valve cases london - bcs.com · ©2013 mfmer | slide-12 case •lives at 8500 ft elevation •no...

Challenging Cases in Valve Diseases II

CCU 2013

Grace Lin, MD

Consultant, Cardiovascular Diseases

Director, Heart Failure Program

Mayo Clinic, Rochester MN

©2013 MFMER | slide-2

CASE

•55 year old male with heart murmur since childhood

•Mitral valve prolapse diagnosed by echo 9 years ago

•Lives in Colorado, skis at altitude 11,000 ft to 8500 ft

•Cycles 20-30 miles 2-3 weekly


CASE

•Notes↓ exercise tolerance for 6 months

•No dyspnea or chest pain with usual activity

•No fevers, persisted in using SBE prophylaxis

•Self referred for evaluation


CASE

•Exam: •BP 110/80 mmHg, HR 51 bpm • JVP normal •CV: RRR, mid-systolic click,

systolic murmur •Lungs: Clear •Ext: No edema


CASE

•ECHO •Mildly enlarged left ventricle

Ejection fraction 68% (volumetric) •Normal RV •Estimated RVSP 30 mmHg •MVP with mitral regurgitation


ECHO


What would you recommend now?

Refer to surgery

Quantify the MR

Assess his symptoms

Reassurance

TEE


CASE

• Surgeon reviews echo images

• Not convinced of severity of mitral regurgitation

• “Could be only moderate”

• “He’s not that symptomatic”

• Requests further imaging


CASE

• Lives at 8500 ft elevation

• No symptoms with exercise at this altitude

• Mildly dyspneic when running up the mountain…

• Cardiopulmonary exercise test

• Remember- this is not a Bruce protocol

• 11 minutes, 8 METS

• Peak VO2 28.2 ml/kg/min (84% predicted)

• Borderline-Average pVO2

• RER 1.1- good effort


Doppler Quantification of MR

European Association of Echocardiography recommendations • Color flow area is not recommended

for quantification of MR • Quantification is recommended if >

mild central MR • PISA • Vena contracta

Lancellotti Eur J Echo 2010


Proximal Isovelocity Surface Area Method

Flow Convergence and Conservation of Mass


• Blood accelerates towards a hole

• Forms waves of increasing velocities

• Same velocity for surface of each wave

• “Isovelocity shells”

Hydrodynamic principle

V = 20 cm/sec

V = 40 cm/sec

V = 60 cm/sec


Flow Rate at PISA= PISA x Valiasing

V = 20 cm/s

V = 40 cm/s

V = 60 cm/s

60 cm/s

20 cm/s


Conservation of mass

Flow rate at PISA

(PISA x Valiasing)

Flow rate at regurgitant

orifice

(ERO x VMR)

=

PISA

Effective regurgitant orifice


PISA calculation

ERO = 2π x R2 x (Valiasing / VMR)

RV = ERO x TVI MR


Valvular Regurgitation Severity

AR MR TR

ERO (cm2) 0.3 0.4 0.4

RVol (cm3) 60 60 45


Vena Contracta to estimate ERO

•PISA less accurate for eccentric jets

•Vena contracta is less affected by eccentricity

•VC ≥ 7𝑚𝑚 =𝑠𝑒𝑣𝑒𝑟𝑒 𝑀𝑅


CASE Aliasing Velocity

49cm/sec

r = 1.03 cm

CW Doppler Velocity

V = 527 cm/sec

ERO = 2π x 1.02 x 49/527 cm/s) ERO = 0.58 cm2


CASE CW Doppler

Holosystolic MR

CW Doppler

Mid-systolic MR

VTI = 131 cm

Only trace what you see- not where you think the MR should be…..


CASE

CW Doppler

VTI = 131 cm

RV = 0.58 cm2 x 131 cm = 76 cc Severe MR, ERO 0.58 cm2, RV 76 cc


TEE

• European Association of Echocardiography recommendations • TTE is recommended for first line

analysis • TEE if TTE is non-diagnostic or further

diagnostic refinement is needed • TEE (except for intra-op) is not

recommended if TTE is of good quality

Lancellotti Eur J Echo 2010


TEE

No flail segments- MR due to bileaflet mitral valve prolapse

LUPV

RUPV

PV systolic flow reversal


Case

•Cath •Normal coronary arteries

•Surgery •Myxomatous mitral changes, central jet •Very redundant PML, no ruptured

chordae • Triangular excision of middle scallop

PML • C shaped posterior annuloplasty ring


MVP: Summary

•Quantify mitral regurgitation •Don’t rely on color flow area •Worse outcomes in asymptomatic MR if

ERO ≥0.40 cm2

• Surgery is indicated for severe MR and: • Symptomatic •Asymptomatic with pulmonary

hypertension or LV dysfunction (dilatation)

Lancellotti Eur J Echo 2010, Vahanian Eur Heart J 2012


Case

•77 year old male executive

• Self referred for routine physical

•History of murmur; army physical

• Smokes 1 ppd, cigars

•Hypertension; HCTZ 25 mg daily

•Hyperlipidemia; Simvastatin 20 mg daily

•Runs 3 miles daily at 5 AM


Case

• Exam: • 130/82 mmHg, HR 67 bpm • JVP : normal • CV: Regular rhythm, 3/6 holosystolic

murmur at apex • Lungs: Clear •Abdomen: non-tender • Ext: No edema


Case

• Echo: •Normal LV size, EF 59% •Normal RV, RVSP 29 mmHg • Left atrial enlargement •MR: Eccentric, anteriorly directed jet • ERO 0.5 cm2, RV 56 cc • Cannot exclude flail leaflet • “PISA may be inaccurate due to eccentric

jet”


TEE Case 2


There is a flail segment. Which segment is flail?

Help! I need a 3D image!

Help I need a tutorial!

A1 P1

P3

Who cares??!! Let the surgeon sort it out


Case

• Surgeon reviews the case…..


Case

• “Which valve?”

• “A flail leaflet?”

• “Of course I’ll do it…..”

• “By the way….which scallop did you say is flail?”


Which scallop is flail?

STEP 1 Which leaflet?

STEP 2

Jet direction anterior

Jet direction posterior

Posterior

leaflet

Anterior

leaflet

Which scallop?


Which scallop is flail?

A1 and P1 closest to LAA

Left atrial appendage

Aorta

Posteromedial

Anterolateral


3D TEE Anterolateral

Posteromedial


Which scallop is flail? P1 P2 P3


• TEE: • Flail segment of posterior leaflet (Medial,

P3), PV systolic flow reversals • ERO 0.5 cm2, RV 58 cc, VC 7 mm

•Asymptomatic, flail mitral leaflet with severe MR, Normal LV size and EF

Would you recommend surgery or “watchful waiting”?

Case


Outcome of Medically Managed Flail MV Leaflet- Single Center

Ling: NEJM 335:1417, 1996

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10

Observed

Surv

ival

(%

)

No. at risk Observed 229 133 115 103 84 70 52 34 21 12 7

P=0.016

Years

Expected


Outcomes of Medically Managed Flail MV Leaflet-MIDA

•Multicenter registry- 6 centers

• Severe MR due to flail leaflet without surgical indications: •Asymptomatic • LVESD ≥ 40 mm, EF ≥ 60%

•Rare- 1021 patients with severe MR over 25 yrs • 7 patients per year at each center

Suri JAMA 310:609, 2013


Outcome of Medically Managed Flail MV Leaflet-MIDA

No. at risk Medical management 575 477 296 126 42 Early surgery 446 412 203 41 10

0

20

40

60

80

100

0 5 10 15 20

Surv

ival

(%

)

Medical management

P


Case

• Surgical consult arranged

•Cath: • 80% mid LAD, 70% prox Cx, 90% prox RCA

• Surgery: •Mitral valve repair • Triangular resection of PML and suture

repair of medial scallop • 3 vessel bypass


Flail MV- Summary

•Outcomes may be improved with early surgery • Consider risk of surgery • Likelihood of repair vs replacement

valve cases london - bcs.com · ©2013 mfmer | slide-12 case •lives at 8500 ft elevation •no...

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