『The Mitral Valve, Part 2: Grading Regurgitation and Stenosis』のカバーアート

The Mitral Valve, Part 2: Grading Regurgitation and Stenosis

The Mitral Valve, Part 2: Grading Regurgitation and Stenosis

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概要
 A patient comes for coronary bypass. Last month's echo called the mitral regurgitation severe. After induction, it looks moderate. The surgeon asks: "Do I need to touch the valve?" This is part two of two on the mitral valve on transoesophageal echo, following the mitral valve chapter of the fourth edition of Practical Perioperative Transoesophageal Echocardiography. It's all about severity — and the rule that runs through it: never trust one number. For regurgitation, we start with why general anaesthesia can make it look a whole grade better, and how to restore awake loading before you grade. Then the clues from the rest of the heart, including why a "normal" ejection fraction in severe regurgitation isn't normal. Then each method in turn: colour jet area and why wall-hugging jets are severe until proven otherwise; vena contracta width and three-D vena contracta area; PISA, the effective regurgitant orifice area and regurgitant volume, the radius-squared-over-two shortcut and its pitfalls; and pulmonary vein flow, continuous-wave density and the E-wave. We cover timing within systole, slit-like orifices, and the long argument over thresholds for secondary regurgitation. For stenosis: rheumatic versus calcific disease, commissural fusion and the hockey stick, the left atrial appendage and spontaneous echo contrast; then mean gradient, valve area and the A-to-D staging, pressure half-time and what distorts it, and why 3D planimetry is the preferred method. We finish by writing the report the surgeon in the cold open actually needs. Chapters (00:00) Cold open — severe on the ward, moderate in theatre(00:50) Grading under anaesthesia(01:40) What the rest of the heart tells you(02:20) Colour jet area and wall-hugging jets(03:05) Vena contracta width(04:05) Vena contracta area in 3D(04:40) PISA, EROA and regurgitant volume(06:05) The PISA shortcut(06:45) PISA pitfalls(07:25) Pulmonary veins, CW density and the E-wave(08:25) Timing in systole and orifice shape(09:10) Secondary regurgitation and its thresholds(09:55) Mitral stenosis: causes(10:20) Recognising the rheumatic valve(11:20) Grading stenosis and A-to-D staging(12:15) Mean gradient(12:30) Pressure half-time(13:35) Planimetry in 3D(14:00) PISA and continuity in stenosis(14:25) Writing the report Key takeaways General anaesthesia can make MR look a whole grade less severe — grade awake if possible, or restore awake loading firstUse several methods together: flow convergence, vena contracta, jet size and downstream effectsIn severe MR the EF should be supranormal; a "normal" EF may hide dysfunction — report it "in the presence of severe MR"Jet area under 20% of the LA suggests mild and over 40% severe, but it's unreliable — and wall-hugging jets are severe until proven otherwiseVena contracta width in the mid-oesophageal long axis: under 3 mm mild, 7 mm or more severe; not valid with multiple jets3D vena contracta area makes no assumption about orifice shape and can sum multiple jetsPISA: EROA = 2πr² × Nyquist ÷ peak MR velocity; EROA under 0.2 cm² mild, over 0.4 cm² (regurgitant volume ≥60 mL) severeShortcut: at a Nyquist of 40 cm/s and a 5 m/s jet, EROA ≈ r²/2 — a radius of 1 cm or more suggests severe (not valid with a poor LV)Systolic flow reversal in two or more pulmonary veins is specific for severe MR; an A-dominant mitral inflow argues against itSecondary MR is load-dependent, often slit-like and underestimated — the best time to grade it is preoperatively, awakeRheumatic MS: commissural fusion, thickened tips, chordal involvement and diastolic doming; check the LA appendage for thrombusMS severity: mild >2.5 cm² and mean gradient <5 mmHg; moderate 1.6–2.5 cm² and 5–9 mmHg; severe <1.5 cm² and >10 mmHg — report the heart ratePressure half-time: MVA ≈ 220 ÷ PHT; distorted by anything that changes LV filling, and unreliable straight after repair or valvotomy3D planimetry at the leaflet tips is the preferred way to measure mitral valve area References / further reading The mitral valve (Chapter 8). In: Lambert AS, Allen SJ, Sidhu S, eds. Practical Perioperative Transoesophageal Echocardiography, 4th edn. Oxford: Oxford University Press, 2025. ISBN 9780198873686Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation. J Am Soc Echocardiogr 2017; 30: 303–71Pandian NG, Kim JK, Arias-Godinez JA, et al. Recommendations for the use of echocardiography in the evaluation of rheumatic heart disease: a report from the American Society of Echocardiography. J Am Soc Echocardiogr 2023; 36: 3–28Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation 2021; 143: e72–e227Grayburn PA, Chandrashekhar YS. Functional mitral regurgitation: more questions than answers. JACC Cardiovasc Imaging 2021; 14: 711–14 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @...
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