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Characteristic Pulsed Doppler Findings in Patients with Flail Mitral Valve
Characteristic Pulsed Doppler Findings in Patients with Flail Mitral Valve* Moh'd A Habbab, M.D.; andJacob I. Haft, M.D., EC.C.P.
Pulsed mode Doppler findings in the left atrium were studied in 18 patients with moderate to severe catheterizationproven mitral regurgitation, four with and 14 without 8ail mitral valve. Atypical markedly turbulent antegrade 80w in the left atrium was observed in all four patients with 8ail
mitral valve, whereas the typical retrograde mitral regurgitation pattern of 80w was observed in the 14patients without 8ail mitral valve. This Doppler pattern appears to be indicative of a 8ail mitral valve.
In patients with mitral regurgitation, pulsed Doppler echocardiography typically shows retrograde flow toward the left atrial roof during systole. 1.2 The degree of mitral regurgitation usually correlates with how deep into the left atrium" the retrograde flow is detected on Doppler mapping. We recently observed markedly turbulent antegrade flow with little retrograde Bow during systole within the left atrium in four patients with marked mitral regurgitation due to Bail mitralleaHet. To determine if the finding was characteristic of mitral regurgitation due to a BailleaHet, the Doppler findings in these four patients were compared with the findings in 14 patients with catheterizationproven mitral regurgitation who did not have evidence of a Bail valve.
heart failure and was round to have a grade 4/6 holosystolic murmur associated with a thrill at the apex, radiating to the axilla. M-mode echocardiography showed an enlarged left atrium and left ventricle and coarse diastolic 8utterlng of the anterior leaflet of the mitral valve with mitral valve prolapse. Two-dimensional echocardiography con6rmed the left atrial and left ventricular enlargement and revealed a 8ail anterior leaflet of the mitral valve (Fig 1)and mitral valve prolapse. Left atrial mapping by pulsed mode Doppler done in multiple 2-D planes, and particularly In the apical four-chamber view, revealed a markedly turbulent antegrade 80w with little retrograde flow during systole mainly at the site of the 8ail lea8et (Fig 2). Cardiac catheterization confirmed the diagnosis of severe mitral valve regurgitation with mitral valve prolapse.
METHODS AND PATIENTS Eighteen patients with moderate to severe mitral regurgitation by cardiac catheterization were studied. Echocardiographic studies were performed In all patients with a Hewlett-Packard sector scanner with a 3.5 MHz transducer. M-mode and 2-D echocardiograms were screened ror evidence of8ail mitral valve as described by Child et ale and others. 5 Pulsed mode Doppler mapping of the left atrium was performed In multiple 2-D planes. particularly in the apical four-chamber view. In the rour patients with history and echocardiographic 6nding suggestive of 8ail mitral valve. the diagnosis was con6rmed at the time of surgery ror mitral valve replacement.
CASE 2
A 66-ye8J'oOld woman with 11 years of hypertenslon presenting with six months of fatigue, palpitations, and heart failure was round to have a grade 3/6 holosystolic murmur associated with a thrill and cardiomegaly. M-mode echocardiography demonstrated an enlarged left atrium and left ventricle with anterior displacement of the posterior leaftet In early diastole with coarse diastolic 8uttering of the posterior leaflet, The 2-D echocardiogram confirmed the left ventricular and atrial enlargement and revealed mitral and tricuspid valvular prolapse with a Bail posterior lea8et of the mitral valve. Pulsed Doppler revealed 4 + mitral regurgitation and 2 + tricuspid
RESUUS
Eighteen patients were studied, and 14 had no history of echocardiographic findings suggestive of Bail mitral valve. All were found to have retrograde Bow in various parts of the left atrium on Doppler mapping . Four patients had flailmitral valve and are described in detail as follows: CASE
1
A 55-ye8J'oOld man with previously diagnosed mitral valve prolapse pre~ented with a two-week history of chest pain, diaphoresis, and
*From the Department of Cardiology, Saint Michaels Medical Center, Newark, NJ. Manuscript received July 10: revision accepted October 20. Reprint requem: Dr: Haft. St. Mlchaefs Hospital. 306 High Street, Newark. N] 07102
FICURE 1, Case 1. lWo-dimensional echocardiogram In the parasternal long-axis view demonstrating a 8ail anterior lea8et of the mitral valve (arrow) . LA is left atrium; LV, left ventricle. CHEST I 91 14 I APRIL, 1987
571
FIGURE2, Case 1. Pulsed Doppler echocardiogram in the apical lOur chamber view with the sample volume placed in the left atrium just below the mitral valve (arrotD1aetJd). A markedly turbulent antegrade How with little retrograde How during systole is demonstrated (afT'0W8). regurgitation with markedly turbulent antegrade How, clearly systolic, in the area below the mitral valve (Fig 3). Cardiaccatheterization revealed severe mitral regurgitation with mild aortic regurgitation and the diagnosis of Hail posterior mitralleaHet was confirmed at the time of surgery lOr replacement of the mitral valve.
CASE 3 A 69-YeaMlld hypertensive man with one month of severe heart failure had a grade 4/6 apical holosystolic murmur with radiation to the axilla and marked cardiomegaly. M-mode and 2-D echocardio-
grams revealed concentric left ventricular hypertrophy, an enlarged left atrium, and mitral valve prolapse. A chaotic diastolic Hutter of the posterior leaHet suggestive of Hail mitral valve was also noted on M-mode echocardiogram. Pulsed mode Doppler done In multiple 2-D planes, particularly in the apicallO~berview, revealed markedly turbulent antegrade How with little retrograde How during systole mainly in the area below the posterior mitral valve (Fig 4). Cardiac catheterization revealed severe mitral regurgitation and at the time of surgery the diagnosis of Hail posterior mitralleaHet was
made.
FIGURE3, Case 2. Pulsed Doppler echocardiogram in the four-chamber view with the sample volume place4 in the left atrium below the mitral valve (blac1t arrowhead) showing a markedly turbulent antegrade during systole (afT'0W8).
Haw
572
PuI8ed DopplerFIncIngsin FlaIl Mitral VaIYe (H8bbab . Haft)
FIGURE 4, Case 3. Pu1sed Doppler echocardiogram in the fOur-chamber view with the sample volume p1aced in the left atrium below the mitral valve (QfTOlDhsDd) showing a markedly turbulent antegrade flow during systole (QrTOWB). CASE
4
A 78-YeaN>ld man with 20 years of hypertension with progressive heart failure necessitating three hospitalizations for pulmonary edema in one month was found to have a 4/6 holosystolic murmur at the apex radiating to the axilla and a 2/6 ejection systolic murmur at the left sternal border. M-mode echocardiography showed a thickened mitral anulus and aortic root with coarse diastolic fluttering of the posterior leaflet of the mitral valve . The 2-D echocardiogram also showed a thickened mitral anulus and aortic root with mitral valve prolapse and was suggestive of Ilail posterior leaflet of the mitral valve. Pulsed Doppler revealed 4 + mitral regurgitation with turbulent antegrade systolic flow in the left atrium just below the mitral valve (Fig 5). Cardiac catheterization revealed severe mitral regurgitation, and coronary arteriogram showed total occlusion of the right coronary artery and the distal circumflex artery with 85 percent lesion in the left anterior descending artery. The patient had coronary artery bypass surgery with mitral valve replacement. The diagnosis of Ilail posterior mitral leaflet was confirmed at surgery. The incidence of this pattern was significantly (p
DISCUSSION
Pulsed Doppler echocardiography is the procedure of choice fur the detection of mitral regurgitation with high sensitivity and specificity.1.1 Retrograde Bow disturbance on the atrial side of the mitral valve during systole is typically detected producing a box-like appearance throughout systole due to turbulence and aliasing (Fig 6).3 The severity of mitral regurgitation usually correlates with the extent and distribution of the retrograde Bow disturbance in the left atrium. 3 The only antegrade Bow normally described in the left atrium is that produced by pulmonary venous return which is a diastolic/systoliclaminar Bow detected close to the posterior wall of the left atrium . In our four patients with Bail mitral leaflet, we detected an antegrade markedly turbulent Bow with little retrograde Bow during systole within the left atrium close to the
FIGURE5, Case 4. Pu1sed Doppler echocardiogram in the fOur-chamber view with the sample volume placed in the left atrium below the mitral valve (QfTOlDhsDd) showing a markedly turbulent antegrade flow during systole (QrTOWB). CHEST I 91 I 4 I APRIL. 1987
573
FIGURE 6, Case 5. Pulsed Doppler echocardiogram in the four chamber view with the sample volume placed in the left atrium below the mitral valve (arrowhead). The typical retrograde flow of mitral regurgitation is shown producing a box-like appearance throughout systole due to turbulence and aliasing (mItJ1l arrowheads).
mitral valve just below the leaflets. This pattern of antegrade systolic Bow was not seen on mapping the left atrium with pulsed Doppler echocardiography in 14 patients with moderate to severe catheterizationproven mitral regurgitation with no evidence of Bail mitral leaflets by M-mode and 2-D echocardiography. The typical box-like turbulent systolic Bow of mitral regurgitation was observed in all of these 14 patients (Fig 6). Although the cause of the observed predominant antegrade systolic turbulence in patients with a Bail mitral valve leaflet remains speculative, it is probably due to swirling of the large mass of blood regurgitating rapidly into the left atrium and ricocheting offthe walls of the left atrium . The Doppler image of this ricocheting blood may be more turbulent than the Doppler image of the retrograde Bow. This would cause the net algebraic sum of the Doppler-recorded turbulence due to the retrograde Bow and that due to the antegrade turbulence to favor the antegrade turbulence with the appearance of only a small amount of retrograde turbulence. An eccentric regurgitant jet might also have been sufficiently localized to cause only the small amount of retrograde Doppler turbulence seen in parts of the left atrium. However, in all four patients on LV angiography, the mitral regurgitation was so prompt and massive that an eccentric jet could not be identified. Color Doppler imaging may help in the future to further delineate the mechanism of this
574
phenomenon. It is possible that a similar pattern might be expected in patients with severe possibly eccentric mitral insufficiency secondary to other causes such as valve perforation due to bacterial endocarditis or massive paravalvular leak around a prosthetic valve. In summary, we have found that patients with mitral regurgitation due to a Bailleaflet have markedly turbulent antegrade left atrial Bow during systole on pulsed Doppler study, a pattern not seen in patients with mitral regurgitation not due to a Bailleaflet. This unique finding may be due to the swirling of a large rapidly regurgitant jet and is characteristic of a Bail mitral leaflet. REFERENCES 1 Abbasi AS, Allen MW, DeCristofare D , Ungar I. Detection and estimation of the degree of mitral regurgitation by range gated pulsed Doppler echocardiography. Circulation 1980; 61:143-47 2 Miyatake K, Kinoshita N, Nagata S, Beppu S, Park Y, Sakakibara H, et al. Intracardiac 80w pattern in mitral regurgitation studied with combined use of the ultrasonic pulsed Doppler technique and cross-sectional echocardiography. Am ] Cardiol 1980; 45: 155-62 3 Adhar CC, Nanda NC. Doppler echocardiography: Part II. Adult valvular heart disease. Echocardiography 1984; 1:219-41 4 Child ]S, Skorton OJ, 'Iaylor Rl?, Krivokapich J, Abbasi AS, Wong M, et al. M-mode and cross sectional echocardiographic features of8ail posterior mitrallea8ets. Am] Cardio1198O; 44:1383-90 5 Mintz GS, Kotler MN, Parry WR, Segal BL. Statistical comparison ofM-mode and two-dimensional echocardiographic diagnosis of 8ail mitrallea8ets. Am ] Cardiol 1980; 45:2.53-59
PlJIsed Doppler AndIngs In Rail Mitral YaMt (Hllbbab, HIIIt)
Pulsed mode Doppler findings in the left atrium were studied in 18 patients with moderate to severe catheterizationproven mitral regurgitation, four with and 14 without 8ail mitral valve. Atypical markedly turbulent antegrade 80w in the left atrium was observed in all four patients with 8ail
mitral valve, whereas the typical retrograde mitral regurgitation pattern of 80w was observed in the 14patients without 8ail mitral valve. This Doppler pattern appears to be indicative of a 8ail mitral valve.
In patients with mitral regurgitation, pulsed Doppler echocardiography typically shows retrograde flow toward the left atrial roof during systole. 1.2 The degree of mitral regurgitation usually correlates with how deep into the left atrium" the retrograde flow is detected on Doppler mapping. We recently observed markedly turbulent antegrade flow with little retrograde Bow during systole within the left atrium in four patients with marked mitral regurgitation due to Bail mitralleaHet. To determine if the finding was characteristic of mitral regurgitation due to a BailleaHet, the Doppler findings in these four patients were compared with the findings in 14 patients with catheterizationproven mitral regurgitation who did not have evidence of a Bail valve.
heart failure and was round to have a grade 4/6 holosystolic murmur associated with a thrill at the apex, radiating to the axilla. M-mode echocardiography showed an enlarged left atrium and left ventricle and coarse diastolic 8utterlng of the anterior leaflet of the mitral valve with mitral valve prolapse. Two-dimensional echocardiography con6rmed the left atrial and left ventricular enlargement and revealed a 8ail anterior leaflet of the mitral valve (Fig 1)and mitral valve prolapse. Left atrial mapping by pulsed mode Doppler done in multiple 2-D planes, and particularly In the apical four-chamber view, revealed a markedly turbulent antegrade 80w with little retrograde flow during systole mainly at the site of the 8ail lea8et (Fig 2). Cardiac catheterization confirmed the diagnosis of severe mitral valve regurgitation with mitral valve prolapse.
METHODS AND PATIENTS Eighteen patients with moderate to severe mitral regurgitation by cardiac catheterization were studied. Echocardiographic studies were performed In all patients with a Hewlett-Packard sector scanner with a 3.5 MHz transducer. M-mode and 2-D echocardiograms were screened ror evidence of8ail mitral valve as described by Child et ale and others. 5 Pulsed mode Doppler mapping of the left atrium was performed In multiple 2-D planes. particularly in the apical four-chamber view. In the rour patients with history and echocardiographic 6nding suggestive of 8ail mitral valve. the diagnosis was con6rmed at the time of surgery ror mitral valve replacement.
CASE 2
A 66-ye8J'oOld woman with 11 years of hypertenslon presenting with six months of fatigue, palpitations, and heart failure was round to have a grade 3/6 holosystolic murmur associated with a thrill and cardiomegaly. M-mode echocardiography demonstrated an enlarged left atrium and left ventricle with anterior displacement of the posterior leaftet In early diastole with coarse diastolic 8uttering of the posterior leaflet, The 2-D echocardiogram confirmed the left ventricular and atrial enlargement and revealed mitral and tricuspid valvular prolapse with a Bail posterior lea8et of the mitral valve. Pulsed Doppler revealed 4 + mitral regurgitation and 2 + tricuspid
RESUUS
Eighteen patients were studied, and 14 had no history of echocardiographic findings suggestive of Bail mitral valve. All were found to have retrograde Bow in various parts of the left atrium on Doppler mapping . Four patients had flailmitral valve and are described in detail as follows: CASE
1
A 55-ye8J'oOld man with previously diagnosed mitral valve prolapse pre~ented with a two-week history of chest pain, diaphoresis, and
*From the Department of Cardiology, Saint Michaels Medical Center, Newark, NJ. Manuscript received July 10: revision accepted October 20. Reprint requem: Dr: Haft. St. Mlchaefs Hospital. 306 High Street, Newark. N] 07102
FICURE 1, Case 1. lWo-dimensional echocardiogram In the parasternal long-axis view demonstrating a 8ail anterior lea8et of the mitral valve (arrow) . LA is left atrium; LV, left ventricle. CHEST I 91 14 I APRIL, 1987
571
FIGURE2, Case 1. Pulsed Doppler echocardiogram in the apical lOur chamber view with the sample volume placed in the left atrium just below the mitral valve (arrotD1aetJd). A markedly turbulent antegrade How with little retrograde How during systole is demonstrated (afT'0W8). regurgitation with markedly turbulent antegrade How, clearly systolic, in the area below the mitral valve (Fig 3). Cardiaccatheterization revealed severe mitral regurgitation with mild aortic regurgitation and the diagnosis of Hail posterior mitralleaHet was confirmed at the time of surgery lOr replacement of the mitral valve.
CASE 3 A 69-YeaMlld hypertensive man with one month of severe heart failure had a grade 4/6 apical holosystolic murmur with radiation to the axilla and marked cardiomegaly. M-mode and 2-D echocardio-
grams revealed concentric left ventricular hypertrophy, an enlarged left atrium, and mitral valve prolapse. A chaotic diastolic Hutter of the posterior leaHet suggestive of Hail mitral valve was also noted on M-mode echocardiogram. Pulsed mode Doppler done In multiple 2-D planes, particularly in the apicallO~berview, revealed markedly turbulent antegrade How with little retrograde How during systole mainly in the area below the posterior mitral valve (Fig 4). Cardiac catheterization revealed severe mitral regurgitation and at the time of surgery the diagnosis of Hail posterior mitralleaHet was
made.
FIGURE3, Case 2. Pulsed Doppler echocardiogram in the four-chamber view with the sample volume place4 in the left atrium below the mitral valve (blac1t arrowhead) showing a markedly turbulent antegrade during systole (afT'0W8).
Haw
572
PuI8ed DopplerFIncIngsin FlaIl Mitral VaIYe (H8bbab . Haft)
FIGURE 4, Case 3. Pu1sed Doppler echocardiogram in the fOur-chamber view with the sample volume p1aced in the left atrium below the mitral valve (QfTOlDhsDd) showing a markedly turbulent antegrade flow during systole (QrTOWB). CASE
4
A 78-YeaN>ld man with 20 years of hypertension with progressive heart failure necessitating three hospitalizations for pulmonary edema in one month was found to have a 4/6 holosystolic murmur at the apex radiating to the axilla and a 2/6 ejection systolic murmur at the left sternal border. M-mode echocardiography showed a thickened mitral anulus and aortic root with coarse diastolic fluttering of the posterior leaflet of the mitral valve . The 2-D echocardiogram also showed a thickened mitral anulus and aortic root with mitral valve prolapse and was suggestive of Ilail posterior leaflet of the mitral valve. Pulsed Doppler revealed 4 + mitral regurgitation with turbulent antegrade systolic flow in the left atrium just below the mitral valve (Fig 5). Cardiac catheterization revealed severe mitral regurgitation, and coronary arteriogram showed total occlusion of the right coronary artery and the distal circumflex artery with 85 percent lesion in the left anterior descending artery. The patient had coronary artery bypass surgery with mitral valve replacement. The diagnosis of Ilail posterior mitral leaflet was confirmed at surgery. The incidence of this pattern was significantly (p
DISCUSSION
Pulsed Doppler echocardiography is the procedure of choice fur the detection of mitral regurgitation with high sensitivity and specificity.1.1 Retrograde Bow disturbance on the atrial side of the mitral valve during systole is typically detected producing a box-like appearance throughout systole due to turbulence and aliasing (Fig 6).3 The severity of mitral regurgitation usually correlates with the extent and distribution of the retrograde Bow disturbance in the left atrium. 3 The only antegrade Bow normally described in the left atrium is that produced by pulmonary venous return which is a diastolic/systoliclaminar Bow detected close to the posterior wall of the left atrium . In our four patients with Bail mitral leaflet, we detected an antegrade markedly turbulent Bow with little retrograde Bow during systole within the left atrium close to the
FIGURE5, Case 4. Pu1sed Doppler echocardiogram in the fOur-chamber view with the sample volume placed in the left atrium below the mitral valve (QfTOlDhsDd) showing a markedly turbulent antegrade flow during systole (QrTOWB). CHEST I 91 I 4 I APRIL. 1987
573
FIGURE 6, Case 5. Pulsed Doppler echocardiogram in the four chamber view with the sample volume placed in the left atrium below the mitral valve (arrowhead). The typical retrograde flow of mitral regurgitation is shown producing a box-like appearance throughout systole due to turbulence and aliasing (mItJ1l arrowheads).
mitral valve just below the leaflets. This pattern of antegrade systolic Bow was not seen on mapping the left atrium with pulsed Doppler echocardiography in 14 patients with moderate to severe catheterizationproven mitral regurgitation with no evidence of Bail mitral leaflets by M-mode and 2-D echocardiography. The typical box-like turbulent systolic Bow of mitral regurgitation was observed in all of these 14 patients (Fig 6). Although the cause of the observed predominant antegrade systolic turbulence in patients with a Bail mitral valve leaflet remains speculative, it is probably due to swirling of the large mass of blood regurgitating rapidly into the left atrium and ricocheting offthe walls of the left atrium . The Doppler image of this ricocheting blood may be more turbulent than the Doppler image of the retrograde Bow. This would cause the net algebraic sum of the Doppler-recorded turbulence due to the retrograde Bow and that due to the antegrade turbulence to favor the antegrade turbulence with the appearance of only a small amount of retrograde turbulence. An eccentric regurgitant jet might also have been sufficiently localized to cause only the small amount of retrograde Doppler turbulence seen in parts of the left atrium. However, in all four patients on LV angiography, the mitral regurgitation was so prompt and massive that an eccentric jet could not be identified. Color Doppler imaging may help in the future to further delineate the mechanism of this
574
phenomenon. It is possible that a similar pattern might be expected in patients with severe possibly eccentric mitral insufficiency secondary to other causes such as valve perforation due to bacterial endocarditis or massive paravalvular leak around a prosthetic valve. In summary, we have found that patients with mitral regurgitation due to a Bailleaflet have markedly turbulent antegrade left atrial Bow during systole on pulsed Doppler study, a pattern not seen in patients with mitral regurgitation not due to a Bailleaflet. This unique finding may be due to the swirling of a large rapidly regurgitant jet and is characteristic of a Bail mitral leaflet. REFERENCES 1 Abbasi AS, Allen MW, DeCristofare D , Ungar I. Detection and estimation of the degree of mitral regurgitation by range gated pulsed Doppler echocardiography. Circulation 1980; 61:143-47 2 Miyatake K, Kinoshita N, Nagata S, Beppu S, Park Y, Sakakibara H, et al. Intracardiac 80w pattern in mitral regurgitation studied with combined use of the ultrasonic pulsed Doppler technique and cross-sectional echocardiography. Am ] Cardiol 1980; 45: 155-62 3 Adhar CC, Nanda NC. Doppler echocardiography: Part II. Adult valvular heart disease. Echocardiography 1984; 1:219-41 4 Child ]S, Skorton OJ, 'Iaylor Rl?, Krivokapich J, Abbasi AS, Wong M, et al. M-mode and cross sectional echocardiographic features of8ail posterior mitrallea8ets. Am] Cardio1198O; 44:1383-90 5 Mintz GS, Kotler MN, Parry WR, Segal BL. Statistical comparison ofM-mode and two-dimensional echocardiographic diagnosis of 8ail mitrallea8ets. Am ] Cardiol 1980; 45:2.53-59
PlJIsed Doppler AndIngs In Rail Mitral YaMt (Hllbbab, HIIIt)