1. Structural and Functional Mitral Regurgitation:
Echo Subleties and Hallmarks
Steven A. Goldstein, MD
Director, Noninvasive Cardiology
Washington Hospital Center
Sunday, February 21, 2010

2. The Mitral Apparatus Mitral leaflets Chordae tendinae
Papillary muscles
Mitral annulus
Left ventricle
Left atrium

3. Mitral Valve Anatomy Dilatation Left atrium Annulus Leaflets Chordae
tendinae
Papillary
muscles
LV free
wall
Dilatation
Calcification
Prolapse
Redundancy
Thickening
Perforation
Cleft
Commissural fusion
Abnormal insertion
Elongation
Rupture
Thickening/fusion
Ischemia
Fibrosis
Rupture
Lateral displacement
(ischemia, fibrosis,
dilatation)

4. Mechanisms of Mitral Regurgitation
Prolapse
Normal
Apical
Tethering
Dilated anulus
Restricted PML
Ruptured pap muscle

5. Mitral Valve Repair Mechanisms to be Discussed
Ruptured chordae tendinae
Mitral valve prolapse (MVP)
Ischemic/functional MR

6. Ruptured cords

7. Case 1
Ruptured cords P2

10. Gastric short-axis view
1.6 cm + . . . +
Gastric short-axis view
(PSR view)

12. Systolic flow reversal  severe MR
L-upper pulm vein
Systolic flow reversal  severe MR

14. Roadmap for the surgeon

15. Mitral Valve Repair Information Required by Surgeon
Exact lesion(s) - affected segment(s)
Extent
Degree of calcification (leaflet/annulus)
Dilatation/size of annulus

16. Case 2
Ruptured cord P2

20. Case 3
Ruptured cords A2 and A3

24. Surgeon’s roadmap  A2 and A3

25. MVP

26. Case 4
Mitral Valve Prolapse

28. AML

30. S/P repair

31. Functional MR

32. Morphologic Changes in Heart Failure
Papillary muscles displaced apically and laterally
Bolling J Heart Valve Dis 11:S28(2002)

33. Functional Mitral Regurgitation
Global LV dysfunction
Regional LV dysfunction
Sphericity of LV
Excessive pap muscle displacement
Decreased overlap of leaflets
LA enlargement
Loss of systolic mital anular contraction
Increased “tenting” area
Delayed activation of P-M pap muscle (dyssynchrony)

34. Ischemic Mitral RegurgitationB C A D
Mitral leaflets are tented apically
Mitral annulus is enlarged (A-B = 45mm)
Mitral coaptation depth is increased (C-D = 13 mm)

35. Effect of Annular Dilatation on Tethering Area
MROP340

36. Apical Tethering of Mitral Leaflets
Basal cord tents
anterior leaflet
(“seagull sign”)

37. Increased tenting area
Basal cord tents
anterior leaflet
(“seagull sign”)
Increased tenting area

38. Distance from Mitral Annulus to Mitral Leaflet Coaptation Point
Normal Ventricle
Spherical Ventricle

39. Ischemic MR

40. Ischemic Mitral Regurgitation
"Ischemic MR" is a commonly used term,
but its definition is not clearcut; Most
articles discussing ischemic MR do not
even define it !

41. Ischemic Mitral Regurgitation Definition
Moderate to severe MR due to CAD
(MI, myocardial ischemia, or resulting
LV remodeling) in the absence of primary,
preexisting leaflet or chordal pathology

42. Ischemic Mitral Regurgitation Mechanisms
Dislocation of papillary muscles
Increased tenting length and area
Antero-posterior dilatation of the MV annulus
Kinetics of MV annulus during cardiac cycle
Intraventricular synchrony/dyssynchrony
Atrio-ventricular synchrony

43. Ischemic Mitral Regurgitation Single Papillary Muscle Involved
Local malfunction of LV wall adjacent to a single pap muscle
Calafiore Eur Assoc Cardio-Thorac Surg 2005

44. Abnormal Mitral Valve Coaptation
Normal coaptation
Abnormal coaptation

45. Ischemic MR  restricted PML
Case 7
Ischemic MR  restricted PML

48. Dilated LV; posterior wall thinner than septum
LVIDd = 6.4 cm
Dilated LV; posterior wall thinner than septum

51. Bent anterior mitral leaflet

52. Increased tenting area

53. The End

54. Mitral Annular Calcification
(MAC)

55. Mitral Annulus Calcification
Ventricular and Leaflet Extension

56. Ischemic Mitral Regurgitation Mechanisms
Dislocation of papillary muscles
Increased tenting length and area
Antero-posterior dilatation of the MV annulus
Kinetics of MV annulus during cardiac cycle
Intraventricular synchrony/dyssynchrony
Atrio-ventricular synchrony
- Papillary muscles dislocated toward apex
Apply traction to chorade
Chordae tendinae lack elasticity

57. Ischemic Mitral Regurgitation Mechanisms
Dislocation of papillary muscles
Increased tenting length and area
Antero-posterior dilatation of the MV annulus
Kinetics of MV annulus during cardiac cycle
Intraventricular synchrony/dyssynchrony
Atrio-ventricular synchrony
Anterior MI  displacement of the 2 pap muscles
Posterior MI  displacement of the postero-medial
in the global LV enlargement
pap muscle responsible for an asymmetric tethering

58. Ischemic Mitral Regurgitation Mechanisms
Dislocation of papillary muscles
Increased tenting length and area
Antero-posterior dilatation of the MV annulus
Kinetics of MV annulus during cardiac cycle
Intraventricular synchrony/dyssynchrony
Atrio-ventricular synchrony
A-P dilatation of the mitral annulus can determine
the degree of MR, even if no anomaly of the mitral
leaflets exists

59. Ischemic Mitral Regurgitation Mechanisms
Dislocation of papillary muscles
Increased tenting length and area
Antero-posterior dilatation of the MV annulus
Kinetics of MV annulus during cardiac cycle
Intraventricular synchrony/dyssynchrony
Atrio-ventricular synchrony
Progress in echo imaging, particularly including 3D-echo
have demonstrated the importance of motion and
specific features of kinetics of the annulus

60. Ischemic Mitral Regurgitation Mechanisms
Dislocation of papillary muscles
Increased tenting length and area
Antero-posterior dilatation of the MV annulus
Kinetics of MV annulus during cardiac cycle
Intraventricular synchrony/dyssynchrony
Atrio-ventricular synchrony
- Several investigators have demonstrated correlation
b/w width of QRS and degree of “functional” MR
- Observational data on resynchronization by pacing
can improve functional ischemic MR