Download 3D Echo and Secondary MR - Society of Cardiovascular

3D Echo and Secondary MR
Also referred to as Functional,
Ischemic, Carpentier Type IIIb
Dr. Bollen
Dr. Shernan
Dr. Bollen/Dr.Shernan 2015
Advanced Echo Workshop
March 23-27, 2014
SCA Echo Week – Atlanta, GA
Dr. Bollen/Dr.Shernan 2015
Stages of Secondary MR
Nishimura, RA et al.
Dr. Bollen/Dr.Shernan
2014 AHA/ACC Valvular Heart
Disease Guideline 2015
Summary of Recommendations for
Chronic Severe Secondary MR
Nishimura, RA et al.
Dr. Bollen/Dr.Shernan
2014 AHA/ACC Valvular Heart
Disease Guideline 2015
2014 Guideline Comment


The “Mitral Clip” has not been approved in the
USA for treatment of secondary MR and
symptoms.
Remember that patients with secondary MR
have a poor 5 year prognosis regardless of
therapy. Patients are treated for symptoms
(CABG, MV ring vs replacement). See following 6 slides.


Heart failure cardiologists questioned the
superiority of MV clip vs medical therapy in
patients with severe MR who are not candidates
for surgery.
Thus a clinical trial comparing medical therapy
vs Mitral Valve clip is ongoing.
Dr. Bollen/Dr.Shernan 2015
W. Bouma et al.
European Journal of Cardio-thoracic Surgery
37 (2010)
Dr. Bollen/Dr.Shernan
2015
Fig. 6. Several new mechanism-based subvalvular and ventricular surgical techniques for CIMR. (A) Second-order chordal cutting.
Inferior MI causes leaflet tethering (including a typical anterior leaflet bend) and loss of coapting surface resulting in CIMR. Secondorder (or basal) chordal cutting eliminates the anterior leaflet bend and improves coaptation and CIMR. The primary (or marginal)
chordae prevent leaflet prolapse. Reproduced with permission from Messas et al. Copyright 2003, American Heart Association Inc. (B)
Papillary muscle approximation by passing a single U-shaped suture reinforced by two patches of autologous pericardium through the
bodies of the posterior and anterior papillary muscles. Reproduced with permission from Rama et al. Copyright 2007, the Society of
Thoracic Surgeons. (C) Infarct plication to restore papillary muscle position closer to the anterior mitral annulus and to reduce
tethering. Reproduced with permission from Liel-Cohen et al. Copyright 2000, American Heart Association Inc. (D) The Coapsys
device (Myocor Inc., Maple Grove, MN, USA) was designed to treat mitral annular dilatation and PM displacement. The device
consists of epicardial posterior and anterior pads connected by a flexible subvalvular chord. The two pads are located on the epicardial
surface of the heart with the load-bearing subvalvular chord passing through the LV. When the device is tightened under
echocardiographic guidance, the annular head increases coaptation and the papillary head repositions the PMs. Reproduced with
permission from Fuckamachi et al. Copyright 2004, the Society of Thoracic Surgeons. AML: anterior mitral leaflet, Ao: aorta, AP:
anterior papillary muscle, CHO: mitral valve chordae, LA: left atrium, LV: left ventricle, MR: mitral regurgitation, PM: papillary
muscle, PML: posterior mitral leaflet and PP: posterior papillary muscle.
W. Bouma et al.
Dr. Bollen/Dr.Shernan
2015
European Journal of Cardio-thoracic
Surgery 37 (2010)
Computer generated image (Q-labs, Philips Heathcare,Inc)
showing significant apical tethering of posterior and
anterior mitral valve leaflets with large tenting volume
Dr. Bollen/Dr.Shernan 2015
Fig. 1. The influence of CIMR on survival
after myocardial infarction.
(A) Survival depending on the presence or
absence of CIMR diagnosed after MI.
(B) Survival depending on CIMR severity
expressed as the effective regurgitant
orifice area (ERO) diagnosed after MI.
Numbers at the bottom indicate patients
at risk for each interval. Reproduced with
permission from Grigioni et al.
Copyright 2001, American Heart Association Inc.
W. Bouma et al.
European Journal of Cardio-thoracic
Surgery 37 (2010)2015
Dr. Bollen/Dr.Shernan
Fig. 4. Survival after surgery for CIMR. (A)
Propensity-matched survival after CABG alone
and after CABG and restrictive mitral valve
annuloplasty (MVA) for grade 3+ or 4+ CIMR.
After 10 years survival is similar. Modified and
reproduced with permission from Mihaljevic et
al. Copyright 2007, the American College of
Cardiology Foundation.
(B) Survival for propensity-matched quintiles of
patients after mitral valve repair (predominately
MVA) and mitral valve replacement for CIMR.
Quintile I represents the most severely ill
patients. Survival is similar after repair or
replacement.
(C) Quintiles III through V represent
progressively better risk patients, and they derive
a survival benefit from mitral valve repair
(predominately MVA). Reproduced with
permission from Gillinov et al. Copyright 2006,
Springer Science and Business Media LLC.
Original copyright 2001, the American
Association for Thoracic Surgery.
W. Bouma et al.
European Journal of Cardio-thoracic
Surgery 37 (2010)
Dr. Bollen/Dr.Shernan
2015
Fig. 5. Persistence and recurrence of CIMR after restrictive mitral annuloplasty.
Postoperative prevalence of CIMR grades 3+ or 4+. Dashed lines are 68% confidence
limits of average prevalence. Reproduced with permission from McGee et al.
Copyright 2004, the American Association for Thoracic Surgery.
W. Bouma et al.
European Journal of Cardio-thoracicDr.
Surgery
37 (2010) 2015
Bollen/Dr.Shernan

Echocardiographic predictors of restrictive
mitral annuloplasty failure secondary MR
have been proposed.

Slides 13 and 14 from W. Bouma et al.
European Journal of Cardio-thoracic
Surgery 37 (2010) 170—185

Slides 15 and 16 from Silbiger et al.
Journal of the American Society of
Echocardiography Vol. 24 No. 7
Dr. Bollen/Dr.Shernan 2015
Images referencing Table 1, slide 14
W. Bouma et al.
Dr. Bollen/Dr.Shernan
2015
European Journal of Cardio-thoracic Surgery
37 (2010) 170—185
Independent preoperative echocardigraphic
predictors of restrictive mitral annuloplasty failure.
Table1.
W. Bouma et al.
Dr. Bollen/Dr.Shernan
2015
European Journal of Cardio-thoracic Surgery
37 (2010) 170—185
Images referencing Table 1, slide 16
Figure 9 Leaflet deformation indices. (A) Parasternal long-axis view. The tenting area is outlined in green. The tenting height (red
arrow)extends from the annulus to the coaptation point. (B) Apical four-chamber view demonstrating leaflet angles. The proximal
anteriorleaflet angle is formed by the intersection of the annulus (dashed line) and the anterior leaflet bending distance. The distalanterior
leaflet angle is formed by the intersection of the annulus and the anterior leaflet tip distance. The posterior leaflet angle isformed by the
intersection of the annulus and the posterior leaflet length. The green dot represents the point of leaflet coaptation.LA, Left atrium; LV, left
ventricle. Reproduced with permission from Am J Cardiol. 56
Dr. Bollen/Dr.Shernan 2015
Echocardiographic predictors of
persistent and/or recurrent MR
Table 1.
Silbiger et al.
Journal of the American Society of Echocardiography
Vol. 24 No.
Dr. Bollen/Dr.Shernan
20157

Mitral Valve pathology in secondary
MR presents in a complex and variable
anatomic and dynamic
annular/leaflet/chordal/LV presentation.
Dr. Bollen/Dr.Shernan 2015
Anatomic 3-dimensional images of mitral annulus and leaflets created to observe actual
configuration of annulus and leaflets with surface coloration. Inferior (left) and anterior
(right) myocardial infarction. Tenting of mitral leaflets, which were tethered into left
ventricle (LV), were seen in both groups of patients with ischemic mitral regurgitation.
For patients with anterior infarction, mitral valve leaflets are widely tethered and bulged
toward LV, in contrast with patients with inferior infarction showing localized tenting of
leaflet with less bulging. L, Lateral; LA, left atrium; M, medial; A, anterior; P, posterior.
Watanbe et al
JASE 2006;19:71-75
Dr. Bollen/Dr.Shernan 2015
Secondary MR:3D and Coaptationtenting height and area

3D DICOM images can be sliced with i-slice
or other methods to define the mitral leaflet
coaptation tenting height and area at
different AP slice locations form AL to PM
side of the annulus.

Help to define where the annular and leaflet
tethering occurs.

This was shown nicely by Saito et al.
Dr. Bollen/Dr.Shernan 2015
Saito et al.
Dr. Bollen/Dr.Shernan
2015
JACC: Cardiovascular Imaging
Vol. 5, No. 4, 2012
Figure 4. MV Apparatus Geometry
MV apparatus geometry in the onset of mitral leaflet closure (left) and the timing of maximum
closure of mitral leaflet (right). The 3-dimensional tenting closed leaflet area does not include
coapted leaflet area in this study. Abbreviations as in Figure 1.
Saito et al.
Dr. Bollen/Dr.Shernan
2015
JACC: Cardiovascular Imaging
Vol. 5, No. 4, 2012
Gorman, Cheung et al showed nicely,
using 3D echo, the variation of
regional mitral annular dysfunction in
patients with ischemic mitral
regurgitation.
 See next two slides.

Dr. Bollen/Dr.Shernan 2015
Dr. Bollen/Dr.Shernan 2015
Vergnat et al.
Ann Thorac SurgDr.
2011;91:157-64
Bollen/Dr.Shernan 2015
Philips 3DQ Advances
Can be used to help define the
segmental wall motion abnormalities
influencing leaflet tethering
 Regional wall motion varies based
upon anterior, inferior lateral or
combined ischemia.
 Wall motion changes affect motion
influencing mitral valve closure
causing tethering.

Dr. Bollen/Dr.Shernan 2015
Chinitz et al.
JACC: Cardiovascular Imaging Vol.
6, No. 4, 2012 2015
Dr. Bollen/Dr.Shernan
Chinitz et al.
Dr. Bollen/Dr.Shernan
2015
JACC: Cardiovascular Imaging
Vol. 6, No. 4, 2012
Secondary MR: Role of abnormal longitudinal
and circumferential LV contraction

Classic LV wall motion assessment has looked at LV
radial contraction.

Keep in mind that as the normal LV contracts, the LV
muscle contraction causes circumferential and
longitudinal shortening influencing normal MV closure

Abnormal LV contraction from ischemia or
cardiomyopathy contributes to abnormal motion and
flow affecting mitral valve closure.

Next 2 slides give idea of normal LV circumferential
and longitudinal contraction (MRI studies)

2D and 3D strain studies of LV contraction are
providing new insights into abnormal LV function on
MV closure.
Dr. Bollen/Dr.Shernan 2015
Codreanu et al.
Dr. Bollen/Dr.Shernan 2015
Journal of Cardiovascular Magnetic
Resonance 2010
Codreanu et al.
Dr.Resonance
Bollen/Dr.Shernan
Journal of Cardiovascular Magnetic
2010 2015
Dr. Bollen/Dr.Shernan 2015
Ischemic MR
Treat for symptoms (in severe MR)
not to increase lifespan
 Mycocardial viability, degree of LV
dysfunction is key to long term success
 Some echocardiographic predictors
 Move by some to replace not repair in
patient
 Mitral clip in future?

Dr. Bollen/Dr.Shernan 2015