General Principles and State-of-the-Art Echocardiographic Evaluation of the Mitral Valve
Federico M. Asch
MedStar Cardiovascular Research Network at MedStar Washington Hospital Center, Washington, DC, USA
Search for more papers by this authorDiego Medvedofsky
MedStar Cardiovascular Research Network at MedStar Washington Hospital Center, Washington, DC, USA
Search for more papers by this authorFederico M. Asch
MedStar Cardiovascular Research Network at MedStar Washington Hospital Center, Washington, DC, USA
Search for more papers by this authorDiego Medvedofsky
MedStar Cardiovascular Research Network at MedStar Washington Hospital Center, Washington, DC, USA
Search for more papers by this authorRon Waksman
Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
Search for more papers by this authorToby Rogers
Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
Search for more papers by this authorSummary
Mitral regurgitation (MR) is the second most frequent valve disease after aortic valve stenosis. Cardiac imaging in general and echocardiography in particular play a pivotal role in the evaluation of each of the potential consequences of MR. The underlying mechanism of MR, either primary or secondary, implies distinct disease processes of varying etiologies, with different management strategies and outcomes. The continuous-wave Doppler envelope of the MR signal can provide clues to lesion severity. Pulmonary vein systolic flow reversal, a high peak mitral E-velocity >1.5m/s by guidelines, and a pulsed-wave Doppler mitral-to-aortic velocity time integral ratio >1.4 are additional indicators in favor of severe MR. Understanding the specifics of the valve, mechanisms of regurgitation, and other characteristics of the patient is essential for proper selection of patients. The MitraClip experience is one that highlights the importance of proper patient selection.
References
- Iung, B., Baron, G., Butchart, E.G. et al. (2003). A prospective survey of patients with valvular heart disease in Europe: the euro heart survey on Valvular heart disease. Eur. Heart J. 24: 1231–1243.
- Nkomo, V.T., Gardin, J.M., Skelton, T.N. et al. (2006). Burden of valvular heart diseases: a population-based study. Lancet 368: 1005–1011.
- Enriquez-Sarano, M., Avierinos, J.F., Messika-Zeitoun, D. et al. (2005). Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N. Engl. J. Med. 352: 875–883.
- Nishimura, R.A., Otto, C.M., Bonow, R.O. et al. (2014). 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J. Am. Coll. Cardiol. 63: 2438–2488.
- Carabello, B.A. and Crawford, F.A. Jr. (1997). Valvular heart disease. N. Engl. J. Med. 337: 32–41.
- Gaasch, W.H. and Meyer, T.E. (2008). Left ventricular response to mitral regurgitation: implications for management. Circulation 118: 2298–2303.
- Enriquez-Sarano, M., Akins, C.W., and Vahanian, A. (2009). Mitral regurgitation. Lancet 373: 1382–1394.
- O'Gara, P.T., Grayburn, P.A., Badhwar, V. et al. (2017). 2017 ACC expert consensus decision pathway on the Management of Mitral Regurgitation: a report of the American College of Cardiology Task Force on expert consensus decision pathways. J. Am. Coll. Cardiol. 70: 2421–2449.
- Carpentier, A., Adams, D.H., and Filsoufi, F. (2010). Carpentier's Reconstructive Valve Surgery. From Valve Analysis to Valve Reconstruction. Philadelphia, PA: Saunders, Elsevier.
- Jain, P. and Fabbro, M. 2nd. (2019). ACC expert consensus decision pathway on the Management of Mitral Regurgitation: a review of the 2017 document for the cardiac anesthesiologist. J. Cardiothorac. Vasc. Anesth. 33: 274–289.
- Baumgartner, H., Falk, V., Bax, J.J. et al. (2017). 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur. Heart J. 38: 2739–2791.
- Nishimura, R.A., Otto, C.M., Bonow, R.O. et al. (2017). 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the Management of Patients with Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Circulation 135: e1159–e1195.
- Lancellotti, P., Tribouilloy, C., Hagendorff, A. et al. (2013). Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. Eur. Heart J. Cardiovasc. Imaging 14: 611–644.
- Zoghbi, W.A., Adams, D., Bonow, R.O. et al. (2017). Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J. Am. Soc. Echocardiogr. 30: 303–371.
- Irvine, T., Li, X.K., Sahn, D.J., and Kenny, A. (2002). Assessment of mitral regurgitation. Heart 88 (Suppl 4): iv11–iv19.
- Lancellotti, P., Moura, L., Pierard, L.A. et al. (2010). European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur. J. Echocardiogr. 11: 307–332.
- O'Gara, P., Sugeng, L., Lang, R. et al. (2008). The role of imaging in chronic degenerative mitral regurgitation. JACC Cardiovasc. Imaging 1: 221–237.
- Grayburn, P.A., Fehske, W., Omran, H. et al. (1994). Multiplane transesophageal echocardiographic assessment of mitral regurgitation by Doppler color flow mapping of the vena contracta. Am. J. Cardiol. 74: 912–917.
- Heinle, S.K., Hall, S.A., Brickner, M.E. et al. (1998). Comparison of vena contracta width by multiplane transesophageal echocardiography with quantitative Doppler assessment of mitral regurgitation. Am. J. Cardiol. 81: 175–179.
- Zhou, X., Jones, M., Shiota, T. et al. (1997). Vena contracta imaged by Doppler color flow mapping predicts the severity of eccentric mitral regurgitation better than color jet area: a chronic animal study. J. Am. Coll. Cardiol. 30: 1393–1398.
- Enriquez-Sarano, M., Bailey, K.R., Seward, J.B. et al. (1993). Quantitative Doppler assessment of valvular regurgitation. Circulation 87: 841–848.
- Van de Heyning, C.M., Magne, J., Vrints, C.J. et al. (2012). The role of multi-imaging modality in primary mitral regurgitation. Eur. Heart J. Cardiovasc. Imaging 13: 139–151.
- Stone, G.W., Lindenfeld, J., Abraham, W.T. et al. (2018). Transcatheter mitral-valve repair in patients with heart failure. N. Engl. J. Med. 379: 2307–2318.
- Asch, F.M., Grayburn, P.A., Siegel, R.J. et al. (2019). Echocardiographic outcomes after transcatheter leaflet approximation in patients with secondary mitral regurgitation: the COAPT trial. J. Am. Coll. Cardiol. 74 (24): 2969–2979.
