Echocardiographic evaluation of

mitral regurgitation
S.R.Sruthi Meenaxshi MBBS,MD,PDF
 Causes of mitral regurgitation
• Mitral valve prolapse(myxomatous prolapse)
• Rheumatic heart disease
• Infective endocarditis
• Post MI papillary muscle rupture
• Connective tissue disorder - Marfans, Ehler Danlos
syndrome , Pseudoxanthoma elasticum
• SLE,Scleroderma
• Dilated cardiomyopathy
• HOCM
 Indications of echocardiography in MR
• Diagnosis and evaluation of the etiology/mechanism
of MR
• • Asessment of hemodynamic severity, including
impact on ventricular size, function, and
hemodynamics
• • Initial assessment and re-evaluation of
asymptomatic and symptomatic patients with MR
• • Assessment of effects of medical and surgical
therapies in MR, including mitral valve repair or
replacement
Mitral valve
CARPENTIER CLASSIFICATION
 Mitral valve prolapse
• Classic MVP exists when there is exaggerated (>2
mm) superior displacement (“buckling” or
“hammocking”) of thickened mitral leaflets (>5 mm
thick in diastole) beyond the plane of the mitral
annulus during late systole.

• One of the most common reasons for MVP is fibro

myxomatous degeneration of the mitral valve, which
can lead to leaflet prolapse, chordal rupture, or partial
flail of a segment of one or both leaflets
Thickened myxomatous mitral leaflet more
than 5 mm suggest MVP
Mitral valve prolapse
 M MODE
• M MODE – PSAX VIEW
MVP shows posterior
displacement of C-D
segment in mid and late
systole
 DOPPLER METHODS IN GRADING MR
SEVERITY
• MR jet area
• Vena contracta width
• EROA by PISA METHOD
• Systolic flow reversal of pulmonary veins
Determination of severity
 Coanda effect
• Larger color jet areas indicate more severe MR
when the jet is centrally directed, but can be
misleading with eccentrically directed jets.
• Hugging or entertainment (Coanda effect) of
the eccentric jet to the LA wall results in
smaller jet areas even when MR is severe.
COLOR FLOW JET AREAS
WRAP AROUND EFFECT IN SEVERE MR
 VENA CONTRACTA WIDTH
• The vena contracta is the narrow neck of
the MR jet as it traverses the regurgitant
orifice
• Semi quantitative method of assessment
of severity of MR
• Assessed in 2 chamber and 4 chamber
view
VC WIDTH
 PROXIMAL FLOW CONVERGENCE AND
PROXIMAL ISOVELOCITY SURFACE AREA

• This method can be used for estimating the area ofthe regurgitant orifice—
• As regurgitant blood converges toward the regurgitant orifice at the proximal
convergence zone, the size and velocity of the innermost shell or hemisphere can
be measured
• Furthermore, according to the continuity principle the amount of fluid that passes
through the regurgitant orifice is the same as amount that flows in the regurgitant
jet (the law of conservation of mass).
• Therefore, total flow at the proximal isovelocity surface area (PISA) will equal
total flow in the distal MR jet.
 EROA BY PISA METHOD
• Apical 4 chamber is used
• The velocity at which blue
red colour shift occurs
identify the PISA shell
• The pisa radius (R) is then
measured and multiplied
by PISA velocity ie aliasing
velocity to give regurgitant
flow rate.
PISA METHOD
Calculation of regurgitant volume
 CW DOPPLER IN MR
• Peak MR jet velocities by continuous-
wave (CW) Doppler typically range
between 4 and 6 m/s—a reflection of
the systolic pressure gradient between
LV and LA.
Notching cw envelope in severe MR
 Systolic flow reversal in pulmonary artery
• The presence and the degree of
reversal of blood flow from the LA
into the pulmonary veins can indicate
• the hemodynamic impact of the MR
jet.
• Visualization of flow reversal into
one or more pulmonary veins on
colour flow Doppler.
PW in upper pulmonary artery produces a
negative S wave
PW at mitral valve produces a E dominance

• E dominance of more
than 1.2m/s , marked
early diastolic flow
Typical of in severe MR
 Structural parameters
• left atrial size
• LV size
• appearance of the mitral apparatus.
LA SIZE
• LA will dilate in response to chronic volume
and pressure overload
• Acute onset MR due to papillary muscle
rupture can produce LA dilatation
• Increased LA diameter and systolic flow
reversal of pulmonary veins may be only
echocardiographic diagnosis in severe MR
 Left ventricular performance
• Acute MR phase
• Chronic compensated MR
• Chronic decompensated MR
 Index of severity
Color Doppler regurgitant jet width and penetration
Color Doppler proximal isovelocity surface area
diameter
Continuous wave Doppler characteristics of the
regurgitant jet
Tricuspid regurgitant jet-derived pulmonary artery
pressure by continuous wave Doppler
Pulse wave Doppler pulmonary venous flow pattern
Left atrial size by 2D echocardiography
 Quantitative measurements in mitral
regurgitation
• Using the PISA method and various volumetric
methods,
• quantitative measures
• regurgitant volume,
• regurgitant fraction
• effective regurgitation orifice area (EROA) can
be calculated 
Quantitative parameters
THANKYOU