Echo Assessment

Question 1

What is the “seagull” sign in ischaemic MR?

Answer 1

• Asymmetric tethering of amvl due to secondary chords
• Creates kink in amvl => poor coaptation
• Concave appearance of amvl

Question 2

Hypertrophic CM: Aetiology of MR and Mechanism of MR

Answer 2

• Aetiology: dynamic – hypertrophic obstructive cardiomyopathy
• Mechanism: abnormal – systolic anterior motion of amvl (Type IV)
• Note: the mechanism is important – MV repair is NOT indicated as the valve is not causing the MR

Question 3

What is the definition of mitral valve prolapse (MVP)?

Answer 3

• Primary cause of MR; Carpentier Type II (excessive leaflet motion)
• Abnormal systolic displacement of one or both leaflets into LA due to a disruption or elongation of leaflets, chordae or papillary muscles

Question 4

Label the MV scallops seen in PSAX?

Answer 4

• Top leaflet = A (anterior)
• Bottom leaflet = P (posterior)
• Left to right = lateral, middle, medial
• A3, A2, A1
• P3, P2, P1

Question 5

Which MV scallops are seen in PLAX?

Answer 5

A2 and P2

Question 6

Which MV scallops are seen in PSAX?

Answer 6

All scallops seen

Question 7

Which MV scallops are seen in AP4?

Answer 7

A3, A2 and P1

Question 8

Which MV scallops are seen in AP2?

Answer 8

P3, A2 and P1

Question 9

What is the echo criteria for MVP?

Answer 9

1. Billowing of MV leaflets ≥ 2mm above annular plane in long-axis views
2. “Hammocking” of the MV

(PLAX or AP3; diagnosis should be made on long axis views unless severe)

Question 10

What are the common causes of MVP?

Answer 10

1. Barlow’s disease
2. Fibroelastic deficiency (FED)
3. Mitral annular disjunction (MAD)

Question 11

Barlow’s MVP: Leaflets

Answer 11

• Bulky and billowing
• Cul-de-sac at base of posterior leaflet
• Floppy redundant valve, excessive leaflet tissue
• Fused and matted chords

Question 12

Barlow’s MVP: Prolapse segments

Answer 12

• Multi-segment prolapse

- Bileaflet MVP common

Question 13

Barlow’s MVP: Non-prolapse segments

Answer 13

• Billowing of body of both leaflets including non-prolapsing segments

Question 14

Barlow’s MVP: Annulus

Answer 14

• Always dilated

- Calcification common

Question 15

Barlow’s MVP: Chordal rupture

Answer 15

Uncommon

Question 16

Barlow’s MVP: Patient age

Answer 16

Younger (<60 yrs)

Question 17

FED: Leaflets

Answer 17

• Thin, prolapsing segment may appear bulky
• Thin, almost transparent leaflets
• Chordal thinning, elongation and rupture

Question 18

FED: Prolapse segments

Answer 18

Single segment prolapse (P2 most common)

Question 19

FED: Non-prolapse segments

Answer 19

No billowing of non-prolapsing segments

Question 20

FED: Annulus

Answer 20

Variably dilated (less than Barlow’s)

Question 21

FED: Chordal rupture

Answer 21

Common

Question 22

FED: Patient age

Answer 22

Older (> 60yrs)

Question 23

Barlow’s MVP: Aetiology and Mechanism of MR

Answer 23

Aetiology: primary degenerative MV
Mechanism: abnormal leaflet motion - excessive motion/prolapse (Type II)

Question 24

FED: Aetiology and Mechanism of MR

Answer 24

Aetiology: primary degenerative MV
Mechanism: abnormal leaflet motion - excessive motion/prolapse (Type II)

Question 25

MR Jet Direction in Anterior MVP?

Answer 25

- Posterior MR jet

Question 26

MR Jet Direction in Posterior MVP?

Answer 26

- Anterior MR jet

Question 27

MR Jet Direction in Bileaflet MVP?

Answer 27

- Central MR jet

Question 28

What is mitral annular disjunction (MAD)?

Answer 28

Atrial displacement of hingepoint of MV from ventricular myocardium

Question 29

MAD: Leaflets

Answer 29

- Hypermobility of MV apparatus with systolic curling - Separation between LA-MV junction and LV attachment - Paradoxical systolic ↑ in annulus diameter (systolic diameter > diastolic diameter)

Question 30

MAD: DTI Lateral Annulus

Answer 30

"Pickelhaube" (spike) sign (s' > 16cm/s)

Question 31

MAD: Patient Age/Symptoms

Answer 31

- 30-40yrs | - Present with palpitations

Question 32

MAD: Importance

Answer 32

- Linked with ventricular arrhythmias and sudden cardiac death

Question 33

What is the "Pickelhaube" Sign?

Answer 33

- Seen in MAD - Tugging of PM pap. muscle in mid-systole by prolapsing leaflets - Causes adjacent LV wall to be pulled sharply toward LV apex (s' spike) - Optimal location of highest velocity is from APLAX/AP3 at posterolateral annulus

Question 34

LA Size in Severe (usually primary) Chronic MR

Answer 34

- LA dilatation due to chronic LA volume overload - Normal LA size virtually excludes severe chronic MR - LA dilatation occurs in other disease states therefore LA dilatation does not imply severe MR

Question 35

LV Size in Primary MR

Answer 35

LV dilatation occurs due to chronic LV volume overload

Question 36

LV Size in Secondary/Functional MR

Answer 36

- MR due to LV dysfunction - MR further contributes to ↑ LV size - Progressive LV systolic dysfunction and adverse remodelling => ↑ MR severity - Degree of LV dilatation not reflective of MR severity

Question 37

Pathophysiology of PHTN in MR

Answer 37

- Post-capillary PHTN - Chronic severe MR => compensatory (LV and) LA dilatation => (LV systolic and diastolic dysfunction) => reduced LA compliance and ↑ LAP - Backward transmission of ↑ LAP can cause secondary PHTN

Question 38

Surgical Indications for Severe Primary MR

Answer 38

Surgery should be considered in: - Asymptomatic patients with preserved LV function (LVESD <40mm and LVEF >60%) and AF secondary to MR or PHTN (systolic pulmonary pressure at rest > 50mmHg)