basicII.B-001
Name the six segments of the mitral valve.
→ Anterior leaflet: A1 (lateral), A2 (middle), A3 (medial). Posterior leaflet: P1 (lateral), P2 (middle), P3 (medial).
basicII.B-002
State Carpentier's functional classification of MR.
→ Type I: normal leaflet motion (annular dilation, perforation, cleft). Type II: excessive motion (prolapse — degenerative). Type IIIa: restricted in systole AND diastole (rheumatic, radiation). Type IIIb: restricted in systole only (ischemic/functional tethering).
basicII.B-003
Distinguish leaflet prolapse from billowing.
→ Prolapse: leaflet free edge is ABOVE the annular plane at end-systole → coaptation lost. Billowing: leaflet body bulges above but the free edge stays at/below the plane → coaptation preserved.
basicII.B-004
Fibroelastic deficiency vs Barlow's — key differences.
→ Fibroelastic deficiency: older, short history, focal single-scallop chordal rupture with otherwise thin leaflets — easier repair. Barlow's: younger, diffuse myxomatous change, thickened redundant leaflets, elongated chords, large annulus, multisegment prolapse.
basicII.B-005
Which MR jet direction is typical of functional/ischemic MR?
→ Posteriorly directed jet. The posterior leaflet is tethered by displaced papillary muscle; anterior leaflet overrides the posterior — hockey-stick bend of the anterior leaflet.
basicII.B-006
State the ASE 2017 quantitative thresholds for SEVERE mitral regurgitation.
→ Vena contracta ≥ 0.7 cm; EROA ≥ 0.40 cm²; regurgitant volume ≥ 60 mL/beat; regurgitant fraction ≥ 50%.
basicII.B-007
What pulmonary vein Doppler finding indicates severe primary MR?
→ Systolic flow reversal in the pulmonary vein (S-wave reversal). Normal PV Doppler is S ≥ D; blunted S is nonspecific.
basicII.B-008
Simplified PISA equation for EROA when the aliasing velocity is set to 40 cm/s.
→ EROA ≈ r² / 2. Example: r = 0.9 cm → EROA ≈ 0.4 cm² (severe MR).
basicII.B-009
State the full PISA-based equations for MR quantification.
→ Regurgitant flow = 2π r² × V_aliasing. EROA = Regurg flow / peak MR velocity. Regurgitant volume = EROA × VTI_MR.
basicII.B-010
For PISA-optimized imaging, to what Nyquist aliasing velocity is the color baseline shifted?
→ ~30–40 cm/s in the direction of the regurgitant jet, to enlarge the hemispheric flow convergence for accurate radius measurement.
basicII.B-011
How do you measure MR volume by the volumetric (Doppler continuity) method?
→ RV = SV_mitral − SV_LVOT, where SV_mitral = CSA_MV annulus × VTI_MV inflow and SV_LVOT = CSA_LVOT × VTI_LVOT. Only valid when the aortic valve is competent.
basicII.B-012
What is the Coanda effect and how does it affect MR grading?
→ An eccentric wall-hugging jet loses kinetic energy along the LA wall; using jet area as a % of LA area UNDERESTIMATES severity in wall-hugging jets. Instead use vena contracta, PISA/EROA, or volumetric quantification.
basicII.B-013
How is dP/dt calculated from the MR CW envelope and what is normal?
→ Measure the time (Δt in seconds) between the 1 m/s and 3 m/s points on the MR jet. dP/dt = (4·3² − 4·1²)/Δt = 32/Δt mmHg/s. Normal ≥ 1200 mmHg/s.
basicII.B-014
Why is posteromedial papillary muscle rupture more common than anterolateral?
→ The posteromedial papillary muscle has SINGLE blood supply (from the PDA — RCA in a right-dominant system, LCx in left-dominant). The anterolateral has DUAL supply (LAD + LCx), making it more resistant to ischemia.
basicII.B-015
In asymptomatic patients with a flail leaflet, when is early mitral surgery indicated?
→ When the estimated probability of successful REPAIR is > 90% (better repair rates for posterior than anterior leaflet lesions) — even with preserved LV function.
basicII.B-016
Is endocarditis prophylaxis recommended for isolated mitral valve prolapse? What about after surgical repair or replacement?
→ No prophylaxis for isolated MVP. Prophylaxis IS indicated after surgical repair or replacement of the mitral valve.
basicII.B-017
List the four components of the Wilkins score for BMV suitability and the total-score cutoff for favorable morphology.
→ 1) Anterior leaflet MOBILITY. 2) Leaflet THICKNESS. 3) Leaflet CALCIFICATION. 4) Subvalvular THICKENING. Each scored 1–4. TOTAL ≤ 8 = favorable for BMV.
basicII.B-018
List five contraindications to percutaneous balloon mitral valvuloplasty (BMV).
→ 1) Wilkins score > 8. 2) Moderate or greater MR. 3) LA thrombus. 4) Heavy commissural calcification. 5) Severe concomitant TR requiring surgery.
basicII.B-019
State the ASE-recommended criteria for SEVERE mitral stenosis.
→ MVA ≤ 1.5 cm² (very severe ≤ 1.0), mean transmitral gradient > 5–10 mmHg at HR 60–80, PHT ≥ 150 ms (very severe ≥ 220 ms).
basicII.B-020
State the formula for MVA using pressure half-time.
→ MVA (cm²) = 220 / PHT (ms). Equivalently PHT = 0.29 × deceleration time, so MVA = 750 / DT (ms).
basicII.B-021
List three conditions in which the pressure-half-time method OVERESTIMATES the MVA (falsely appears less severe).
→ Stiff (non-compliant) LV, stiff LA, and moderate-to-severe aortic insufficiency. An ASD also alters LA/LV pressure decay. In these settings PHT shortens due to non-MV mechanisms.
basicII.B-022
When should the pressure-half-time method NOT be used to calculate MVA?
→ Immediately after balloon mitral valvuloplasty — rapid changes in LA/LV compliance make the calculation unreliable. Also in stiff LV/LA, mod-sev AI, or ASD.
basicII.B-023
Is Doppler intercept angle a concern for MVA measurement by PHT?
→ No — PHT depends on the DECAY SLOPE shape, not absolute velocity. Contrast with MR quantification, which is angle-dependent.
basicII.B-024
How does the transmitral gradient change with heart rate in MS?
→ Directly rate-dependent. High HR (shorter diastole) → higher mean gradient. Low HR → lower gradient. Report the gradient at a heart rate of 60–80.
basicII.B-025
How does rheumatic MS classically appear morphologically?
→ Commissural fusion; leaflet-tip calcification; anterior leaflet doming with concavity toward the LV ('hockey-stick'); posterior leaflet moves in the SAME direction as the anterior (fixed together).
basicII.B-026
How is Cor triatriatum sinistrum distinguished from valvular mitral stenosis by Doppler?
→ Cor triatriatum shows a gradient BOTH in systole and diastole (the membrane divides the LA into two chambers). Valvular MS produces a diastolic-only gradient.
basicII.B-027
Name the components of Shone complex.
→ Sequential left-sided obstructions: 1) supravalvular mitral ring, 2) parachute mitral valve (subvalvular MS), 3) subaortic membrane, and 4) coarctation of the aorta.
basicII.B-028
What is a parachute mitral valve?
→ A congenital anomaly in which all mitral chordae insert into a single papillary muscle, producing subvalvular MS. Component of Shone complex.
basicII.B-029
Which pharmacologic maneuver is used during echo to unmask latent LVOT obstruction in HCM?
→ Amyl nitrite inhalation — decreases preload and afterload, increases dynamic outflow obstruction and systolic anterior motion of the mitral valve (SAM).
basicII.B-030
After LVOT reduction (myectomy) for HCM, what mitral repair may be needed for residual MR, and what is its downside?
→ Alfieri edge-to-edge repair (anterior and posterior leaflets sutured at their mid-portion, creating a double-orifice MV). Can create relative mitral stenosis.
basicII.B-031
Is mitral annular calcification (MAC) a contraindication to MitraClip? Is calcification at the device landing zone?
→ MAC alone is NOT a contraindication to MitraClip. Leaflet calcification AT the device landing zone (typically A2 and P2) IS a contraindication.
basicII.B-032
How is BMV appropriate for pregnancy-related symptomatic mitral stenosis?
→ MS is poorly tolerated in pregnancy (increased blood volume and HR). Medical therapy is often inadequate; percutaneous BMV is the treatment of choice for symptomatic favorable-morphology MS.
basicII.B-033
Mid–late systolic MR vs holosystolic MR — which is generally more clinically favorable?
→ Mid-to-late systolic MR is more favorable — typically seen with MVP; smaller total regurgitant volume than holosystolic MR of comparable jet appearance.
basicII.B-034
How is the pressure half-time defined mathematically?
→ The time for the peak transmitral velocity to decrease to a value at which the pressure gradient is HALF of its initial peak — equivalent to velocity falling to peak × (1/√2), i.e., ~0.7 of peak.
basicII.B-035
State the 2020 ACC/AHA staging of primary MR.
→ Stage A: at risk (mild MVP, mild MAC). Stage B: progressive. Stage C1: asymptomatic severe with LVEF > 60% and LVESD < 40 mm. Stage C2: asymptomatic severe with LVEF ≤ 60% OR LVESD ≥ 40 mm. Stage D: symptomatic severe.
basicII.B-036
Class I indications for MV surgery in chronic PRIMARY severe MR?
→ 1) Symptomatic severe MR. 2) Asymptomatic severe MR with LVEF ≤ 60% or LVESD ≥ 40 mm. 3) Severe MR undergoing other cardiac surgery.
basicII.B-037
For chronic SECONDARY MR, when is transcatheter edge-to-edge repair (TEER / MitraClip) indicated?
→ Persistent NYHA III–IV HF despite maximally-tolerated GDMT and CRT (if indicated), with severe secondary MR, LVEF 20–50%, LVESD ≤ 70 mm, and PASP ≤ 70 mmHg (COAPT-like criteria).
basicII.B-038
State the mitral regurgitation severity threshold for a positive PISA method requiring baseline shift.
→ Baseline shift lowers the aliasing velocity to ~30–40 cm/s. Do it in the DIRECTION of the jet (usually downward for MR viewed from apex).
basicII.B-039
How do you correctly grade an eccentric wall-hugging (Coanda) MR jet?
→ Do NOT use jet area or LA-area percentage — will underestimate. Use vena contracta width (severe ≥ 0.7 cm), PISA-derived EROA/RV, or volumetric SV-difference method.
basicII.B-040
Which valve maneuver increases the mitral prolapse murmur duration and moves the click earlier?
→ Valsalva strain phase (decreases preload) — smaller LV cavity causes earlier prolapse. Also standing. Increased venous return (squatting, leg raise) does the opposite (delays click, shortens murmur).
basicII.B-041
State three settings in which the pressure-half-time method underestimates MVA (overestimates severity).
→ 1) Stiff (non-compliant) LV. 2) Stiff LA. 3) Moderate-to-severe aortic insufficiency. 4) ASD. In all, PHT shortens due to non-MV mechanisms, not from valve disease alone.
basicII.B-042
How is prosthetic mitral valve stenosis identified on TTE Doppler?
→ E velocity ≥ 1.9 m/s, mean gradient ≥ 6 mmHg, VTI ratio (prosthesis/LVOT) ≥ 2.2, and PHT ≥ 130 ms. Use the continuity equation (not PHT) to calculate EOA.
basicII.B-043
Why does an eccentric wall-hugging jet appear smaller than a central jet on color Doppler?
→ The Coanda effect — as the jet adheres to the wall, kinetic energy is lost to friction, reducing the visible flow area. A wall-hugging jet may have 40% less color area than an equivalent central jet.
basicII.B-044
How do you distinguish mitral valve prolapse from billowing?
→ Prolapse: leaflet free edge ABOVE the mitral annular plane at end-systole with loss of coaptation. Billowing: leaflet body bulges above the annular plane, but the free edge remains at or below → coaptation preserved.
basicII.B-045
How does the exercise MR grade change help decide surgical timing in ischemic MR?
→ Exercise-induced increase in MR ≥ 1 grade or exercise EROA ≥ 0.13 cm² identifies patients with worse prognosis and may prompt earlier intervention.
basicII.B-046
After MitraClip, what causes recurrent MR at follow-up?
→ Single leaflet detachment (leaflet grasped only unilaterally), device embolization, progressive underlying disease. Recurrent MR sometimes requires additional clips or surgical intervention.
