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Benoy Shah MD

Mar 12, 2022 • 16 tweets • 9 min read • Read on X

Scrolly

@ASE360

*POSTERIORLY DIRECTED MITRAL REGURGITATION*

How many causes of posterior MR do you know?

Let's take a look in this mini 🧵

But...no cheating...vote first!

#echofirst #cardiotwitter #MedTwitter @ASE360 @BSEcho @TheBJCA @BJCA_Women_LTFT @global_wic @WessexSpRs

1. Anterior MV prolapse

Probably the first thing that occurs to most people

AMVL prolapse is less common than PMVL prolapse

Here you can see the highly eccentric, posteriorly directed jet of MR

This is the AP3Ch view showing the same abnormality

@KyleWKlarich

2. Systolic Anterior Motion (SAM)

SAM of the AMVL tends to (not always) produce posteriorly directed MR; important to remember that SAM is not the only reason a HCM patient may have MR

PLAX here is not mine, it's from an excellent lecture (on YouTube) by Dr @KyleWKlarich

Here you can see the posteriorly directed MR jet on colour Doppler imaging

Here is the still image

3. Ischaemic MR due to posterior leaflet restriction

Inferolateral / inferoposterolateral MI often produces a regional LV abnormality that affects the posteromedial papillary muscle & affects PMVL >> AMVL. The apical PM displacement tethers the PMVL, causing MR

PLAX view here

It may look like there's AMVL prolapse, but if you look closely you'll see the PMVL barely moves

Issue here is PMVL tethering due to inferolateral MI, causing apical displacement of PM pap muscle, thus tethering the leaflet

As a result, we see this highly eccentric, posteriorly directed MR jet

Here's a still frame of that MR jet

4. Atrial functional MR (AF-MR)

Huge atrial enlargement. There are multiple postulated mechanisms for MR in patients with AF - one is posterior leaflet tethering

Again, posteriorly directed MR jet seen here in AP4Ch view

MR still image...

@Thind888

A nice review on AF-MR in JACC Imaging details mechanisms of MR in such patients

@Thind888 @HiteshiKc @suheildhanse @senguptasp @AJamilTajik @renujain19 @BonitaEcho @vonBardelebenRS @doconmoney @SachinGoelMD

These are the 4 main causes of posterior MR that I'm aware of

If you know others, add to the thread! 😁

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**CASE OF THE MONTH**

Female, mid 20s
Fit & healthy
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Only 💊 is COC pill

Experiences central chest pain during sport (exertion), not happened before

Recently has been well, no coryzal or other symptoms

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What would you do next?

Vote in next message...

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Another nice example recently of the importance of a systematic approach to assessment of mitral regurgitation during TOE

Indication was known MR, assess suitability for TEER

Mid oesophageal 4Ch & 5Ch views...wondering if we have the right patient! No real MR to see...

The segmentation approach in the bicommisural view is a very reliable and easy-to-do method

Start at the lateral side of the valve with X-plane (Philips) / MultiD (GE) and you have A1-P1 coaptation on the right side...do this with 2D only & then with colour Doppler too

Then move to the middle of the valve with your cursor, cutting through A2 in bicomm view so you see A2-P2 coaptation on the right side

Still no MR!

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Benoy Shah MD

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Deep dive on #EARLYTAVR from ##TCT2024

Lots already said & discussed

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Some thoughts...🧵

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Here's the 🧵 in case you missed it

https://x.com/dr_benoy_n_shah/status/1850645694698135554?t=TAVDsW79WuDguZBGOutVBg&s=19

EARLY TAVR
Asymptomatic severe AS patients recruited between March '17 - Dec '21

75 sites across 🇺🇲 and 🇨🇦

Asymptomatic status confirmed by negative treadmill test in 90.6%
(Remaining 9.4% unable to do test, relied on detailed physician history)

That's a good % that did ETT 👏

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Benoy Shah MD

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Tomorrow - Oct 28th - we learn the results of 3 landmark randomised studies in patients with aortic stenosis (AS)

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These could well be practice-changing studies...

A 🧵

#TCT2024
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##TCT2024
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*Mitral valve assessment by TTE*

Transthoracic echocardiography (TTE), when performed with care and diligence, can reveal a lot about the valve. TOE isn't necessary in all cases to determine leaflet pathology.

A worked example below:

In the PLAX view, you can assess the scallops of the leaflets

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