1. 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

2. financial relationships
DISCLOSURE
I have N O relevant
financial relationships

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

4. 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)

5. Quantitation of MR

6. 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

7. Mitral Regurgitation Qualitative Assessment
courtesy of Jamil Tajik

8. 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

9. Visualized
Regurgitant = /
Regurgitant Jet
Volume

10. 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

11. 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

12. Case

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

14. Scale decreased
Scale increased

15. 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

16. Severity of Mitral Regurgitation
Indirect Clues
2.0 m/s
Severe: E > m/s

17. 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

18. 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

19. 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)

20. 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)

21. 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

22. Quantitation of MR - PISA Method

23. 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.

24. = 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

25. 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

26. Quantitation of Regurgitation Criteria for Severe Regurgitation
AR MR TR
ERO (cm2)
R Vol (cm3)

27. 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

28. Severe Valve Regurgitation
The magnitude of valve dysfunction
that worsens prognosis

29. 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%

30. 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

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

32. 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

33. 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;

34. 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;

35. 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;

36. Vena Contracta Width

37. 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)

38. 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

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

40. 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)

41. Volumetric Flow

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

43. Mitral Regurgitation Mitral Reg Vol = Mitral SV - Aortic SV 70 120 mL50 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

44. Mitral Regurgitation Mitral Reg Vol = Mitral SV - Aortic SV50 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

45. 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

46. 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)

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

48. Summary

49. 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.

50. The End

51. 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
<
≥ 0.70
Regurgitant
volume (ml)
fraction
Orifice area (cm2)
< 30
< 0.20
30 – 44
30 – 39
0.20 – 0.29
40 – 49
0.30 – 0.39
≥ 60
≥ 50
≥ 0.40
ASE Recommendations J Am Soc Echocardiogr 2003;16:

52. 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)

53. 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)

54. 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