Echo Case: How Much Mitral Regurgitation Is There?

Ronald H Wharton, MD

Disclosures

April 12, 2017

This feature requires the newest version of Flash. You can download it here.

Ronald H Wharton, MD: Greetings. This is Dr Ronald Wharton. I am a cardiologist at Montefiore Medical Center and Assistant Professor of Medicine at the Albert Einstein College of Medicine in Bronx, New York.

This is a recent case from our echo lab. I titled it: How Much Mitral Regurgitation Is There?

A 48-year-old woman comes to the emergency room. She was told by an outpatient cardiologist that she has severe mitral regurgitation. In fact, she has been told this for years. I think it made her so anxious that she came to the ER complaining of palpitations. She shows the ER doctors a copy of an echo report from a different hospital that says she has severe mitral regurgitation. She gets admitted. We obtain our own echocardiogram.

You can see it in this parasternal long axis view with color. Take a look at it for a second.

In this slide, you can see the apical 4-chamber view. Take a look at that.

We can now ask, what do you think?

Let us take another look, this time more closely. Here is that same parasternal long axis without color. Look at that for a second. Also note the scale.

In the next slide, you can see the same apical 4-chamber view. Here are a few other views you have not seen before.

In this slide you can see an apical 2-chamber view. I think you will agree the left ventricular (LV) function is normal.

Here you can see the apical long-axis, or apical 3-chamber, view. Not only is the LV function normal, but most of the chamber sizes look pretty normal, too.

This slide shows a pulsed-wave Doppler through the left ventricular outflow tract (LVOT). You will notice the peak velocity is about 80 cm/s.

What did we just see? The LV size is normal. You usually do not get that with chronic severe mitral regurgitation. The left atrial size is also normal. You usually do not get that with chronic severe mitral regurgitation. The flow through the left ventricular outflow tract is not in any way diminished or it does not appear to be. You should not see that with severe mitral regurgitation, either.

What is going on? Why do we see that color jet, which looks like there is a lot of MR, yet we have all these 2D findings that would speak contrary to that?

Here you can see a pulsed-wave Doppler through the right superior pulmonary vein. Take a close look at it. You will notice that all the flows are antegrade. With severe mitral regurgitation, often you will get systolic flow reversal. We do not have any of that here.

How do we interpret all of this? All the flows antegrade do not look like MR. What is going on?

In the next slide, you can see what might be happening. Notice that the rhythm is sinus but the PR interval is 344 ms.

Let us take another look at the MR jet with spectral Doppler and color M-mode. Here is the spectral Doppler. You will notice that the MR jet during systole is not particularly dense. It is confined to the beginning systole, maybe a tiny bit of MR at the very end of systole in the isovolumetric relaxation period. The densest part of the MR jet is not in systole at all, it is all in diastole.

If you look at the color M-mode, which you can see in this image, you will notice that all of the turbulent flow going away from the transducer and the apical 4-chamber view is in the presystolic period.

What is going on? The PR interval is 344 ms. That allows ample time for left atrial relaxation to occur before the onset of LV systole.

Let us take another look in the next slide at the pulsed-wave Doppler of the right superior pulmonary vein.

S1 is supposed to be systolic flow; S1 is actually occurring in diastole. Why? Because S1 happens because of left atrial relaxation. The PR interval is so long that S1 is actually occurring in diastole. The first signal in systole in this Doppler tracing is actually S2 from the descent of the mitral annulus during systole and then the diastolic flow that happens thereafter. It's not often that you see S1 in diastole, but here it is.

All of this was diastolic mitral regurgitation. This can happen anytime you have prolonged AV conduction because of atrial relaxation, which is not accompanied by left ventricular systole. You can see it in atrial flutter in between the systoles and any time the LV diastolic pressure is very high such that it exceeds LA pressure, as occurs with restrictive filling, amyloid, or severe acute aortic regurgitation.

As for our patient, she was reassured that she has virtually no significant mitral regurgitation and told not to worry. I thought you would enjoy this. Always look at timing and when you look at jets and you say, Jesus, it looks severe but the 2D images just do not corroborate what you would expect to see.

This is Ronald Wharton from Montefiore Medical Center, Bronx, New York for theheart.org on Medscape Cardiology. I hope you found that fun. Take care.

Editor's Recommendations

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....