Mitral Regurgitation Jet Research Articles

New Model for Non-Invasive Echocardiographic Assessment of Pulmonary-Capillary Wedge Pressure in Patients With Aortic and Mitral Regurgitation

The pulmonary-capillary wedge pressure (PCWP) is a central parameter of cardiac function. In this work, we propose an equation based on a simple physical model, which should be applicable to any class of patient, provided they present some level of aortic and mitral regurgitation. We modeled the left cardio-circulatory system as three chambers placed in a series as follows: left atrium (LA), left ventricle (LV), and aorta (A). Starting from the principle of energy conservation, knowing pressure gradient between A and LV (transaortic gradient) and between LV and LA (trans mitral gradient), we can measure blood pressure in A with a non-invasive central blood pressure (BP) analysis device and then we can derive pressure in LA. With the model described, we derive the equation PCWP ≈ {[(systolic central BP + 4 maximal aortic valve outflow velocity2) − 4 maximal mitral valve regurgitation jet velocity2] + [(diastolic central BP − 4 telediastolic aortic valve regurgitation jet velocity2) + mean mitral valve inflow gradient]} / 2. Herein, we propose a new model for PCWP determination using Doppler echocardiography and a non-invasive central blood pressure (BP) analysis device. One of the main advantages of the method we proposed is that, given it is based on a simple physical model instead of multilinear regression, it should be applicable to any class of patient, provided they present some level of aortic and mitral regurgitation. Further studies are needed for its validation by parallel analysis using invasive methods.

Understanding Non-P2 Mitral Regurgitation Using Real-Time Three-Dimensional Transesophageal Echocardiography: Characterization and Factors Leading to Underestimation

P2 prolapse is a common cause of degenerative mitral regurgitation (MR); echocardiographic characteristics of non-P2 prolapse are less known. Because of the eccentric nature of degenerative MR jets, the evaluation of MR severity is challenging. The aim of this study was to test the hypotheses that (1) the percentage of severe MR determined by transthoracic echocardiography (TTE) would be lower compared with that determined by transesophageal echocardiography (TEE) in patients with non-P2 prolapse and also in a subgroup with "horizontal MR" (a horizontal jet seen on TTE that hugs the leaflets without reaching the atrial wall, particularly found in non-P2 prolapse) and (2) the directions of MR jets between TTE and real-time (RT) three-dimensional (3D) TEE would be discordant. One hundred eighteen patients with moderate to severe and severe degenerative MR defined by TEE were studied. The percentage of severe MR between TTE and TEE was compared in P2 and non-P2 prolapse groups and in horizontal and nonhorizontal MR groups. Additionally, differences in the directions of the MR jets between TTE and RT 3D TEE were assessed. Eighty-six percent of patients had severe MR according to TEE. TTE underestimated severe MR in the non-P2 group (severe MR on TTE, 57%; severe MR on TEE, 85%; P<.001) but not in the P2 group (severe MR on TTE, 79%; severe MR on TEE, 91%; P=.157). Most "horizontal" MR jets were found in the non-P2 group (85%), and this subgroup showed even more underestimation of severe MR on TTE (TTE, 22%; TEE, 89%; P<.001). There was discordance in MR jet direction between two-dimensional TTE and RT 3D TEE in 41% of patients. Non-P2 and "horizontal" MR are significantly underestimated on TTE compared with TEE. There is substantial discordance in the direction of the MR jet between RT 3D TEE and TTE. Therefore, TEE should be considered when these subgroups of MR are observed on TTE.

Treatment of severe mitral regurgitation that mimics a para-ring mitral regurgitation after failed annuloplasty ring with MitraClip: A case report

BackgroundProgressive remodelling of the left ventricle with lateral and apical displacement of one or both papillary muscles can lead to recurrence of severe mitral regurgitation (MR) in the presence of the mitral valve (MV) ring. The MitraClip (Abbott, USA) is the only option in cases with annuloplasty rings too large for implantation of a Sapien prosthesis in high surgical-risk patients. We present a case where the MR jet was directed toward a para-ring hole, and the MitraClip system was used successfully to treat this severe MR.Case summaryAn 80-year-old woman underwent coronary artery bypass surgery plus MV repair with C-shaped ring 6 years ago. In the past year, she experienced severe shortness of breath; her ejection fraction dropped to 15%. A transesophageal echocardiogram revealed that severe MR started at the level of MV leaflets and then passed to the left atrium beside the MV ring. Live 3D showed the severe MR coming through the oval-shaped hole beside the C-shaped MV repair ring. MitraClip implantation was decided, the two leaflets were grasped successfully, the clip was fully closed, and only trace MR remained at the MV leaflets with no flow to the para-ring hole. The patient was extubated after 12 hours and discharged home after 2 days. Follow-up transthoracic echocardiography after 6 months showed the clip in place and trace residual MR.ConclusionImplantation of MitraClip in the presence of MV repair ring is feasible and safe. The para-ring defect can be left if the origin of MR from the MV coaptation line is treated successfully with MitraClip. Symptomatic improvement with no rehospitalization was documented in this case.

Mid-term effect of balloon aortic valvuloplasty on mitral regurgitation in aortic stenosis

BackgroundBalloon aortic valvuloplasty (BAV) offers an alternative to conventional aortic valve replacement in elderly and frail patients with severe aortic stenosis (AS) for whom there are no other effective options. We aimed to investigate the mid-term effect of BAV on mitral regurgitation (MR) in patients with severe AS.MethodsOur analysis was based on the data from 83 patients with severe AS (mean age, 86 ± 5 years; female, 68) treated using BAV. Echocardiography was performed before the procedure and at 1 and 3 months after. MR was quantified by measuring the MR jet area, with more-than-moderate MR being clinically significant.ResultsForty patients were classified in this group (MR group). Significant reduction of MR was observed in the MR group at 1 month and 3 months after procedure, with no improvement in patients in the non-MR group. At 3 months, 15 of the 40 patients in the MR group still had significant MR, with the change at 1 month in the left ventricular end-systolic dimension (OR: 1.36; 95% CI: 1.05–1.76; P = 0.022) and MR jet area (OR: 1.95; 95% CI: 1.16–3.29; P = 0.012) being predictive of persisting significant MR at 3 months after BAV. The prevalence of New York Heart Association functional class III or IV decreased at 1 and 3 months after BAV in both groups.ConclusionsBAV provides a useful therapeutic strategy for elderly patients with severe AS who are not candidates for surgical or transcatheter aortic valve replacement, especially in those with significant MR.

P1525 Residual functional mitral regurgitation post-MitraClip is associated with worse hemodynamics and predicts poor outcome at 2-year follow-up

Abstract Background Percutaneous mitral valve repair using MitraClip offers symptomatic benefit and improves rest and exercise hemodynamics in patients with severe functional mitral regurgitation (MR). Recent randomized trials have shown contradictory results regarding the impact of MitraClip on mid-term survival in functional MR. It is unknown whether improved hemodynamics are related to patients" outcome. Purpose To assess whether residual MR and altered resting and exercise hemodynamics are predictors of outcome in patients with functional MR treated with MitraClip. Methods Consecutive patients (n = 45, 72 ± 10years, left ventricular ejection fraction (LVEF) 34 ± 9%) with symptomatic severe functional MR were prospectively evaluated by Doppler echocardiography at rest and during symptom-limited exercise on a semi-supine bicycle pre- and 6 months post-MitraClip procedure. LVEF, MR severity, cardiac output (CO), systolic pulmonary artery pressure (SPAP) and a flow-corrected SPAP/CO ratio were assessed at rest and peak exercise. 2-year follow-up clinical data were collected from patient records. Results During 2-year follow-up post-MitraClip, 15 patients (33%) experienced major cardiac events (hospitalization for heart failure (n = 14) and/or cardiac death (n = 5)). Age, gender, a history of coronary artery disease, diabetes, baseline MR severity and baseline SPAP/CO ratio at rest and during exercise were not related to a worse event-free survival. In contrast, patients with events at 2-year follow up had more often a history of hospitalization for heart failure (73 vs. 37%, p = 0.029), lower baseline LVEF (30 ± 8 vs. 36 ± 10%, p = 0.041), more residual MR at 6 months post-MitraClip (MR jet area/left atrial area 27 ± 14 vs. 15 ± 10%, p = 0.004) and higher SPAP/CO ratios at rest and during exercise 6 months post-MitraClip (13.9 ± 5.3 vs. 9.9 ± 3.4mmHg/L/min, p = 0.007 and 13.6 ± 4.9 vs. 9.4 ± 4.6mmHg/L/min, p = 0.009, respectively). When corrected for baseline LVEF, residual MR 6 months post-MitraClip remained an independent predictor for worse 2-year outcome. Residual MR was moderately correlated to a worse SPAP/CO ratio 6 months post-MitraClip (Pearson Rho 0.518, p &amp;lt; 0.001). Conclusions In patients with functional MR treated with MitraClip, residual MR at 6-month follow-up is associated with impaired hemodynamics, and is an independent predictor of cardiac events at 2-year follow-up.

P271 Hypoplastic posterior mitral leaflet associated with Marfan syndrome

Abstract A sixty-two years old female presents with shortness of breath. She has Marfan syndrome (c.6448C &amp;gt; T mutation variant) with a previous history relevant for type A aortic dissection which was treated by Bentall procedure with a mechanical aortic prosthesis and ascending aorta prosthesis, coronary artery bypass graft on the right coronary artery and pacemaker for third degree AV block; subsequent aortic arch reconstruction and endovascular repair of the descending aorta for thoracic aorta aneurism rupture. Upon visit she is in NYHA class III, blood pressure of 145/85 mmHg and heart rate of 75 bpm. A systolic murmur with a prosthetic second tone was heard at heart auscultation and bilateral crackles were heard at pulmonary auscultation. Peripheral pulses were symmetrical. ECG showed sinus rhythm, right bundle branch block with left anterior hemiblock and left ventricular hypertrophy. Blood tests were within normal range. Chest X-ray showed bilateral pulmonary congestion. She underwent transesophageal echocardiography which showed severe mitral regurgitation (MR) with a normal bi-ventricular systolic function. Posterior mitral leaflet (PML) was severely hypoplastic especially at the level of P1 which was confirmed by CT (see picture). Diuretic therapy together with an ACE inhibitor was introduced with a decrease in MR severity. The patients was sent home with an indication for strict follow up visits. Congenital mitral valve defects are very rare and can be isolated or associated with other cardiac malformations. Limited data are available about hypoplastic posterior mitral leaflet (PML) including singular case reports or anecdotal descriptions, therefore its etiology, association with other cardiac or systemic syndromes and prognosis is not well understood. However, it is suggested that absence of PML has a high fetal or infant mortality due to severe mitral regurgitation (MR). The degree of MR varies among patients and in the same patient at different timepoints as it depends on anatomical variations of the anterior mitral leaflet, residual PML tissue, posterior ventricular wall conformation and other associated cardiac abnormalities. We showed a case of a patient with hypoplastic PML and advanced age with a concomitant history of Marfan syndrome. Picture legend (A) Mid-esophageal 4-chamber view shows severe hypoplasia of PML (red arrow) and the posterior ventricular myocardial shelf (green arrow). (B) Mid-esophageal commissural view shows a large central MR jet. (C) 3D ventricular perspective of the mitral valve: an almost complete absence of the PML can be appreciated in the central and lateral scallops (grey arrows). (D) CT 3 chamber view shows the myocardial shelf which takes the role of the posterior mitral annulus (blue arrow) and direct PML chordal insertion into the ventricular wall (yellow arrow). (E) CT reconstruction of the mitral valve shows a virtually absent P1 (&amp;lt; 1mm), a P2 length of 4.1 mm, and a P3 length of 5 mm. Abstract P271 Figure. Hypoplastic posterior mitral leaflet

P1577 Mitral regurgitant "splay": an important clue to severity of regurgitation

Abstract Background Visual assessment of mitral regurgitation (MR) severity by color Doppler can be difficult, especially in eccentric jets. Examination of the proximal flow acceleration signal (PISA) on the ventricular side of the mitral valve can be helpful but, is not always intuitive. We describe a color signal ("splay") on the atrial side of the valve that can often be helpful in recognizing significant MR. Methods Clinical echocardiograms were reviewed to obtain two data sets: 100 patients with reported mild MR and another 100 with reported severe MR. All echocardiograms were reviewed to confirm that MR was truly mild or severe. Splay was defined as a non-physiologic arc of color (figure) centered at the point where the MR jet emerges into the atrium. Results Splay was present in the large majority of severe MR cases (table). It was seen across 3 vendors’ machines and was present with normal and reduced EF as well as primary and secondary MR. Color scale and transducer frequency did not differ according to presence or absence of splay, but gain was higher when splay was present (57.5 ± 6.8 vs 55.2 ± 6.1, p = 0.04). In mild MR patients, splay was present on fewer frames and had lesser dimensions vs severe MR. Splay was particularly prevalent in patients with wall hugging jets (28/30, 93%). Conclusions The splay signal occurs as a side lobe artifact, at the point where a high energy MR jet emerges into the left atrium. Its presence often indicates significant MR and may be a useful clue in highly eccentric jets which are otherwise difficult to grade. Table 1 Mild MR Severe MR P value Splay Present (%) 18 82 &amp;lt;0.0001 No. of Frames 2 ± 1.6 3.6 ± 1.3 &amp;lt;0.0001 Width of Splay (cm) 2.2 ± 0.5 3.2 ± 0.9 &amp;lt;0.0001 Depth of Splay (cm) 0.36 ± 0.11 0.47 ± 0.16 0.01 Abstract P1577 Figure. Splay Image

Reverse Remodeling of the Mitral Valve Complex After Radiofrequency Catheter Ablation for Atrial Fibrillation: A Serial 3-Dimensional Echocardiographic Study.

Mitral regurgitation is frequently complicated with atrial fibrillation without apparent organic changes in the leaflet, which occasionally improves after successful radiofrequency catheter ablation. We aimed to evaluate a possible geometric effect of radiofrequency catheter ablation on the mitral valve apparatus. Forty-three consecutive patients who underwent successful catheter ablation for persistent atrial fibrillation (maintaining sinus rhythm for 6 months after their procedure) were examined by serial real-time 3-dimensional transesophageal echocardiography before and 6 months after catheter ablation. Mitral valve complex geometry was measured using dedicated software for 3-dimensional transesophageal echocardiography. Mitral valve apparatus showed significant reverse remodeling along with left atrial reverse remodeling 6 months after successful catheter ablation (50.5 [39.2-61.0] versus 36.4 [28.9-43.1] mL/m2; P<0.001). The degree of mitral regurgitation decreased in a majority of patients (mitral regurgitation jet area; 1.83 [0.78-3.09] versus 0.77 [0.36-1.47] cm2; P<0.001). Annular area significantly decreased (5.32±0.91 versus 4.73±0.76 cm2/m2; P<0.001) in both anterior-posterior and medial-lateral directions. Mitral annular contraction significantly recovered after maintaining sinus rhythm for 6 months (7.51 [4.82-9.62]% versus 9.71 [6.27-13.85]%; P=0.008). There were no significant changes in tenting volume or tenting height (0.46 [0.27-0.89] versus 0.51 [0.32-0.72] mL/m2, P=0.744; 2.34 [1.75-3.48] versus 2.76 [1.99-3.08] mm/m2, P=0.717). The leaflet surface area also significantly decreased after catheter ablation (5.74 [5.01-6.33] versus 5.19 [4.63-5.64] cm2/m2; P<0.001). Maintaining sinus rhythm after successful catheter ablation promotes reverse remodeling in the mitral valve apparatus and improves so-called atrial functional mitral regurgitation. The positive geometric effect of catheter ablation would be expected to be a possible contributor to better outcomes in patients with atrial fibrillation, in addition to the postprocedural freedom from rhythm disturbance.

P916The effect of a novel, user-friendly, transcatheter edge-to-edge mitral valve repair device in a porcine model of mitral regurgitation

Abstract Objective A new technique has been devised to treat mitral regurgitation (MR) through the transapical route by replicating the edge-to-edge repair surgery. This system encompasses an easy-to-use leaflet clamp and a smaller-sized delivery system (14F–16F). We aimed to evaluate the effectiveness of this device in a porcine model of acute MR. Methods Acute MR was induced in 36 anesthetized porcine subjects by severing the major chordae supporting the corresponding segment of the leaflet. This device was then transapically implanted on the prolapsing segment under 3D epicardial echocardiographic guidance. All of the animals were killed 30 days after the procedure to verify the proper location of the implanted devices. Results Cutting the major chordae induced an eccentric MR jet (MR grade: 3+, 27.8%/4+, 72.2%) in all of the animals. Every single pig was then successfully implanted with one clamp. The duration of catheterization ranged from 18 to 40 minutes. Overt MR reduction was observed following the procedure through echocardiography; residual MR was mild in 8 cases, trivial in 19 cases, and absent in 9 cases. In terms of hemodynamic parameters, the mean and maximum mitral valve pressure gradients were increased significantly (p&lt;0.01), but these values were less than 4 mmHg in all of the cases. Autopsy demonstrated that all but one device were precisely placed to clip the prolapsing segment of the mitral valve, and there was no evidence of thrombosis, thromboembolism or impairment of the cardiac structure. Table 1. Changes in hemodynamic parameters, cardiac size, and functional parameters after the procedure Preoperation Postoperation P value MR-maxA (mm2) 7.27±2.13 1.54±1.29 0.000 MVPG-max (mmHg) 1.95±0.47 3.66±0.62 0.000 MVPG-mean (mmHg) 0.87±0.31 1.7±0.28 0.000 LVEDD (mm) 46.08±2.85 46.44±3.53 0.239 LVESD (mm) 29.11±3.44 29.08±3.62 0.940 LVEF (%) 66.53±6.4 67.14±4.93 0.256 LAD (mm) 35.75±2.24 36.42±1.99 0.057 LAA (mm2) 12.95±2.22 12.64±1.55 0.301 Figure 1 Conclusions Transapical implantation of the novel mitral valve repair device is effective and safe in reducing acutely induced MR in pigs; thus, suggesting that it has great potential for clinical benefit in patients with MR. Acknowledgement/Funding Shanghai Science and Technology Committee

P4366Application of 3D-dual volume layout imaging for rapid intraprocedural guidance in Mitraclip procedure

Abstract Introduction Intraprocedural guidance and monitoring with transesophageal echocardiography (TEE) and invasive hemodynamic assessment are currently the best available options for evaluating procedural success of percutaneous mitral valve (MV) repair with Mitraclip System (Abbott Vascular, Santa Clara, CA, USA). However, despite its crucial importance, echocardiography has some limitations in immediate evaluation of residual jets after clip implantation, so that, in absence of validated method for double orifice effective regurgitant orifice (ERO) assessment, the most reliable parameter that is currently used is the mean trans-valvular gradient. Purpose This prospective study aimed to assess the role of a new echocardiographic parameter obtained from 3D-Color-Full volume imaging of MR for evaluation of outcomes of mitraclip procedures, comparing it with invasive LAP measurements. Material and methods We prospectively performed the computation of a new parameter in patients with symptomatic moderate-severe to severe primary or secondary mitral regurgitation (MR) underwent MitraClip procedure. This parameter is easy and fast to be obtained out of 3D dataset and represents the 2D area of the proximal isovelocity surface zone visualized from the ventricular view, without any imaging processing (“3D dual volume PISA area”) (figure). It was obtained as following: i) acquisition of 3D-zoomed-color image of MR jet with adequate frame rates; ii)displaying of the volume sampling in “dual volume layout” so one can see the “ventricular aspect” of the jet area corresponding to proximal isovelocity surface “zone”; iii) awareness of correct alignment to the direction of the flow in proximal zone; iiii) freezing and direct measurement of this area (summarize if more than 1 orifice) (1 attached). We compared the variation of this parameter from the beginning to end of procedure with the variation of LAP measurements, that is currently the most important parameter for assessing outcome of procedures. Results The study includes dataset of 11 patients. The baseline value of 3D dual volume PISA area was 1,191±0,40 cm2 and the mean change we obtained was 0,65±0,30 cm2 (mean of 77% of reduction until the end of procedure). Mean values of LAP were slightly decreased in all cases: basal m-LAP was 12±3,3 mmHg and decreased by 15%. Despite the small number of patients, we observed a significant correlation between the changes of LAP and the change of 3D dual volume PISA area (R: 0.6, p: 0,048). Conclusions This is the first demonstration of the usefulness of echocardiographic parameter obtained by 3Ddual volume layout imaging for rapid intraprocedural guidance in Mitraclip procedure. This parameter is related to hemodynamic variations that it currently considerable surrogate of outcomes. These data need to be confirmed by a larger study.

Mechanisms of recurrent regurgitation after transapical off-pump mitral valve repair with neochord implantation†.

The aim of this study was to describe possible mechanisms of recurrent mitral regurgitation (MR) in patients who have been treated with the NeoChord procedure. Patients presenting with recurrent severe or moderate MR were categorized as Not Expected Surgical-Like Result (NESLR)-Redo and NESLR-MR2 [NESLR reintervention or moderate MR (2+), respectively]. NESLR patients were stratified by onset (intraoperative, perioperative 24 h-30 days, or early 30 days to follow-up), by MR jet direction (central or eccentric) and by jet orientation (anterior or posterior). Specific mechanisms of NESLR were analysed. Fifty-two patients were identified with 13 (25%) categorized as NESLR-Redo, and 39 (75%) as NESLR-MR2. NESLR-Redo patient stratification included: intraoperative = 2 patients (1.2%), both eccentric anteriorly directed jets; perioperative = 7 patients (4.2%), all eccentric with 3 anteriorly and 4 posteriorly directed jets; and early = 4 patients (2.4%), 1 central, 3 eccentric, 2 posteriorly and 1 anteriorly directed jets. NESLR-MR2 patient stratification included: perioperative = 2 patients (5.1%), both eccentric, 1 anteriorly and 1 posteriorly directed jets; and early = 37 patients (94.9%), 4 central, 33 eccentric, 22 anteriorly and 11 posteriorly directed jets. Possible mechanisms of recurrent MR were identified as: patient selection (17.3%), technical issues (28.8%), progression of baseline disease (15.4%), left ventricle reverse remodelling (1.9%), excessive over-tensioning (35.8%) and PML curling (30.8%). The mechanisms of recurrent MR after the NeoChord procedure can be determined. Understanding recurrent MR mechanisms has led to improvements in procedural standardization and ad hoc prevention strategies that have been widely adopted since our initial clinical experience.

Three-Dimensional Echo and Three-Dimensional Transesophageal Echocardiography for Mitral Valve Disease

Three-dimensional (3D) echocardiography is one of the greatest technologies, which has a significant contribution in the field of valvular heart disease, especially after the development of real-time (RT) capability in transthoracic as well as transesophageal imaging during the past decade. RT 3D transesophageal echo has provided a simplified imaging tool for the anatomy of mitral valve (MV), including the MV annulus, leaflets, and subvalvular apparatus. Three scallops of anterior and posterior leaflets are easily recognized. This helps in localizing the MV abnormality, for example, MV prolapse and flail MV. This also helps in localizing the mitral regurgitation (MR). Even the quantification of MR has also seen a novel understanding of RT 3D planimetry of MR jet, which is possible by newer machines. Commissural inequality and calcification is well identified, and it helps in choosing the cases for percutaneous balloon mitral valvuloplasty. More recently, this technology with RT 3D transesophageal echocardiography has found a role in interventional procedure, for example, balloon mitral valvuloplasty, paravalvular leak closure, and edge-to-edge (MitraClip) repair of degenerative MV.

"RFEF" and mitral regurgitation jet direction: surrogate markers for likelihood of left ventricle reverse remodeling in patients with moderate chronic ischemic mitral regurgitation.

Surgical management of moderate chronic ischemic mitral regurgitation (CIMR) is controversial. We propose a simplified classification of moderate CIMR based on regurgitant fraction (RF), ejection fraction (EF), and jet direction (central/eccentric) to predict left ventricle (LV) remodeling and identify patient subsets which need mitral valve (MV) repair along with coronary artery bypass grafting (CABG). In this prospective controlled study (n = 210), patients with moderate CIMR were randomized. Group I (n = 106) underwent off-pump CABG alone while group II (n = 104) underwent CABG + MV repair. The product of regurgitation fraction and ejection fraction ("RFEF") was taken as a surrogate for myocardial reserve. The cut-off defined was 0.12; patients with RFEF ≤ 0.12 were categorized as the "bad" and those with RFEF > 0.12 as the "good" subset. The patients were further subdivided on the basis of their mitral regurgitation (MR) jet direction (central/eccentric). The percentage improvement in left ventricular end-systolic volume index (LVESVI) and MR grade were recorded 6monthly. Analysis of the continuous variable "RFEF" in conjunction with jet direction was performed. At 12months, the patient in good subset with central direction of jet showed improvement in LVESVI % in both groups (p = 0.428), while the patients in bad subset with eccentric direction of jet showed significantly higher improvement in LVESVI %, group II as compared to group I (p = 0.004). This study thus identifies "RFEF" as a surrogate for reverse remodeling capacity. In association with MR jet direction, predicts the subset of moderate CIMR patients most likely to have maximum LVESVI and MR grade reduction.

POINT-OF-CARE ULTRASOUND HELPED DIAGNOSE PERSISTENT RIGHT UPPER LOBE INFILTRATE FROM ECENTRIC JET OF MITRAL INSUFFICIENCY

SESSION TITLE: Critical Care 3 SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Approximately 0.2% of all cardiogenic pulmonary edema is unilateral and almost always associated with severe mitral regurgitation. It is often mistaken as focal lung disease like pneumonia, infarction or aspiration. It may lead to misdiagnosis and delay in management (1). Use of bedside echocardiography in diagnosis and management of critical illness is continuously evolving. Here we present a case of persistent right upper lobe infiltrate secondary to mitral valve insufficiency diagnosed with bedside focused echocardiography. CASE PRESENTATION: A 78-year-old woman with history of Heart failure (preserved ejection fraction), atrial fibrillation, severe chronic obstructive pulmonary disease and left upper lobe lung cancer status-post lobectomy presented with worsening dyspnea and respiratory failure. She was intubated in the emergency room for hypoxic and hypercapnic respiratory failure. She was treated for pneumonia of right upper lobe three weeks prior to this presentation. Her vital signs were BP156/78 mmHg, HR 120 bpm, Temp 99.0 F and saturation 96% of 60% FiO2. Respiratory exam was notable for rhonchi on right lung field and diffuse wheezes bilaterally. Chest x-ray showed persistent right upper lobe infiltrate. CT scan chest confirmed airspace opacity of the right upper lobe. Patient was started on intravenous antibiotics and IV steroids for presumed pneumonia and COPD exacerbation. Her infectious and cardiac work up remained negative. She remained on mechanical ventilation because of rapid shallow breathing. Bedside echocardiography was performed and showed eccentric jet of mitral regurgitation around posterior mitral leaflet occupying less than 40% of left atrial area consistent with mild to moderate mitral insufficiency. This finding was confirmed with transthoracic Echo. Patient had aggressive diuresis and after load reduction. Her rapid shallow breathing index improved and she came off mechanical ventilation and discharged later. DISCUSSION: Goal directed echocardiography helps integrate data and images to answer clinical question. It has been shown that bedside echocardiography performed by trained intensivist gives information promptly otherwise not accessible by physical exam alone(2). American college of chest physician competence in basic and advanced critical care echocardiography requires cognitive skills in recognition of clinical syndrome associated with acute massive valvular regurgitation and to answer whether valvulopathy is clinically relevant respectively(3).Our case is an excellent example demonstrating the advanced use of critical care echocardiography to diagnose a rare clinical presentation of mild to moderate mitral insufficiency causing right upper lobe infiltrate. CONCLUSIONS: Persistent right upper lobe infiltrate should prompt the use of bedside echocardiography looking for eccentric jet of posterior mitral leaflet. Reference #1: Attias, David, et al. "Prevalence, characteristics, and outcomes of patients presenting with cardiogenic unilateral pulmonary edema.” Circulation 122.11 (2010): 1109-111 Reference #2: Beaulieu, Yanick. "Specific skill set and goals of focused echocardiography for critical care clinicians.” Critical care medicine 35.5 (2007): S144-S149. Reference #3: Mayo, Paul H., et al. "American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography.” Chest 135.4 (2009): 1050-1060 DISCLOSURES: No relevant relationships by Mohammedumer Nagori, source=Web Response No relevant relationships by Muhammad Shafi, source=Web Response No relevant relationships by Ziad Shaman, source=Web Response No relevant relationships by Edward Warren, source=Web Response

The Mechanism of Mitral Regurgitant Jets Identified by 3-Dimensional Transesophageal Echocardiography.

This study is a case report, which presents a case of severe mitral regurgitation in a 77-year-old man. Two-dimensional transesophageal echocardiography (TEE), regurgitant jets directed anteriorly in early systole and centrally to laterally in late systole were seen, while three-dimensional TEE showed a flail posterior middle scallop not only angulated centrally, but also laterally, which provided insight into the mechanism of mitral regurgitant jet direction. This case demonstrates the clinical usefulness of 3-dimensional TEE for identifying the mechanism of mitral regurgitant jets.The institution where the figures and the videos were recorded: Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta Hospital, Edmonton, Alberta, Canada.

Assessment of Preoperative Echocardiographic Parameters as Predictors of Early Right Ventricular Failure in the Current Era of Continuous-Flow Left Ventricular Assist Devices

Background The development of right ventricular failure (RVF) is common following continuous-flow left ventricular assist device (CF-LVAD) implantation, occurring in 13%-40% of patients. With the LVAD and right heart operating in series, LVAD function relies heavily on RV function for adequate preload. Severe RVF can lead to systemic hypoperfusion, multi-organ failure, prolonged hospitalization, poor quality of life, and death. Hypothesis Identifying patients at risk of developing severe RVF post-implantation may assist the care team in taking the necessary precautions to potentially avoid RVF or to be aggressive in its management. Methods This was a single-center review of CF-LVAD implantations from 2014 to 2016. Excluded were INTERMACS1 patients, redo LVADs, preoperative advanced RVF, refractory pulmonary vascular resistance >6 WU, and prosthetic mitral or tricuspid valve. RVF was defined as requiring RVAD or inhaled nitric oxide or other pulmonary vasodilator post-op for ≥48h or inotropic therapy for ≥7d any time post-op. Assessment of pre-implant RV function was based on an extensive set of echocardiographic parameters ( Tables 1 & 2 ). Results Of 55 patients (95% were HeartMate II), a total of 46 (84%) developed significant RVF. Those with and without RVF did not differ in gender or age. RV stroke volume (P=0.04), RV stroke volume index (P=0.04), and mitral valve regurgitation jet area (P=0.05) were significantly lower in patients with RVF ( Table 1 ). Conclusion RV cardiac output is calculated as RV stroke volume x heart rate. Thus, early RVF post-LVAD may be explained by low RV stroke volume. In standard practice, however, RV stroke volume and RV stroke volume index are not routinely calculated from the pre-implant echocardiogram. This study, despite its small sample size, suggests potential prognostic value for these echo parameters for the evaluation of RVF. Larger studies are needed to validate these results.

Effects of cardiac resynchronization therapy after inferior myocardial infarction on secondary mitral regurgitation and mitral valve geometry.

The effects of cardiac resynchronization therapy (CRT) on secondary mitral regurgitation (MR), and mitral valve (MV) and left ventricular (LV) geometry, in patients with prior inferior myocardial infarction is not clearly defined. We assessed these outcomes utilizing two-dimensional echocardiography, and analyzed echocardiographic geometric variables that may correlate with follow-up MR severity. Between 2009 and 2012, 229 CRT were implanted. Twenty-two had prior inferior myocardial infarction, ≥mild MR at baseline, and serial echocardiography. A left bundle branch block was present in 12 (54.5%) patients. The pre-CRT and follow-up echocardiograms were analyzed for: (1) MR severity; (2) MV and LV geometry; and (3) LV remodeling. The median follow-up time was 2.2 years (interquartile range, 0.7-4). In 16 patients without an inferior myocardial scar, there was a reduction in MR jet area/left atrial area ratio (33.2%vs 25.8%; P=0.06) and MR grade (2.3vs 1.8; P=0.05), and an increased LV ejection fraction (26.1%vs 30.9%; P=0.04) and end-systolic posterior ventricular sulcus-anterolateral papillary muscle angle (133.9vs 143.9 degrees; P=0.01). In six patients with scar, there was no change in LV or MR parameters. Regression analysis revealed linear associations between baseline MV tenting height (r=0.57; P=0.006), LV end-diastolic diameter index (r=0.5; P=0.02), mitral septolateral annular diameter (r=0.48; P=0.03), and MV tenting area (r= 0.46; P = 0.03), with follow-up MR jet area/left atrial area ratio. In patients with prior inferior myocardial infarction and no scar, CRT is associated with decreased MR severity, and improved papillary muscle alignment and LV systolic function at follow-up.

Savremeno lečenje akutnog infarkta miokarda sa st elevacijom komplikovanog srčanim zastojem na terenu

A 57 year old woman referred to our clinic for the evaluation of the mitral regurgitation. She was a candidate for potential valvular intervention. Transthoracic echo showed a flail leaflet in the region of the prolapsing P2 scallop of the posterior leaflet and the mitral regurgitant jet was directed toward the interatrial septum. The left ventricle systolic function was preserved. The patient underwent three-dimensional transoephageal echocardiography to investigate the precise anatomy of the mitral valve complex. The anatomical analysis was done by post-processing prior the reconstruction. During surgery, a rigid ring was implanted and Gerbode plastic of the large P3 segment was performed-which turned out to be the prolapsing scallop with 'flail'. Echocardiography is important in assessing mitral valve disease.

The Great Pretender: A Case of Unilateral Pulmonary Oedema

Case synopsis: A 47-year-old man presented with a 3-day history of dyspnoea, productive cough, and a low-grade fever. A chest X-ray revealed an opacity in the right middle lobe and he was treated empirically for community-acquired pneumonia in the intensive care unit. The patient deteriorated quickly requiring intubation. At the time of intubation, he was noted to have pulmonary oedema and a pan–systolic murmur. Owing to clinical suspicion, diagnostic echocardiography was performed that showed an eccentric postero-lateral mitral regurgitation (MR) jet. Other echocardiographic findings included moderate aortic regurgitation from a bicuspid aortic valve. Blood cultures were negative and coronary angiography revealed no significant coronary artery disease. The patient proceeded to mechanical aortic valve and mitral valve replacements after stabilisation with an intra-aortic balloon pump.

Nonbacterial thrombotic endocarditis - Not forgotten

We report the case of a 36-year-old man who presented with an incidental echocardiographic finding of a 1.1 × 0.8 cm mobile structure on the mitral valve associated with mild to moderate eccentric jet of mitral regurgitation. Surgical excision confirmed the diagnosis of nonbacterial thrombotic endocarditis (NBTE), formerly known as marantic endocarditis. The cardiolipin IgG and IgM antibodies and the lupus anticoagulant were strongly positive confirming the diagnosis of antiphospholipid syndrome. The patient was promptly anticoagulated. NBTE is a rare condition associated with advanced mucin secreting malignant tumours and hypercoagulable states. It is associated with high incidence of embolic events the most frequent ones being cerebral; the diagnosis is usually reached at post-mortem. Our case clearly demonstrates that vegetations on cardiac valves may pose a diagnostic dilemma and surgical intervention may be needed to reach a diagnosis. We propose that in patients with high likelihood of NBTE a transthoracic echocardiogram should be considered to assess for the above diagnosis which carries a high risk of life threatening embolic events. Anticoagulation or surgical excision is likely to improve cardiovascular outcome.