Echocardiography in the Diagnosis of Mitral Valve Prolapse

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Echocardiography in the Diagnosis of Mitral Valve
Prolapse
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2-D Criteria

• At one time the diagnosis of mitral valve
  prolapse was based on M-mode criteria.
• With the application of 2-D echocardigraphy,
  which visualizes mitral valve motion in real
  time, however, this method has a higher
  sensitivity in the diagnosis of mitral valve
  prolapse

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2-D Criteria

• The mitral valve is shaped like a saddle in 3
  dimensions, with its high points, farthest from
  the apex, located anteriorly and posteriorly in
  the long-axis view.

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2-D Criteria

• A 4 chamber view through such a structure can
  normally show leaflets apparently budging upward
  relative to the low points of the annular saddle
  without any leaflet disease or distortion.

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2-D Criteria
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2-D Criteria

• This particularly applies to superior bowing of
  the anterior mitral leaflet which heads
  superiorly towards the aortic root in the
  anterior posterior view but more apically towards
  the central fibrous body of the heart in the
  apical 4 chamber view.

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2-D Criteria

• Therefore, the diagnosis of mitral valve prolapse
  is based on the parasternal long-axis view
• Anterior or posterior mitral leaflet prolapse is
  considered present when any portion of the
  leaflet protrudes beyond the mitral annular plan
  gt2mm

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2-D Criteria

• The diagnosis is more certain when the mitral
  leaflets are thickened (myxomatous).
• When leaflet thickness is gt5mm measured in the
  parasternal long axis view during diastole or
  diastolic leaflet thickness is gt 1.4 times the
  thickness of the posterior wall of the aorta

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2-D Criteria

• The size of the LA should be measured at
  end-systole.
• This is an inner edge to inner edge measurement
  (normal 2.3 to 2.8cm)

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2-D Criteria

• Other associated conditions should be ruled out
  such as Marfan syndrome

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2-D Criteria
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2-D Criteria
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M-mode Criteria

• Because of the excellent temporal resolution of
  M-mode, it can still be used in conjunction to
  the 2-D diagnosis of MVP
• The leaflets will appear thick, redundant. The
  thickness of the mitral valve leaflets can be
  determined by measuring the thickness of the
  anterior and/or posterior leaflets in
  mid-diastole.
• gt 5mm which correlates with 2-D is considered to
  be evidence of myxomatous leaflets

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M-mode Criteria

• Mid to late systolic sagging back of the
  anterior, posterior, or both leaflets gt 2mm from
  the C-D points

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M-mode Criteria

• Holosystolic (pansystolic) sagging back of the
  anterior, posterior, or both mitral valve
  leaflets gt 3mm from the C-D points

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M-mode Criteria

• LA dilatation (significant mitral regurgitation)

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Doppler/color Doppler Criteria

• In color-flow imaging of mitral regurgitation,
  the area of the regurgitant jet relative to the
  size of the LA is most predictive of regurgitant
  severity determined with angiography.
• Color-flow imaging of valvular regurgitation
  depends on the gain setting, pulse repetition
  frequency, field depth, direction of jet, and
  loading conditions.

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Doppler/color Doppler Criteria

• A flow jet directed against the atrial wall
  appears smaller than a free jet of the same
  regurgitant volume (Coanda effect). Therefore,
  jet size on color-flow imaging should be
  interpreted in the context of jet geometry and
  the surrounding solid boundaries

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Doppler/color Doppler Criteria

• On Doppler, the velocity of MR tends to be lower
  lt5m/sec with increasing severity because the
  increase in LA pressure reduces the transmitral
  systolic gradient, unless the LV pressure is
  markedly increased.

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Doppler/color Doppler Criteria

• In severe MR, there may be systolic flow reversal
  in the pulmonary veins

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Doppler/color Doppler Criteria

• Most recently, vena contracta width by color-flow
  mapping correlates well with other quantitative
  measures for mitral regurgitation severity.
• Vena contracta is the narrowest portion of the MR
  jet downstream from the orifice.
• A biplane vena contracta width gt0.5cm. This would
  be considered hemodynamically significant MR.

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Doppler/color Doppler Criteria

• In the case of prolapse, MR is often late
  systolic
• Depending on the leaflet or leaflets that are
  affected, will determine the direction of the
  mitral regurgitant jet
• If there was an posterior MVP which direction
  would the MR jet go?
• If there was a anterior MVP which direction would
  the MR jet go?
• If both leaflets prolapsed, which direction would
  the MR jet go?

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Doppler/color Doppler

• E.g., posterior prolapse, anterior direction,
  anterior prolapse, posterior direction, both
  leaflets, central direction

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Doppler/color Doppler Criteria
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Case Study
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Echocardiography in the Diagnosis of Flailed
Mitral Valve

• A flail mital valve is best detected with 2-D
  echocardiography
• Extension of part of the valve into the left
  atrium in SYSTOLE can be readily noted.
• What views would show a flailed leaflet the best?

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2-D

• TEE Flailed myxomatous mitral valve

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2-D

• It is important to try and identify the reason
  for the flailed MV leaflet
• Ruptured chordae
• Ruptured papillary muscle
• Endocarditis
• Hyperdynamic LV wall motion will be present
  secondary to acute MR

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Doppler/color Doppler

• As with mitral valve prolapse, the Doppler jet is
  usually eccentric with flail mitral leaflet. The
  degree of mitral regurgitation usually is more
  severe with a flail leaflet. Like MVP, the
  direction of the jet is opposite to the fail
  leaflet.

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TEE

• Can provide spectacular views of flail mitral
  leaflets.

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M-mode

• Several M-mode signs of flail can be described
• One patter is indistinguishable from marked
  mitral valve prolapse and usually primarily
  involves the posterior leaflet.
• Course diastolic fluttering of the mitral leaflets

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M-mode

• Flailed anterior mitral valve due to
  endocarditis, exhibits chaotic, coarse fluttering.

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Case Study TEE
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Echocardiography in the Diagnosis of Mitral
Annular Calcification
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2-D Criteria
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M-mode

• The principle observation on M-mode is a band of
  dense high-intensity echoes between the mitral
  valve and the posterior left ventricular wall.

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M-mode

• Frequently, these echoes may obscure the
  posterior leaflet.
• The echoes from the annulus may also be in direct
  contact with the posterior left ventricular
  endocardial echo and may partially obscure those
  echoes and hide the inferioposterior wall on the
  short axis view because of acoustic shadowing.

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M-mode

• Because of the highly reflective nature of the
  calcium, the effective beam width is wide. Thus,
  some apparent echoes may be artifactual.
• Calcification may not be limited to only the
  annular or submitral area. Calcification
  frequently extends throughout the bse of the
  heart. It may extend into both the mitral and
  aortic valves.

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• Many conditions have been reported in association
  with a calcified mitral annulus. This
  abnormality is commonly associated with mitral
  regurgitation, various conduction abnormalities,
  and left ventricular outflow obstruction.

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• The MR is probably due to interference with
  normal contraction and function of the mitral
  annulus.
• There can be mild to moderate mitral
  regurgitation due to increased rigidity of the
  mitral annulus.
• Occasionally, the calcification extends into the
  base of the mitral leaflet themselves, resulting
  in functional mitral stenosis due to narrowing of
  the diastolic flow area.

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• If this occurs, then the inflow velocities may be
  high and difficult to distinguish from MS.
• Calcific mitral stenosis can be distinguished
  from rheumatic disease by careful imaging
  techniques to demonstrate thin and mobile mitral
  leaflet tips without commissural fusion