Image Question-47
Contents
What is the diagnosis of IMAGE?
![](https://medicinequestionbank.com/wp-content/uploads/2023/03/IMG_20230315_141650-1024x461.jpg)
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 regurgitation | Mechanism of mitral regurgitation |
---|---|
Atrial fibrillation | Annular dilation, leaflet mal-coaptation |
Acute ischemia | Papillary muscle dysfunction or rupture |
Congenital or genetic disorders; Marfan syndrome, Ehlers-Danlos syndrome, Down syndrome | Leaflet prolapse, cleft or rudimentary leaflets |
Endocarditis; infective and marantic | Leaflet perforation, mal-coaptation, chordal rupture |
Drugs; fenfluramine and dexfenfluramine | Leaflets, chordae |
Functional/secondary; dilated cardiomyopathy | Left ventricular remolding, papillary muscle displacement leading to leaflet tethering and annulus dilation |
Hypertrophic obstructive cardiomyopathy | Systolic anterior motion of anterior mitral valve leaflet |
Myxomatous degeneration (primary) (1) Barlow’s disease (2) Fibroelastic deficiency | Leaflets prolapse Rupture chordae |
Mitral annular calcifications | Annulus, leaflets |
Rheumatic heart disease | Leaflets, chordae |
Radiation | Leaflets, chordae |
Grading the severity of mitral regurgitation
Mild | Moderate | Severe | |
---|---|---|---|
Qualitative parameters | |||
MV morphology | Normal/abnormal | Normal/abnormal | Flail leaflet/chordal rupture |
Color flow Doppler of MR jet* | < 20% of LA size | 20%-40% of LA size | > 40% of LA size |
Continuous wave Doppler MR jet density MR jet contour | Faint Parabolic | Dense Parabolic | Dense Early peaking-triangular |
Flow convergence zone* | No or small | Intermediate | Large |
Semi-quantitative parameters | |||
Vena contracta | < 0.3 cm | 0.3-0.69 cm | ≥ 0.7 cm |
Mitral valve inflow | A-wave dominant | E-wave dominant, > 1.2 m/s | |
Mitral to aortic TVI ratio < 1 m/s | Mitral to aortic TVI ratio 1 to 1.4 m/s | Mitral to aortic TVI > 1.4 m/s | |
Pulmonary veins flow | Systolic dominance | Normal or systolic blunting | Systolic flow reversal in > 1 vein |
LA/LV size | Normal | Intermediate | Enlarged, particularly with normal LV function |
Quantitative parameters | |||
Effective regurgitant orifice area by PISA or 3D color Doppler echo | < 0.2 cm2 | 0.2-0.29 cm2; Mild to moderate 0.3-0.39 cm2; Moderate to severe | ≥ 0.4 cm2 |
Regurgitant volume | < 30 mL/beat | 30-44 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