1. No category

CLINICAL CHALLENGES
QUANTIFYING MITRAL REGURGITATION (MR)
WHY STRESS ECHO MATTERS
MR is dynamic
Mitral regurgitation is a dynamic disease; therefore, its evaluation only under
resting conditions may underestimate its full severity and its clinical effects.1
Prognostic value
Dynamic increase in MR during exercise is of diagnostic and prognostic value.1
Better assessment
Stress echo can provide a better assessment of MR severity and can help
correlate symptoms with degree of cardiac involvement in patients with heart
failure and ischemic functional MR.1-3
Rest
ERO 19 mm2
1.00
Exercise
ERO 41 mm2
Survival
0.75
ERO diff
0.50
< 13 mm2
0.25
≥ 13 mm2
p < 0.0001
0.00
0
End-systolic stop frame images and
proximal flow-convergence region at rest
and during exercise. Under stress, the
severity of MR increases greatly.2
20
Months
40
60
Survival curves according to the
difference in ERO (effective regurgitant
orifice) between rest and exercise.3
KNOWMOREMR.com
CLINICAL CHALLENGES
QUANTIFYING MITRAL REGURGITATION (MR)
ECHOCARDIOGRAPHIC CRITERIA FOR THE DEFINITION OF SEVERE VALVE REGURGITATION4
Qualitative
Valve morphology
Flail leaflet/ruptured papillary muscle/large
coaptation defect
Colour flow regurgitant jet
Very large central jet or eccentric jet adhering,
swirling, and reaching the posterior wall
of the left atrium
CW signal of regurgitant jet
Dense/triangular
Other
Large flow convergence zonea
Semiquantitative
Vena contracta width (mm)
≥ 7 (> 8 for biplane)b
Upstream vein flowc
Systolic pulmonary vein flow reversal
Inflow
E-wave dominant ≥ 1.5 m/sd
Other
TVI mitral/TVI aortic > 1.4
Quantitative
Primary
Secondary e
EROA (mm2)
≥ 40
≥ 20
R Vol (ml/beat)
≥ 60
≥ 30
+ enlargement of cardiac chambers/vessels
LV, LA
Evaluation of MR under stress may help
optimise the timing for intervention5
CW = continuous wave; EDV = end-diastolic velocity; EROA = effective regurgitant orifice area; LA = left atrium; LV = left ventricle; PISA = proximal isovelocity surface
area; RA = right atrium; RV = right ventricle; R Vol = regurgitant volume; TR = tricuspid regurgitation; TVI = time-velocity integral.
At a Nyquist limit of 50-60 cm/s.
For average between apical four- and two-chamber views.
Unless other reasons for systolic blunting (atrial fibrillation, elevated atrial pressure).
d
In the absence of other causes of elevated left atrial pressure and of mitral stenosis.
e
Different thresholds are used in secondary MR where an EROA > 20 mm2 and regurgitant volume > 30 ml identify a subset of patients at increased risk of cardiac events.
a
b
c
1. Patrizio Lancellotti and Julien Magne, Stress testing for the evaluation of patients with mitral regurgitation, Curr Opin Cardiol 2012, 27:492–498.
2. Luc A Piérard, Patrizio Lancellotti, STRESS TESTING IN VALVE DISEASE, Heart 2007;93:766–772.
3. P atrizio Lancellotti, Paul L. Gérard, and Luc A. Piérard, Long-term outcome of patients with heart failure and dynamic functional mitral regurgitation, European Heart
Journal (2005) 26, 1528–1532.
4. Published on ESC website: http://www.escardio.org/guidelines-surveys/esc-guidelines/Pages/valvular-heart-disease.aspx.
5. R
Lee, B Haluska, D Y Leung, C Case, J Mundy, T H Marwick. Functional and prognostic
implications of left ventricular contractile reserve in patients with asymptomatic severe
mitral regurgitation, Heart 2005;91:1407–1412.
Abbott Vascular, 3200 Lakeside Dr., Santa Clara, CA 95054
©2015 Abbott. All rights reserved. AP2941082-OUS (04/2015)
KNOWMOREMR.com