Mitral regurgitation cardiac catheterization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed A. Sbeih, M.D. [2]; Rim Halaby, M.D. [3]

Overview

Cardiac catheterization is useful to evaluate mitral regurgitation when the results of the non-invasive testing are insufficient.[1] In addition, cardiac catheterization might be performed when there is lack of consistency between the clinical findings and the results of the non-invasive testing in order to rule out cardiac etiologies or pulmonary hypertension as the cause of the patient's symptoms.[2] Coronary angiography should be considered prior to mitral valve surgery among patients with risk factors of coronary artery disease among whom the underlying etiology of mitral regurgitation is suspected to be of ischemic origin.[3]

Cardiac Catheterization

Left ventriculography and hemodynamic assessment by cardiac catheterization can be used to evaluate mitral regurgitation when the results of the non-invasive testing are inconclusive. Cardiac catheterization should also be considered when there is lack of consistency between the clinical findings and the results of the non-invasive testing in order to rule out cardiac etiologies or pulmonary hypertension as the cause of the patient's symptoms.[2]

Both the RAO and LAO cranial projections can be used during left ventriculography to identify significant mitral regurgitation. Grading the amount of regurgitation is based on the amount of opacification of the left atrium compared to the left ventricle, the atrial size, and the number of cycles required for maximal opacification of the left atriun. Elevation of left atrial pressure in acute regurgitation and dilation of the left atrium from chronic regurgitation can both interfere with the use of this grading system. The grading of mitral regurgitation based on the left ventriculography findings is as follows:

  • +1: There is brief and incomplete atrial opacification over several cycles. The dye clears rapidly. There is no atrial enlargement.
  • +2: There is moderate opacification of the left atrium with each cycle. The opacification is never greater than left ventricular opacification. There is no significant left atrial enlargement.
  • +3: There is atrial opacification equal to ventricular opacification. There is delayed clearing of atria over several cycles. There is significant enlargement of the left atrium.
  • +4: There is left atrial opacification which is immediate and is greater than that of the left ventricle. There is severe enlargement of the left atrium. There is opacification of the pulmonary veins.

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary[2]

Recommendations for Chronic Primary Mitral Regurgitation

Cardiac Catheterization Recommendations

Class IIa
"1. Exercise hemodynamics with either doppler echocardiography or cardiac catheterization is reasonable in symptomatic patients with chronic primary mitral regurgitation (MR) where there is a discrepancy between symptoms and the severity of MR at rest (stages B and C). (Level of Evidence: B) "

Exercise Testing Recommendations

Class IIa
"1. Exercise treadmill testing can be useful in patients with chronic primary mitral regurgitation to establish symptom status and exercise tolerance (stages B and C). (Level of Evidence: C"

Recommendations for Chronic Secondary Mitral Regurgitation

Class I
"1.Noninvasive imaging (stress nuclear/positron emission tomography, CMR, or stress echocardiography), cardiac CT angiography, or cardiac catheterization, including coronary arteriography, is useful to establish etiology of chronic secondary MR (stages B to D) and/or to assess myocardial viability, which in turn may influence management of functional MR. (Level of Evidence: C)"

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT) [4]

Cardiac Catheterization Indications (DO NOT EDIT) [4]

Class I
"1. Left ventriculography and hemodynamic measurements are indicated when noninvasive tests are inconclusive regarding severity of MR, LV function, or the need for surgery.(Level of Evidence: C) "
"2. Hemodynamic measurements are indicated when pulmonary artery pressure is out of proportion to the severity of MR as assessed by noninvasive testing.(Level of Evidence: C) "
"3. Left ventriculography and hemodynamic measurements are indicated when there is a discrepancy between clinical and noninvasive findings regarding severity of MR.(Level of Evidence: C) "
"4. Coronary angiography is indicated before mitral valve repair or mitral valve replacement in patients at risk for CAD.(Level of Evidence: C) "
Class III
"1. Left ventriculography and hemodynamic measurements are not indicated in patients with MR in whom valve surgery is not contemplated.(Level of Evidence: C) "

References

  1. Nishimura RA, Carabello BA (2012). "Hemodynamics in the cardiac catheterization laboratory of the 21st century". Circulation. 125 (17): 2138–50. doi:10.1161/CIRCULATIONAHA.111.060319. PMID 22547754.
  2. 2.0 2.1 2.2 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
  3. American College of Cardiology. American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Society of Cardiovascular Anesthesiologists. Bonow RO, Carabello BA, Chatterjee K; et al. (2006). "ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons". J Am Coll Cardiol. 48 (3): e1–148. doi:10.1016/j.jacc.2006.05.021. PMID 16875962.
  4. 4.0 4.1 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)



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