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34	Underestimation of regurgitant severity by loss of Momentum (Impingement)
35	Underestimation of regurgitant severity by loss of Momentum (Impingement)
36	Underestimation of regurgitant severity in eccentric wall-adherent Jet (Coanda) because jet is viewed only from the side (profile instead of en face). Jet area may appear 40% smaller
37	Jet area Highly dependent on gain and other instrument settings (filter) Depends on jet momentum more than on flow rate Momentum can be lost d/t impingement on the wall of the receiving chamber (MR: LA; AR: LV) Wall-adherence of eccentric jets (Coanda) decreases its size in most planes leading to underestimation of regurgitant severity Eccentric jets are curved, our imaging views are planar; the full extent of eccentric jets can therefore never be fully visualized in 2D Jet are is only a gross estimate of regurgitant severity
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43	Vena Contracta Less dependent on gain and other instrument settings Reflects size of effective orifice area Less dependent on driving pressure (hemodynamics) In TTE more reliable for quantification of AR (cut-off values < 0.3 and > 0.6) than for MR (cut-off values < 0.3 and > 0.7) Robust TEE method for both AR and MR Measure only if clear “bottleneck” can be identified by flow convergence proximal to it, and expanding jet distal to it Always use long-axis views for VC measurements, particularly in MR (short diameter of effective orifice, avoids overestimation) In TTE it is best to use parasternal views, if possible zoom for convenient measurement
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48	The proximal flow convergence zone is not necessarily hemispheric
49	Reasons for a nonhemispheric proximal flow convergence shape (finite orifice, wall constraints, LV outflow)
50	Extreme confinement of proximal flow convergence by adjacent wall in posterior leaflet prolapse (“wall PISA”)
51	At which alias velocity is the flow convergence zone most hemispheric (not necessarily where it looks hemispheric)? How can we find the sweet zone?
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53	"There is phasic variation of..." There is phasic variation of regurgitant flow dependent on mechanism (more in functional MR) and severity (less in more severe MR) So when to measure? – Greatest flow convergence radius after closure of mitral valve (don’t use a frame before/during MV closure)
54	Proximal Flow Convergence EROA calculation by PFC is a reasonable estimate of regurgitant severity in MR, more problematic in AR. Results can be easily translated into grades I – IV, and should be, since the method has its limitations (as any quantitative method has) Although less accurate in eccentric jets, very valuable to alert to significant regurgitation precisely in eccentric jets Dial alias velocity of 40 cm/s, higher if regurgitation appears to be more severe, avoid going lower, if possible Use the frame where the size of the PFC region is maximal, but not before valve closure
55	Back to PW and CW Doppler - MR Systolic predominance Diastolic predominance Systolic flow reversal
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74	Mitral Valve Surgery – A Paradox ?
75	"MR is only a marker..." MR is only a marker of poor myocardial function and annuloplasty will therefore not significantly affect outcome?
76	McGee EC, Gillinov AM, Cosgrove DM Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2004 During the first 6 months after repair, the proportion of patients with 0 or 1+ mitral regurgitation decreased from 71% to 41%. 60% had at least 2+ MR! The proportion with 3+ or 4+ regurgitation increased from 13% to 28% ( P < .0001). Almost 30% had severe MR.
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83	ACC/AHA Guidelines for the timing of surgery for asymptomatic patients with severe MR With the appearance of echocardiographic indicators for LV dysfunction: LVEF < 0.60 and/or LVESD > 40 mm (> 0.26 mm/m²) Normal LV function, but recent onset of episodic or chronic AF and high likelihood of successful valve repair Normal LV function, but pulmonary hypertension*
84	LV after valve repair for chronic MR: predictive value of preoperative assessment of contractile reserve by exercise echocardiography 74 pts with severe chronic MR (prolapse or flail), no CAD, FC I or II who underwent uncomplicated valve repair at the Cleveland Clinic EF decreased from 64% + 9% to 55 + 10% 18 (24%) had an EF < 50% 2 weeks postop
85	LV after valve repair for chronic MR: Predictive value of preoperative assessment of contractile reserve by exercise echocardiography
86	LV after valve repair for chronic MR: Predictive value of preoperative assessment of contractile reserve by exercise echocardiography
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89	"Why is vasodilator therapy ineffective..." Why is vasodilator therapy ineffective in chronic organic MR? What are the medical therapeutic options for patients with functional MR?
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93	The way to treat functional MR is addressing the mechanism Increasing closing force Decreasing tethering force
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100	The nonischemic Dynamics of Ischemic MR Dynamic during exercise Ischemia is not a prerequisite for dynamic MR
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102	Long-term outcome of patients with heart failure and dynamic functional MR