Image Question-47

What is the diagnosis of IMAGE?


A. Aortic Regurgitation

B. Mitral Regurgitation

C. Mitral Stenosis

D. Aortic Stenosis

Mitral Regurgitation – Indicators of Severity

• Mitral valve pathology
• LV/ LA size
• Color Doppler: – Vena contracta, Jet Area, Flow convergence
• Mitral E; Pulmonary vein pattern
• Regurgitant flow/fraction
• CW – density and contour

Etiology and mechanism of mitral regurgitation

Etiology of mitral regurgitationMechanism of mitral regurgitation
Atrial fibrillationAnnular dilation, leaflet mal-coaptation
Acute ischemiaPapillary muscle dysfunction or rupture
Congenital or genetic disorders; Marfan syndrome, Ehlers-Danlos syndrome, Down syndromeLeaflet prolapse, cleft or rudimentary leaflets
Endocarditis; infective and maranticLeaflet perforation, mal-coaptation, chordal rupture
Drugs; fenfluramine and dexfenfluramineLeaflets, chordae
Functional/secondary; dilated cardiomyopathyLeft ventricular remolding, papillary muscle displacement leading to leaflet tethering and annulus dilation
Hypertrophic obstructive cardiomyopathySystolic anterior motion of anterior mitral valve leaflet
Myxomatous degeneration (primary)
  (1) Barlow’s disease
  (2) Fibroelastic deficiency
Leaflets prolapse
Rupture chordae
Mitral annular calcificationsAnnulus, leaflets
Rheumatic heart diseaseLeaflets, chordae
RadiationLeaflets, chordae
Causes of Mitral Regurgitation

Grading the severity of mitral regurgitation

Qualitative parameters
MV morphologyNormal/abnormalNormal/abnormalFlail leaflet/chordal rupture
Color flow Doppler of MR jet*< 20% of LA size20%-40% of LA size> 40% of LA size
Continuous wave Doppler
  MR jet density
  MR jet contour
Early peaking-triangular
Flow convergence zone*No or smallIntermediateLarge
Semi-quantitative parameters
Vena contracta< 0.3 cm0.3-0.69 cm≥ 0.7 cm
Mitral valve inflowA-wave dominantE-wave dominant, > 1.2 m/s
Mitral to aortic TVI ratio < 1 m/sMitral to aortic TVI ratio 1 to 1.4 m/sMitral to aortic TVI > 1.4 m/s
  Pulmonary veins flowSystolic dominanceNormal or systolic bluntingSystolic flow reversal in > 1 vein
  LA/LV sizeNormalIntermediateEnlarged, particularly with normal LV function
Quantitative parameters
  Effective regurgitant orifice area by PISA or 3D color Doppler echo< 0.2 cm20.2-0.29 cm2; Mild to moderate
0.3-0.39 cm2; Moderate to severe
≥ 0.4 cm2
  Regurgitant volume< 30 mL/beat30-44 mL/beat; Mild to moderate
45-59 mL/beat; Moderate to severe
≥ 60 mL/beat
  Regurgitant fraction< 30%30%-39%; Mild to moderate
40%-49%; Moderate to severe
≥ 50%

MR: mitral regurgitation; MV: mitral valve; LA: left atrium; LV: left ventricle; TVI: time velocity integral. *At Nyquist limit between 50-70 cm/s. Color Doppler gain needs to be optimized

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