for Severe Regurgitation AR MR TR ERO (cm2) 0.3 0.4 0.4 R Vol (cm3) 60 60 45

MR Severity - New Paradigm 2014 AHA/ACC Valvular Heart Disease Guidelines Stage A Stage B Stage C Stage D At risk for MR Progressive MR Asx severe MR Symptomatic severe MR No or mild MR Mild or mod MR Severe MR Severe MR

Severe Valve Regurgitation The magnitude of valve dysfunction that worsens prognosis

ACC/AHA 2014 Valve Guidelines Primary vs Secondary MR ERO Regurgitant volume Regurgitant fraction ≥ 0.4 cm2 ≥ 60 mL ≥ 50% ≥ 0.2 cm2 ≥ 30 mL ≈ 50%

ACC/AHA 2014 Valve Guidelines Primary vs Secondary MR ERO Regurgitant volume Regurgitant fraction ≥ 0.4 cm2 ≥ 60 mL ≥ 50% ≥ 0.2 cm2 ≥ 30 mL ≈ 50% This change has provoked controversy

Rationale for New MR Grading System Adverse outcomes are associated with smaller ERO Underestimation of ERO due to crescentic shape of regurgitant orifice

PISA - A Terrific Concept . . .but Irregularly shaped regurgitant orifice (ROA)  3D-imaging has shown that the ROA is often 3D-PISA may be more accurate for EROA Remains to be seen if 3D-PISA reproducible PISA shape may not be hemispheric devoid of geometric assumptions and regurgitant orifice and useful in clinical setting

Chronic Mitral Regurgitation Shape of Regurgitant Orifice by MRI MS/Rheumatic Prolapse C D Flail Functional This is real-time volume color Doppler showing mitral regurgitation. There are 3 cardiac cycles, each cardiac cycle is full-volume color Doppler and B-Mode data. Buchner JACC Imaging 2011:4; 1088-96

Chronic Mitral Regurgitation Shape of Regurgitant Orifice 7.00 p<0.01 6.00 p<0.01 5.00 Orifice Shape Index 4.00 This is real-time volume color Doppler showing mitral regurgitation. There are 3 cardiac cycles, each cardiac cycle is full-volume color Doppler and B-Mode data. 3.00 2.00 1.00 Degenerative Prolapse Flail Functional Buchner JACC Imaging 2011:4; 1088-96

Chronic Mitral Regurgitation Shape of Regurgitant Orifice The slitlike appearance in functional MR correlates with a distended mitral apparatus. This is real-time volume color Doppler showing mitral regurgitation. There are 3 cardiac cycles, each cardiac cycle is full-volume color Doppler and B-Mode data. Buchner JACC Imaging 2011:4; 1088-96

Vena Contracta Width

Parameters Used in Grading MR Severity Vena Contracta Narrowest portion of a jet Occurs at or just downstream from orifice High velocity, laminar flow Slightly smaller than anatomic regurgitant Represents a measure of the EROA orifice due to boundary effects Zoghbi, et al J Am Soc Echocardiogr 16:777(2003)

Quantitation of Mitral Regurgitation Vena Contracta Imaging FCR MR jet Vena contracta: the small neck between the PISA region and the flair of the jet in the left atrium

Quantitation of Mitral Regurgitation Vena Contracta Imaging FCR MR jet MR jet Degree of MR Vena contracta width Mild 0.3 cm Moderate 0.3 - 0.6 cm Severe >0.6 cm

Parameters Used in Grading MR Severity Vena Contracta Width Simple, quantitative, good at identifying mild or severe MR Utility/Advantages Limitations Not useful for multiple MR jets; intermediate values require confirmation. Small values; thus, small error leads to large % error Zoghbi, et al J Am Soc Echocardiogr 16:777(2003)

Volumetric Flow

Normal 70 mL 70 mL OK, the volume of blood that enters through mitral valve in diastole is ejected into aorta in systole.

Mitral Regurgitation Mitral Reg Vol = Mitral SV - Aortic SV 70 120 mL 50 mL 70 mL 120 mL When we have MR, not all the blood that comes in goes out into the aorta, as some of it will regurgitate. Mitral Reg Vol = Mitral SV - Aortic SV

Mitral Regurgitation Mitral Reg Vol = Mitral SV - Aortic SV 50 mL 70 mL 120 mL In the presence of regurgitation of one valve, without any intracardiac shunt, the flow through the affected valve is larger than through other competent valves. The difference between the two represents the regurgitant volume. Mitral Reg Vol = Mitral SV - Aortic SV (2) Reg Vol = SV Regurg Valve - SV Compet Valve

Severity of Mitral Regurgitation Integrated Echo Assessment Semiquantitation Quantitation: vena contracta width, PISA Indirect: LA and LV size Color jet area Signal intensity Antegrade flow Pulmonary venous flow V-wave cutoff sign

Parameters Used in Grading MR Severity LA and LV Size Utility/Advantages Limitations Enlargement sensitive for chronic significant MR, important for outcomes. Normal size virtually excludes significant chronic MR Enlargement seen in other conditions. May be normal in acute significant MR Zoghbi, et al J Am Soc Echocardiogr 16:777(2003)

Mitral Regurgitation Situations Where Quantitation Less Reliable Multiple MR jets After MitraClip procedure Paraprosthetic leaks Late systolic MR (MVP)

Summary

Conclusions Accurate assessment of MR depends on integrating all these techniques. All techniques have pitfalls and sources of error. If there is doubt as to severity, TEE can be pursued.

The End

MR Severity Assessment Mild Moderate Severe Color flow jet Central, small Central, moderate Vena contracta ≥ 0.70 with large central jet or wall impinging jet of any size <4 cm2 <20% of LAA 20-40% of LAA > 40% of LAA Vena contracta width (cm) < 0.30 < 0.30-0.69 ≥ 0.70 Regurgitant volume (ml) fraction Orifice area (cm2) < 30 < 0.20 30 – 44 30 – 39 0.20 – 0.29 45 - 59 40 – 49 0.30 – 0.39 ≥ 60 ≥ 50 ≥ 0.40 ASE Recommendations J Am Soc Echocardiogr 2003;16:777-802

Parameters Used in Grading MR Severity Color Flow Jet Area Utility/Advantages Limitations Simple, quick screen for mild or severe central MR; evaluates spatial orientation of jet Subject to technical, hemodynamic variation; significantly under- estimates severity in wall-hugging jets Zoghbi, et al J Am Soc Echocardiogr 16:777(2003)

Angiographic Grade of MR Maximal Color Jet Area vs Angiographic Grade of MR 25 n.s. p<0.05 20 15 Area (cm2) p<0.05 10 5 p<0.05 1+ 2+ 3+ 4+ Angiographic degree Fehske Am J Cardiol 73:268(1994)

Controversy with the Redefined MR Severity If we determine MR severity based on risk, then we should be sure that the risk is purely attributable to the mitral regurgitation 1. Likely not true in functional MR: Age Underlying heart disease LV status Comorbidities 2. Quantification of FMR particularly challenging Low-flow state common Crescentic or slit-like regurgitant orifice 3. Merits of valve intervention in FMR controversial