1. Rheumatic Valvular Heart Disease Assessment of Severity
Prof. P. Krishnam Raju
Care Hospitals, Hyderabad 1

2. Focus on Severity assessment Pitfalls / caveats Role of Exercise Echo
Value of BNP
Gender differences 2

3. VHD Severe VHD + Symptomatic Severe VHD + Asymptomatic
Mild VHD + Symptomatic
Mild VHD + Asymptomatic

4. VHD VHD Assessment EKG History Physical Exam CXR Cath Angio 2D Echo
CT MRI
Stress
Echo
TDI
SRI
TEE

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9. Classification of Aortic Stenosis Severity
Aortic Sclerosis
Mild
Moderate
Severe
Aortic jet velocity (m/s)
 2.5 m/s
3-4
> 4
Mean gradient (mmHg)
<20 (<30**)
20-40* (30-50**)
> 40* (>50**)
AVA (cm2)
> 1.5
< 1.0
Indexed AVA (cm2/m2)
> 0.85
< 0.6
Velocity ratio
> 0.50
< 0.25
* AHA / ACC Guidelines, ** ESC Guidelines 9 9

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19. Exercise Echo Aortic Valve Stenosis
? WHICH PARAMETERS
Total Exercise Time
Maximum work load
Peak HR TVI/ STRAIN/SRI
Peak BP
Symptoms Low flow / Low Gradient AS
> 20% ↑ Forward SV = Good Contractile Reserve
> 20% ↑ LVOT TVI = as above
Peak Aortic Velocity
P mean
A.V.A

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27. Grading of Aortic Regurgitation Severity
Mild
Moderate
Severe
Specific signs
for AR severity
Central jet, width
<25% of LVOT
Vena contracta < 0.3 cm1
No or brief early
diastolic flow reversal in
descending aorta
Signs of AR> mild present but no criteria for severe AR
≥ 65% of LVOT
Vena contracta >
0.6 cm
Supportive
Signs
Pressure half-time
> 500 ms
Normal LV size 2
Intermediat e values
<200 ms
Holodiastolic aortic
flow reversal in
Moderate or
greater LV
enlargement 2 27 27

28. Grading of Aortic Regurgitation Severity
Quantitative Parameters
Mild
Moderate
Severe
RVol (ml/beat)
<30
≥ 60
RF (%)
< 30
≥ 50
EROA (cm2)
<0.10
≥ 0.30
1 At a Nyquist limit of cm/s. 2 LV size applied only to chronic lesions
3. In the absence of other etiologies of LV dilatation’
. AR = aortic regurgitation; EROA = effective regurgitant office area; LV = left ventricle: LVOT = left ventricular outflow tract; R Vol = regurgitant volume; RF = regurgitant fraction 2 28 28

29. The information that can be obtained
by echo includes
Valve disease – Present or absent
Valve morphology
Severity of regurgitation
Mechanism
Hemodynamics
Etiology
Complications
Effect on neighbouring structures
Choice of therapy – Medical / repair or replacement 29

30. Factors affecting assessment of AR by Doppler Color flow imaging include
Physiologic Factors
Loading conditions
Chamber compliance
Orifice size
Driving pressure
Gradient
Entrainment
Viscosity
Temporal variability
Technical Factors
Gain settings
Carrier frequency
Frame rate
Sector size
Scanning depth
PRF
Nyquist Limit
Processing algorithms (Maps)
Doppler angle 30

31. Doppler quantification – Limitations
Eccentric jets
Poor sonic windows
Angle error
Pit falls in assessment of RV / RF
a. Operator
b. Sample volume not at annulus
c. Not tracing envelope properly
d. Not averaging
e. Incorrect annulus diameter
f. Multivalvular lesions
g. Shunts
h. Dense calcification of valve
i. Prosthetic valve shadowing 31

32. Severe AR Jet width / LVOT diameter ratio ≥ 60%
Jet area / LVOT area ratio ≥ 60%
Jet width at origin ≥ 12mm
PHT of AR jet ≤ 250ms
Restrictive MV flow pattern (Acute AR)
Holo diastolic flow reversal in desc aorta
Dense CW signal
RF ≥55%
RV ≥ 60%
LV enddiastolic dimension ≥ 7.5 cm (chronic AR)
LV endsystolic dimension ≥ 5.5 cm
ERO ≥ 0.3 sqcm 32

33. Aortic regurgitation severity : Utility, advantages, and limitations
Structural parameters
LV size
Aortic cusps alterations
Utility / Advantages
Enlargement sensitive for chronic significant AR, important for outcomes. Normal size virtually excluded significant chronic AR.
Simple, usually abnormal in severe AR; Flail valve denotes severe AR
Limitations
Enlargement seen in other conditions may be normal in acute significant AR
Poor accuracy, may grossly underestimate or overstimate the defect 33

34. Aortic regurgitation severity : Utility, advantages, and limitationsII
Doppler parameters
Jet width or jet cross – sectional area in LVOT – Color Flow Vena contracta Width
PISA method
Utility / Advantages
Simple, very sensitive, quick screen for AR
Simple, quantitative, good at identifying mild or severe AR
Quantitative. Provides both lesion severity (EROA) and volume overload (R vol)
Limitations
Exapands unpredictably below the orifice. Inaccurate for eccentric jets
Not useful for multiple AR jets. Small values; thus small error leads to larg % error.
Feasibility is limited by aortic valve calcifications. Not valid for multiple jets, less accurate in eccentric jets. Provides peak flow and maximal EROA. Underestimation is possible with aortic aneurysm. Limited experience. 34

35. Aortic regurgitation severity : Utility, advantages, and limitations
III
Flow quantitation –PW
Jet density –CW
Jet deceleration rate (PHT) –CW
Diastolic flow reversal in
descending aorta-PW
Utility / Advantages
Quantitative, valid with multiple jets and eccentric jets. Provides both lesion severity (EROA, RF) and volume overload (R Vol)
Simple. Faint or incomplete jet compatible with mild AR
Simple
Limitations
Not valid for combined MR and AR, unless pulmonic site is used.
Qualitive. Overlap between moderate and severe AR. Complementary data only
Qualitive; affected by changes in LV and aortic diastolic pressures
Depends on rigidity of aorta. Brief velocity reversal is normal 35

36. Exercise Echo AR ? WHICH PARAMETERS LV EDV LV ESV EF
Annular Systolic Velocities
TVI SR
SRI
? BNP

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42. Classification of Mitral Stenosis Severity
Mild
Moderate
Severe
Specific findings
Valve area (cm2)
> 1.5
1.0 – 1.5
< 1.0
Supportive findings
Mean gradient
(mmHg)
< 5
5 – 10 10
Pulmonary artery
Pressure (mmHg)
< 30
30- 50
> 50
* at heart rates between 60 to 80 beats per minute and in sinus rhythm 42 42

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49. Exercise Echo Mitral Stenosis
? WHICH PARAMETERS
Exercise Tolerance
Trans Mitral Velocities / Gradients
Trans Tricuspid Velocities / Gradients
RVSP = PASP

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52. MR Severity Etiology Pathophysiology Effects of MR on cardiac chambers
Echo Evaluation
Severity
Etiology
Pathophysiology
Effects of MR on cardiac chambers
LV function
Other LV hemodynamic information from MR jet
Associated lesions
PAH
Prognosis
Stress Echo?
Timing of surgery
Type of surgery
Clinical Questions 52 52

53. Grading of Mitral Regurgitation Severity1
Grading of Mitral Regurgitation Severity
Mild
Moderate
Severe
Specific signs of severtiy
Small central jet < 4
cm2 or < 20% of LA area
Vena contracta width
< 0.3 cm
No or minimal flow
convergence
Signs of MR > mild present, but no criteria for severe MR
Vena contracta width ≥ 0.7 cm with large central MR jet (area >40% of LA) or with a wall-impinging jet of any size, swirling in LA
Large flow convergence1
Systolic reversal in
pulmonary veins
Prominent flail MV
leaflet or ruptured
papillary muscle
Supportive signs
Systolic dominant flow in pulmonary veins
A-wave dominant mitral inflow2
Soft density parabolic CW Doppler MR signal
Normal LV size3
Intermediate signs / findings
Dense, triangular CW
Doppler MR jet.
E-wave dominant mitral
inflow (E> 1.2 m/s)2
Enlarged LV and LA size
(particularly when normal
LV function is present) 53 53

54. Grading of Mitral Regurgitation Severity2
Grading of Mitral Regurgitation Severity
Quantitative Parameters
Mild
Moderate
Severe
RVol (ml/beat)
< 30
≥ 60
RF (%)
≥ 50
EROA (cm2)
< 0.20
0.20 – – 0.39
≥ 0.40
Color Nyquist limit of cm/s. 1. Minimal and large flow convergence defined as a flow convergence radius < 0.4 cm and ≥ 0.9 cm for central jet, respectively, with a baseline shift at a Nyquist of 40 cm/s.
2. Usually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA pressure.
3. LV size applied only to chronic lesions. CW = continuous wave; EROA = effective regurgitant orifice area; LA = left atrium; LV = left ventricle; MV = mitral valve ; MR = mitral regurgitaiton; R Vol = regurgitant volume; RF = regurgitant fraction. 54 54

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63. MR TEE Color Doppler Technique Value Comments
Jet area + Technique dependant
Jet hugs LA wall ++ Upgrade MR by 1o
Jet enters LAA ++ Usually severe
Jet enters PV ++ Usually severe
Jet encircles LA ++ Upgrade MR by 1o
Agitated flow in LA + Technique dependant
PISA size ++ Dependant on NL 63 63

64. MR TEE Technique Value Comments PV syst. reversal +++ SevereII
TEE
PW/CW
Technique Value Comments
PV syst. reversal +++ Severe
E ht of MV inflow to 1.8 cm/sec (severe MR)
LVOT / Aortic velocities + with severe MR
MR jet density + Beam alignment dependant
V wave cutoff sign + Severe MR 64 64

65. MR TEE 2 D Echo Technique Value Comments
III
TEE
2 D Echo
Technique Value Comments
LA auto contrast + Excludes severe MR
LA dilation + Severe MR (Except acute MR)
LA systolic expansion + Severe
IAS bulge to right + Severe
Auto contrast in AO + Severe MR + Shock
Flail MV ++ Severe
Dilated RA / RV + PAH + Severe 65 65

66. MR MR Jet area to LA area Mild < 15% Moderate 15 to 35%
TEE
MR Jet area to LA area
Grading
Mild < 15%
Moderate 15 to 35%
Mod severe 35 to 55%
Severe > 55% 66 66

67. MR (severe) Natural History
Variable Estimates of long term survival
97 – 27 % at 5 yrs
Flail leaflet MR
- Annual mortality %
- 10 yr incidence of AF 30%
- 10 yr incidence of CHF 63%
- at 10 yr dead + MV surg 90%
Flail leaflet MR Mortality
- NYHA FC I / II 4.1% /yr
- NYHA FC III / IV 34% /yr
SCD % / yr overall
- 0.8% / yr in pts without risk factors 67

68. MR Assessment for early LV dysfunction
Exercise Testing
Exercise Echo
TDI
Exercise RNV 68

69. Mitral regurgitation (severe) Asymptomatic
Golden Moment
Severe MR
LVEF < 60 %
LVSD (exercise)
LVIDs > 45 mm
A fib
RV dysfunction
PAH 69

70. MV Replacement Vs Repair
MV replacement MV repair
Hospital mortality 3% - 15% 1% - 3%
Annual embolism / Thr 1 - 3% 0 - 1%
Warfarin Usually Rarely
LV function Yes No
LV anatomy affected Yes No
Pap muscle function No Yes
Annual failure rates 1 - 2% < 1%
Annual IE 1 - 2% < 1%
Suitable for all MV disease Yes No
Absolute contraindications None Calcific severe RHD
Relative contraindications None RHD, Isch MR
Ideal pathology All Myxomatous 70 70

71. ECHO MR Repairability of MV Carpentier
Type I Normal anatomy Annular dilatation Leaflet perforation
Type II Excessive leaftlet motion (prolapse) Chordal elongation Pap muscle elongation Pap muscle / chordal rupture
Type III Restricted anatomy Commisural fusion Leaflet thickening Chordal thickening / fusion
Poor results – Type III
Commis. Prolapse, Extensive prolapse, dense calcification AML prolapse 71

72. MV APPARATUS ECHO NORMAL MEASUREMENTS
AML length (ED) 25 mm
PML length (ED) 15 mm
Chordae length (ES) 29 mm
Mitral Annulus (ES) cm 72

73. Mitral Valve Repair Measurements
Carpentier’s Type III B MV
Inter Pap muscle distance
Annulus to base of Pap Muscle
AML – PML Ratio (For Ring Annuloplasty)
MV Coaptation point to septal distance.
Isch.MR
MV Tenting Angle - AML, PML
MV Tenting Area 73

74. Mitral Valve Repair Measurements
Percutaneous Coro Sinus Devices
Coro Sinus to Post. Mitral Annulus Distance.
Lay of Coro sinus
CS relation to post mitral annulus
LCX relation to CS / MV annulus 74

75. Assessment to Preoperative Risk for SAM/LVOTO
Pre-repair TEE
AL /PL ratio
Greater in patient with AL/PL <1
than in patients with AL/PL >3
C-sept
Greater in patients with C-sept < 2.5cm
than in patients with C-sept > 3.0 cm
LVID: LV internal diameter in systole
C-sept:distance form the coaptation point to the septum 75 75 75

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77. STRESS ECHO Mitral Regurgitation
? Who needs
Asymptomatic + Severe organic MR ERO > 40 mm2
Unmasking latent LV dysfunction
Predicting post op EF
Assess EX tolerance
Effects on PA pressure / MR severity
class 2 a /level of evidence c 77

78. STRESS ECHO Mitral Regurgitation
? WHICH PARAMETERS
EXERTIONAL SYMPTOMS
LV LVEDV TVI dp/dt
LVESV SRI Contractile Reserve LVEF SR RW thickening
RV RVEF TVI
RVSP SRI
MR JA Tenting Area
VC PISA - RV / RF/ ERO
ERO
Pulm Vein Doppler flow parameters / PWD profiles MV / PV
TDI E/E’
TR Severity RVSP = PASP 78

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82. STRESS ECHO Mitral Regurgitation
VHD considered static
Most valve diseases have DYNAMIC component (Every day life)
Loading conditions, contractility change – Life activities.
Contractility reserve, compliance, vent-art coupling- change
Reveal
_ Symptoms
Valve dynamics
Ventricle dynamics
Change in forward output
Retrograde flow
Pulmonary pressures
Objective assessment of functional disability
Euro Heart Surgery
- stress testing under used
- Inappropriate use 82

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85. Findings Indicative of Hemodynamically Significant Tricuspid Stenosis
Specific Findings
Mean pressure gradient
≥ 5 mm Hg
Inflow time velocity integral
> 60 cm
T ½
≥ 190 ms
Valve area by continuity equation*
 1 cm2
Supportive Findings
Enlarge right atrium ≥ moderate
Dilated inferior vena cava
* Stroke volume derived from left or right ventricular outflow. In the presence of more than mild tricuspid regurgitation, the derived valve area will be underestimated. Nevertheless a value  1 cm2 implies a significant hemodynamic burden imposed by the combined lesion. 85 85

86. Grading of Tricuspid Regurgitation Severity
Parameter
Mild
Moderate
Severe
Tricuspid Valve
Usually normal
Normal or abnormal
Abnormal / flail leaflet / poor coaptation
RV / RA / IVC size
Normal 1
Normal or dilated
Usually dilated 2
Jet area - Central jets (cm2) 3
< 5
5 – 10
> 10
PISA radius (cm) 4
< 0.5
0.6 – 0.9
> 0.9
Jet density and contour – CW
Soft and parabolic
Dense, variable contour
Dense, triangular with early peaking
Hepatic vein flow 5
Systolic dominance
Systolic blunting
Systolic reversal
1. Unless there are other reasons for RA or RV dilationt. 2 . Exception: acute TR. 3. At a Nyquist limit of cm/s. 4. Baseline shift with Nyquist limit of 28 cm/s. 5. Other conditions may cause systolic blunting (e.g atrial fibrillation, elevated RA pressure). CW = continuous wave Doppler, IVC = inferior vena cava; RA = right atrium; RV = right ventricle; VC = Vena contracta width.

87. Grading of Pulmonary Stenosis
Mild
Moderate
Severe
Peak Velocity (m/s)
< 3
3 – 4
> 4
Peak gradient (mmHg)
< 36
36 to 64
> 64 87 87

88. Grading of Pulmonary Regurgitation Severity
Parameter
Mild
Moderate
Severe
Pulmonic valve
Normal
Normal or abnormal
Abnormal
RV size
Normal 1
Normal or dilated
Dilated 2
Jet size by color Doppler
Thin (usually < 10 mm in length) with a narrow origin
Intermediate
Usually large, with a wide origin; may be brief in duration
Jet density and deceleration rate- CW3
Soft; slow deceleration
Dense; variable deceleration
Dense; steep deceleration, early termination of diastolic flow
Pulmonic systolic flow compared to systemic flow –PW
Slightly increased
Greatly increased
1. Unless there are other reasons for RV enlargement. 2 . Exception: acute PR. 3. Steep deceleration is not specific for severe PR. CW= continuous wave Doppler; PR = pulmonic regurgitation; PW= pulsed wave Doppler; RV = right ventricle. 88 88

89. GENDER DIFFERENCES

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109. Mitral Valve disease Asymptomatic (Severe MR)
Timing of Surgery
LV dysfunction
 LV volume ACC guidelines
Pulmonary Hypertension Univariate Predictors
Atrial fibrillation
ESD / BSA > 22 mm / m Multi variate predictors
EROA > 55 mm2
BNP > 105 pg / ul
BNP annual increase > 25 pg/ml (over 1 year)
New flail leaflet Univariate Predictors
 EDD
LA
JACC 2009; 54
Hamzel et al ,Pizamo et al
109

110. THANKS FOR YOUR TIME
AND LISTENING