ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE

Echocardiographic evaluation of
Mitral Valve Disease
Dr.Nagula Praveen,
Second yr PG2/8/2015

Inge Edler
Carl Hellmuth Hertz
Father of
Echocardiography
1953

Kennedy J W Circulation. 2000;101:2552-2553
Copyright © American Heart Association, Inc. All rights reserved.
Harvey Feigenbaum Harold T Dodge
Used M mode echocardiography for measuring ventricular volumes
Coined the term Echocardiography

Introduction
• Echocardiography is the primary diagnostic tool for evaluating
patients with known or suspected mitral valve disease.
• Mitral valve was the first of the four cardiac valves to be evaluated
with echocardiography(high prevalence of RHD, large excursion of
the mitral valve leaflets – easier target for M mode techniques).

Mitral Valve Apparatus (MVA)
• Mitral annulus
• Mitral valve leaflets
• Commissures
• Chordae tendinae
• Papillary muscles
• LV wall
Bishop Mitre

Mitral Annulus
• Dynamic,anatomically ill defined structure.
• Enface – kidney bean, 3D – nonplanar saddle shape.
• Anterior flatter portion is continuous with aortic annulus – parallel
collagen fibers.
• Posterior is loosely anchored, helps in systolic apical bending along
a medio lateral commissure axis, increase in saddle height, decrease
in circumferential area.
• Normal mitral annular orifice is 4 to 6 cm² .
• Dilatation primarily affects the PML.
• MA area significantly increases in patients with dilated LVs, cause
being MA flattening, decrease and delay of systolic sphincter like
mitral annular area.

Mitral Leaflets
• Anterior and posterior leaflets.
• Leaflet – MA ratio of 1.5 to 2.0 is sufficient to prevent significant
mitral regurgitation.
• Atrial surface of the leaflets is smooth, leaflet body is translucent,
rough zone starts approx. 1cm from the distal leaflet edge.
• Irregular rough zone helps to maintain a seal, when leaflets coapt.
• Ventricular surface of leaflet – basket weave of criss crossed collagen
strands.
• Primary chordae insert at the free leaflet tips.
• Secondary chordae insert close to the rough zone.

(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic
valve, this comprises the clear zone of the leaflet.
McCarthy K P et al. Eur J Echocardiogr 2010;11:i3-i9
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author
2010. For permissions please email: journals.permissions@oxfordjournals.org

ANTERIOR MITRAL
LEAFLET
POSTERIOR MITRAL
LEAFLET
• AORTIC or SEPTAL
• Trapezoid shaped or dome shaped
• Anchored to fibrous portion of the
MA.
• Encircles on 1/3rd of annulus, but
covers 2/3rd of valve orifice area.
• Fibrous continuity with non
coronary cusp of aortic valve.
• Larger, longer, thicker than the
posterior leaflet.
• 3 cm base.
• A1(lateral),A2(middle),A3(medial),
nomenclature does not represent
anatomically distinct structures.
• MURAL
• Crescentric,
• Long circumferential base
• Short radial length.
• Occupies 2/3rd of the annulus, but
covers only 1/3rd of the valve area.
• 5cm base
• Posterior portion of MA
• P1(lateral),P2(middle),P3(medial)
• Slits and indentations within PML
demarcate these scallops.

• Anterior leaflet is twice the height of the posterior leaflet but
has half its annular length.
• Mitral leaflets thicken with advanced age, particularly along
their closing edges.

Structures behind PML
• Left circumflex coronary artery, which courses within the
leftatrioventricular groove near the anterolateral commissure, and the
coronary sinus, which courses within the left atrioventricular groove
adjacent to the annulus of the posterior mitral leaflet.

Commissural leaflet,Accessory or junctional
leaflet
• Anterolateral (A1-P1)
• Posteromedial (A3-P3)
• Tissue length measured from annular insertion is 0.5-1.0cm.

• Mitral leaflet tissue is trilaminar
• Fibrosa/ventricularis – dense collagen fibers – mechanical stability.
• Spongiosa – less organized collagen, water absorbent proteins at the
tips.
• Atrialis layers. – network of collagen and elastin, leaflet remodelling
and adaptation.
• AML – dominant fibrosa – high tensile strength
• PML – thinner, more flexible.
• AML – dense innervation.

Carpentiers nomenclature
Anterior leaflet is
termed as “A”.
 A1 scallop:- lateral third.
 A2 scallop:- middle third.
 A3 scallop:- medial third.
Posterior leaflet is
termed as “P”.
 P1 scallop:- lateral third.
 P2 scallop:- middle third.
 P3 scallop:- medial third.

• Middle scallop is the largest of the three in more than 90% of
normal hearts.
• Either the anterolateral or posteromedial scallop is larger.
• Rarely there are accessory scallops.
• PML prolapse usually involves the middle scallop and can be
assosciated with chordal rupture.

Chordae Tendinae
• Fibrous strings that originate with highly variable branching from the PM
tips(heads) and insert fanlike into the ventricular aspects of the anterior,
posterior and commissural leaflets.
• Chordae from the basal posterior myocardium, insert directly into the
posterior leaflet.
• Interfacing tightly linked collagen.
• Primary marginal chordae – leaflet free edges
• Secondary basal chordae – AML rough zone, PML– through out body.
• Strut chordae – pair of thick secondary chordae – 4 and 8 PM into
ventricular aspect of AML.
• Basket woven collagen fibers distribute chordal force from insertion to the
annulus.
Primary chordae prevent flail leaflet.
• Average length of chordae -20 mm
• Thickness of 1-2 mm.

View of the ventricular surface of an adult mitral valve.

Commissures
• Cleft like splits in the leaflet tissue that represent the sites of
separation of the leaflets.
• Beneath the two comissures, lie the anterolateral and psoteromedial
papillary muscles which arise from the LV free wall.
• Commissural chords – free edge of the leaflets adjacent to the major
commissures, or into two adjacent scallops of the PML,minor
commissures.
• In contrast to congenital cleft, a true commissure is always
assosciated with an underlying papillary muscle and an intervening
array of chordae tendinae.
• Seldom elongated.
• Proper closing plane for the leaflets during the surgical repair.

Papillary muscles
• Lateral and medial
• Originate from the apical one third of LV
• Finger like projection into LV.
• Lateral PM has a single head and dual blood supply from the LCX,
LAD artery.
• Medial PM most commonly has 2 heads –supplied by RCA or LCX.
• Acts as Shock absorber .
• Small left atrial branches supply the most basal aspects of the mitral
leaflets.

Papillary muscle head orientation and distribution.

Rheumatic Mitral Stenosis
Echocardiographic Assessment of
Mitral Stenosis

Introduction
• MS is characterized by pathologic thickening and narrowing of the
valve, resulting in a reduction in the valve orifice area.
Effect :
• 1.Obstruction to transmitral flow in diastole
• 2.An increase in upstream pressures
• 3.Pulmonary hypertension
• 4.A decrease in cardiac output.
Rheumatic Heart Disease (RHD)is the most common cause of Mitral
Stenosis(MS).

Echocardiography helps in early detection of RHD
• Marijon and colleagues demonstrated a prevalence of 2.3cases/1000
by auscultation alone, and a 10 fold higher prevalence of 30.4 cases
per 1000 by echocardiography screening of school age children in
Cambodia and Mozambique.
Prevalence of RHD detected by echocardiographic screening, NEJM 2007;357:470-6
• As many as 54% of patients with echocardiographic features of
RHD can be missed by auscultation alone. Carapetis et al(2008)
• Focused screening of mitral and aortic valves is needed for detection.
• Echocardiography is highly specific for RHD, with a positive
predictive value of 94%. Minich et al (1997).
• WHO recommends echocardiographic screening of endemic
populations(2005).

(A) Specimen demonstrating rheumatic mitral valve.

Echo evaluation done for
• Assessing the severity of stenosis.
• Assosciated mitral regurgitation
• Assosciated valve lesions
• PA pressure estimation from TR
• Valve suitability for BMV.
• Restenosis

M mode
• Parasternal long axis and short axis.
• High temporal resolution – leaflet motion is beautifully illustrated.
• Movement of the normal anterior mitral leaflet has 4 distinct phases,
giving it the characteristic M shape during diastole.
• 1.Early Diastole : a brisk rapid opening or anterior excursion (E wave)
at the onset of the diastole, resulting in rapid filling of the left
ventricle.
• 2.Mid diastole or diastasis : near closure during passive filling of LV
• 3.Late diastole : a smaller anterior excursion caused by left atrial
contraction (A wave)
• 4.Early systole/isovolumic contraction : valve closure

• Posterior mitral leaflet has a less exaggerated independent pattern of
motion, with a W shape.
• In rheumatic MS there is a distinct and easily recognizable
distortion of this M mode pattern.
 Thickening of leaflets
 Delay in amplitude and slope of the E wave (delayed valve opening)
 A slow descent or flattening of the E-F slope (increase in LV filling
pressures)
 Decrease in amplitude of the A wave (decreased atrial contraction).

On M mode in patient with Mitral Stenosis specifically
Rheumatic Etiology,
PML moves anteriorly and in parallel with the AML,
rather than in usual posterior direction.
– highly specific for MS.
Segal et al,Echocardiography clinical application in mitral stenosis. JAMA 1966;195-161-6.
Ticzon et al,1975

• The slower and flatter the slope of the E wave, the more severe the
MS.
• A slow slope of 10-30 mm/sec and an E wave height of 20 mm
indicate severe MS with a valve area of less than 1.0 cm2 .
• Segal et al,JAMA 1966;195:161-6.
Flattening of the E-F slope is due to
 1.increase in left ventricular filling pressure
 2.poor left ventricular compliance
 3.pulmonary hypertension
A wave is absent in patients with AF.
1. E F slope

Winters and associates emphasized that a correlation between E-F slope
and valve area could only be seen in patients with an amplitude greater
than 10 mm.
Winters et al. reported the relationship between E-F slope and amplitude
of excursion.
Correlation of EF slope with MVA was poor (r=0.20) Naccarelli et al,
Cope et al (r = 0.49),Wann et al (r = 0.51).
Grading of Mitral stenosis based on EF slope
E- F slope Mitral Stenosis
< 15 mm/sec Severe
15-25 mm/sec Moderate
26-35 mm/sec Mild
>35 mm/sec Normal
Winters et al.

• B bump indicates increased LVEDP.
• EPSS normal is <0.6cm.or 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in
patients with severe left ventricular systolic dysfunction.
Aloir Queiroz Araujo,, Alaor Queiroz Araujo
• (1) Mitral B bump is essentially a late diastolic phenomenon in which
the leaflets keep a semi-open position without LV inflow
effectiveness.
• (2) The resultant LA pressure which prolongates the duration of AR
wave beyond A wave, analogously work over mitral leaflets, pushing
them toward LV generating the bump.
• (3) DR is caused by LVEDP higher than LA pressure and coexists
with B bump without a cause–effect relationship.
• May 2004,95:1:7-12

• The plane of M-mode cut will change the mitral valve motion .(May be this is most
common .M-mode at tip of mitral valve may be trifid ,however a little beyond may
record a bifid-M pattern .
•Redundant mitral valve
•Mid diastolic AML drag
•Signs of elevated LVEDP
•Finally , it could be a sign of mitral valve fatigue after exercise . Some of these
persons revert back to M pattern after a brief period of Trifid motion following
exercise .

DE amplitude is reduced <15 mm
DE amplitude Normal 17-30 mm
DE slope = 240-380 mm/sec
EF slope = 50-180 mm/sec

Absent A peak in patients not in Atrial
fibrillation

Rapid AC slope 350 mm/sec or 35 cm /sec

Leaflet separation remains constant through
out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic
Leaflet Separation
Michael L. Fisher, Charles E. DeFelice, Nathan H. Carliner.et al.
Arch Intern Med. 1979;139(4):402-406. doi:10.1001/archinte.1979.03630410012009

DE/MAIC
• Mitral echogram measured at the onset of left ventricular isovolumic
contraction(MAIC). (R wave on ECG ,C wave on ACG)
• DE represents the opening amplitude of the mitral valve in early
diastole.
• DE/MAIC ratio used avoid other conditions causing reduced diastolic
closure rate.
• Correlation (r=0.84)
Pavlos Toutouzas et al, British Heart Journal,1977,39.73-79.
MAIC DE/MAIC
NORMAL 2-4 mm (2.7 mm average) 3.3 -6.5 (5.1)
AS and HOCM 2-4 mm (2.9 mm average) 2.7 -6.5 (4.2)
MS 6-17 mm (11.3 mm average) 0.7 -1.5 (1.1)

Shiu’s index(Mitral Valve Closure Index)
• Distance between anterior and posterior mitral leaflet echoes is
measured at early (X1) and at end diastole(X2).
• MVCI is obtained as follows:
X1-X2
t  X1
• MVCI of 20 is assosciated with severe MS and
• MVCI of 80 excludes significant mitral stenosis.
 100 %
MVA (cm²) MVCI
< 1.3 13
1.3-1.8 49
> 1.8 74
British heart Journal 1977:39:839

Left Atrial emptying index
(Strunk et al ,Circulation 1976:54:744)
• Ratio of the amplitude of the posterior aortic wall diastolic motion
during the first third of this interval to the total posterior excursion of
the aortic root during the whole of this interval.
In severe MS, AEI is less than 0.4.
In moderate MS it is 0.5 or 0.6.
In mild MS it is 0.7

Gerald V Naccarelli et al Chest ,76:6,December 1979.
• Close relation between the AEI and MVA ( r =0.93).
• Not correlated well with the left atrial size (r = 0.10 ) or the EF
slope of the mitral valve (r = 0.20).
• Useful in categorizing the patients with mitral stenosis.
• overall predictive value is 86%.
• Sensitive index in estimating mitral stenosis.
• AEI = 0.5 –MVA from 1.3 -1.8 sq cm.

Two Dimensional Echocardiography
• The normal mitral valve leaflets are thin <4mm,translucent and
highly mobile structures, with the AML exhibiting the greater
mobility.
• Maximum mobility is seen in the leaflet tips.
• In rheumatic MS, the leaflet thickening is most pronounced at the tips,
with relative sparing of the midportion, giving the characteristic
“bent knee” or “hockey stick” appearance.
• The leaflets open and close suddenly.
• Appearance of convexity into the LV in diastole (doming)
• Convexity into LA during systole.
• PML is thickened and restricted, paradoxically pulled forward by
the AML in diastole.

Assessment of severity of
Mitral Stenosis
Severity is quantified by
• Doppler transmitral pressure gradient
• Pulmonary hypertension
• Mitral valve area (MVA)

Transmitral Pressure Gradient
• Mean transmitral gradient is extremely important for grading the
severity of MS
<5 mmHg – mild
5-10 mm Hg – moderate
>10mm Hg – severe
• Correlates well with invasive measurements, and is easily
reproducible.
Apical four chamber view
• Mean gradient is highly sensitive to alterations in mitral flow,
atrioventricular compliance and heart rate.
• With tachycardia there is a decrease in diastolic filling, resulting in
elevation of the mean gradient.
• In the presence of AF, atleast 5 and usually 10 cycles have to be
averaged to obtain an accurate mean gradient.

Estimation of
Pulmonary Artery Pressure
• The obstruction of flow at the mitral orifice results in pulmonary
hypertension and increased pulmonary vascular resistance.
• The degree of pulmonary hypertension is a measure of the
hemodynamic burden.
• Pulmonary artery systolic pressure(PAP) is incorporated in grading
the severity of MS
<30 mm Hg – mild
30-50mmHg – moderate
>50 mm Hg - severe
• Echocardiographically estimated RVSP is used as a surrogate for
PAP, in absence of PS.
• RAP is estimated from size of IVC and respiratory collapsibility.
Bonow RO et al 2008 ACC/AHA guidelines

RVSP (mmHg)  PAP =
Transtricuspid gradient +RAP

Mitral valve area
• The normal MVA is 4.0 - 6.0cm2.
• Typically patients with MS do not experience symptoms until the
valve area is less than 2.5cm2.
• Based on mitral valve area, stenosis is classified as
Severe < 1.5 cm²
Very severe < 1.0 cm²

Methods to estimate the MVA
• 1.2D planimetry
• 2.Pressure Half Time (PHT)
• 3.Continuity method
• 4.Proximal Isovelocity Surface area (PISA)method
• 5.3D planimetry
• 6.Color Doppler method
Good correlation with invasively derived area and surgical
anatomic sizing, there are inherent limitations.

• Valve area indexed to body surface area has not been validated.
• Planimetry and PHT methods are the most widely used and easily
applicable.
Planimetry is considered the reference method.
No single method should be solely relied on and data from multiple
methods should be interpretated in the appropriate clinical setting.

2D Planimetry
• Based on direct visualization of the mitral valve orifice.
• Not limited by hemodynamic loading conditions.
• Excellent correlation with direct sizing at surgery (r =0.92),and
invasively derived area using the Gorlin hydraulic formula (r =0.95).
• Mitral inflow is funnel shaped, with the narrowest orifice at the level
of the leaflet tips.
Parasternal short axis view.
• The inner rim of the orifice, including opened commissures, is traced
in mid diastole to calculate the MVA.
• Several measurements to be averaged in patients with HR variability
and AF.
• Can be challenging in setting of poor image quality, heavily
calcified or distorted valves.

limitations
• Irregular orifice difficult to measure.
• A calcified object appears larger than it is actually on echo,as
calcium reflects ultrasound very well.hence the orifice will
appear smaller. (Blooming of echoes)
• If chordae are thickened,they can be mistaken for one of the
leaflet.
• Gain should be kept minimal.

• Pressure gradient is dependent on volume status,stroke volume
and heart rate,which affects filling time.
• Transmitral gradient plus the anticipated LVDP = LAP.
• LAP =PVP =PCWP = hydrostatic pressure.

Hatle and colleagues
• Concept of PHT as a relatively flow independent assessment of MS
severity.
• PHT – the time taken for the transmitral pressure gradient to decay to
half the value at the onset of diastole.
• Time required for the peak velocity to decrease to V/2 or V/ 1.4.
• PHT across isolated MS can be between 90 and 383 msec.
In stenotic mitral valves, there is a linear and inverse relationship
between MVA and PHT.
The more severe the MS, the longer the PHT.
Hatle et al ,Noninvasive assessment of AVPHT by doppler Ultrasound,
Circulation 1979;60:1096-1104

• Hatle and colleagues proposed a derivation of MVA by using the
empirical formula
MVA = 220/PHT
• The PHT can also be calculated by multiplying the deceleration time
(time required for the peak velocity to decrease to the zero baseline)
by 0.29.
• PHT is directly proportional to left atrial and ventricular
chamber compliance and the square root of the initial peak gradient.

Caveats to the blanket use of PHT method
• Unreliable in the presence of tachycardia and AF.
• Post valvotomy period (24-72 hrs) - abrupt changes in the
atrioventricular pressure compliance relationships and
transmitral gradient. Thomas et al,Circulation 1988;78:980-93
• Increased LV stiffness – aortic valve disease or CAD – may
overestimate MVA. Karp et al, JACC 1989:13:594-9
• Concomitant AR – shortening of PHT - overestimation of
MVA. Gillam et al, JACC 1990;16:396-404

Determination of Doppler pressure half-time (T1/2) with a bimodal, non-linear decreasing
slope of the E-wave.
Baumgartner H et al. Eur J Echocardiogr
2008;ejechocard.jen303

Imp points
• If a line drawn above and not within then PHT will be longer.
• In atrial fibrillation use long R-R intervals.
• Severe AR shortens, the PHT and so understimates the severity.
• In patients with LVH,relaxation can be slower,the PHT will be longer.
• PHT can be used in patients with mitral regurgitation.(but not
continuity equation) .

• Mean pressure gradient is directly related to the average area
of the restrictive orifice and cardiac output.
• The peak instantaneous early pressure gradient between the
LA and LV is also related to the early transmitral flow volume.
• Early flow volume is dependent on cardiac output and by high
left atrial volumes – MR ,high output states.
• There is disproportionate increases in the early vs mean
gradient.
• This discrepancy can be a clue to concomitant MR especially
eccentric jets or paravalvular leaks.

DT= 216/0.29= 744 msec
DT Normal <220 msec.
Normal PHT < 60 msec

MVA by continuity method
• Principle of conservation of mass.
• Stroke volumes proximal and distal to the stenotic mitral valve must
be equal.
SV = Valve area  VTI
MVA = LVOT SV / VTI MS

Limitations
• Most accurate in patients without significant mitral regurgitation.
• Accurate pulmonary artery diameter measurement for SV
calculations can be difficult in adult patients because of poor
acoustic access.
• Some degree of AR,MR present in patients wit MS so transaortic
stroke volume dose not equal transmitral stroke volume.

PISA method
• Principle of flow convergence.
• Multiple hemispheric shells of increasing velocity and decreasing
radius – as flow accelerates towards an orifice.
• All blood cells at a particular hemisphere must have the same
velocity and radius.
• To conserve mass flow rate at a given hemispheric shell must be
equal to the flow across the stenotic mitral valve.
Diastolic flow rate at stenotic mitral valve = flow rate
at PISA

• Color flow doppler assessment of the mitral inflow in the
Apical 4 chamber window.

• PISA method has been shown to have a good correlation with
other methods of MVA estimation.
• In the presence of AF, the correlation is decreased but is
reasonable.

3D Echo
• Can visualize the mitral valve enface.
• 3D Planimetry has the closest agreement with invasive gorlin derived
MVA.
• Can be useful immediate postop of PBMV for accurate valve area.

Stress Echocardiography
• Class I indication for exercise echocardiography in patients with
discordant clinical features and stenosis severity by resting ECHO.
• Intervention can be considered in patients with a mean gradient
greater than 15 mm Hg or PAP greater than 60 mmHg with
exercise.
• Gorlin and colleagues – patients with MS experience a significant
increase in HR,LAP,PAP during supine bike exercise.
• In patients with poor left atrial compliance can have substantial
elevations in PAP during exercise.

• Both exercise and dobutamine stress echocardiography have been
studied.
• Supine bike exercise is preferred to dobutamine.
• Exercise is a more physiological stressor, and results in greater
elevations of HR,LVFP,PAP
• In patients who are unable to exercise, DSE can be performed.

Ideal echo scoring system
CRITERIA:
• Global and segmental evaluation (qualitative and quantitative) of each
MV apparatus component separately to localize the deformity in a
specific portion of MV apparatus.
• Inclusion of all points that proved to predict and affect the PMV
outcome via large study.
• Validation in large studies that include patients with different age
groups (not only young).
• Easily applicable and interpretable by most cardiologists within a
reasonable time.
• High reproducibility and reliability.
• Unified for both transthoracic and transesophageal approaches.

Wilkins score
• Also called Boston, Abascal score.
• 1988 Gerard T. Wilkins,Arthur E.Weyman,Vivian M Abascal et al.

Drawbacks of Wilkins score
• Limited in ability to differentiate nodular fibrosis from
calcification.
• Assessment of commissural involvement is not included or
underestimated.
• Doesn’t account for uneven distribution of pathologic
abnormalities.
• Doesn’t account for relative contribution of each variable (no
weighting of variables).
• Frequent underestimation of sub valvular disease.
• Doesn’t use results from TEE or 3D echocardiography.

• CHENNAIAH20150128182116596.avi
• GOVIND CRHD20150127113838630.avi

• PSax view for commissural calcification.
• High intensity bright echoes extending across the commissure
were taken to be areas of commissural calcification.
• Each half commissure with such echoes score of 1.
• Grade 0 -4.

Significance of commissural calcification on outcome of mitral balloon valvotomy
N Sutaria, et al.,Heart 2000.84:398-402.

Chen et al
• A modified Wilkins score parameter for subvalvular thickening
according to the involved segment of chordal length:
• (1) if less than 1/3,
• (2) if more than 1/3,
• (3) if more than 2/3, and
• (4) if involved the whole chordal length with no separation.
Chen CG, Wang X, Wang Y, et al. Value of two-dimensional echocardiography in selecting
patients and balloon sizes for percutaneous balloon mitral valvuloplasty.
J Am Coll Cardiol. 1989;14(7):1651–8.

Reid score
It includes
• leaflet motion,
• leaflet thickness,
• subvalvular disease, and
• commissural calcium.
• Leaflet motion was expressed as a slope by dividing the height (H) by
the length (L) of doming of anterior leaflet.
• Leaflet thickness was expressed as the ratio between the thickness of
the tip of MV and thickness of posterior wall of aortic root.
• The score was assigned as
0 for mild affection,
1 for moderate, and
2 for severe affection
Reid CL et al. Influence of mitral valve morphology on double-balloon
catheter balloon valvuloplasty in patients with mitral stenosis. Analysis
of factors predicting immediate and 3-month results.
Circulation. 1989;80 (3):515–24.

Nobuyoshi score
• Leaflet pliability,
• Commissural disease, and
• Subvalvular apparatus
Nobuyoshi M, Hamasaki N, Kimura T, et al. Indications, complications, and short-term
clinical outcome of percutaneous transvenous mitral commissurotomy.
Circulation. 1989;80 (4):782–92

Cormier score
• Cormier score divided the patients into three groups depending on
leaflets mobility ,calcification and subvalvular affection:
• Group 1, pliable noncalcified AML and mild subvalvular
disease (i.e., thin chordae >10 mm long);
• Group 2, pliable noncalcified AML and severe subvalvular
disease (i.e., thickened chordae <10 mm long); and
• Group 3, calcification of MV of any extent, as assessed by
fluoroscopy, whatever the state of subvalvular apparatus.
Iung B, Cormier B, Ducimetiere P, et al. Immediate results of percutaneous mitral commissurotomy.
A predictive model on a series of 1514 patients.
Circulation. 1996;94(9):2124-30.

3D Echo score
Anwar AM, Attia WM, Nosir YF, et al. Validation of a new score for the assessment of mitral stenosis
using real-time threedimensional echocardiography.
J Am Soc Echocardiogr: Official Publication of the American Society of Echocardiography.
2010;23(1):13–22.
Mild mitral valve < 8
Moderate 8-13
Severe >14

Scallops in 2D Echocardiographic views

Advantages of 3D Echo score
• The 3D score has many potential benefits that help for a detailed
assessment of the MV.
1. Visualization of leaflets. By RT3DE, visualization and assessment of
the whole length of both leaflets is possible through single image
plane, especially in sinus rhythm. Leaflet mobility could be well
assessed.
• RT3DE could detect the thickness of each leaflet scallop.
• The whole leaflet length could not be evaluated by a single 2DE
image especially for the posterior leaflet, which is short and
naturally less mobile than the anterior one.

2. Leaflet calcification. Scoring of leaflet calcification using Wilkins
score depends on the bright areas and the extension of calcification
along the leaflet length . Multiple cut planes are needed for detecting
calcification in all scallops of both MV leaflets.
• RT3DE could predict the extent and distribution of calcification in
each scallop from a single short axis cut plain.
• The new RT3DE score described calcification at the commissural
parts of leaflet by a higher score than the middle leaflets calcification
because it was proved that calcification of commissures is one of the
strong predictors of outcome after PMV ,the degree of commissural
splitting
3. Subvalvular apparatus. RT3DE score included the chordal thickness
and separation, which is a good independent predictor for BMV
outcome.

• Both chordal thickness and separation are scored at three levels by
dividing their length into three parts (proximal, middle, and distal).
This detailed information, especially for chordal separation, was not
obtained by most 2D scoring systems, including Wilkins score .
4. Score applicability. Compared to Wilkins score, the RT3DE score is
simple and more helpful, particularly for less experienced operators as
it provides a simple number for each leaflet scallop and subvalvular
apparatus segment separately. This was evident by good interobserver
and intraobserver agreements for most of the score components.
5. Score approach. The score can be applied using both transthoracic
and transesophageal approaches because the image orientation and
interpretation are not different.

Limitations
• Not available in all cardiac centers.
• Operator dependent.
• Analysis based on software .
• Complex and time consuming.

TEE
• The standard midesophageal (ME) views (four-chamber,
commissural, two-chamber, and long-axis) assist in evaluating the
extent of disease.
• The chordal tendons can display varying degrees of thickening and
contracture.
• The transgastric (TG) long-axis imaging plane provides the best
information with regard to the extent of subvalvular involvement in
the rheumatic process.

Vijaya’s echo criteria
S. NO ECHO FEATURE SCORE
1 Mitral valve and aortic valve thickness >4 mm 2
2 Increased echogenicity of submitral structures 2
3 Rheumatic nodules (beaded appearance) 2
4 MVP,/AVP,/TVP 2
5 Mitral regurgitation and aortic regurgitation,tricuspid
regurgitation
2
6 Reduced mobility of the valves 2
7 Chordal tear 2
8 Pericardial effusion 2

• Saddle shaped annulus plays an active role in mitral valve
leaflet coaptation and in LA,LV systole and diastole.
• Annulus is susceptible to disease processes that are distinct
from those that affect the mitral valve leaflets.
• The calcification may extend onto the posterior leaflet, thereby
increasing the diastolic gradients across the mitral valve.

Mitral Annular Calcification
• MC cardiac findings at autopsy.
• Calcium deposited between posterior LV wall and PML.
• TTE –PLAX view,PSAX
• Anterior involvement – advanced cases,rare
• Calcification of the aortic valve,papillary muscles,chordae
tendinae frequently coexist with MAC.

• Assosciated with female age, advanced age, diabetes, hypertension.
• Patients with MVP.
• 9% of women,3% of men with > 60 yrs of age.
• ESRD requiring dialysis.
• Framingham Heart Study – CKD pts with e GFR <
60ml/min/1.73m2 were 1.9 times more likely to have MAC compared
to those without CKD after age and sex matching.
• Deranged calcium and phosphorus metabolism
• MAC is marker for atherosclerotic burden and is assosciated with an
increased risk of atrial arrhythmias, stroke and CV morbidity and
mortality.
• For each mm increase in size of the MAC,the event rate increased by
approx.10%.
• Increased burden of aortic atherosclerosis is seen in pts with MAC.

CCMA
• Caseous Calcification of Mitral Annulus
• Rare variant.
• Misinterpreted as tumor, abscesses or thrombus on echo.
• Combination of fatty acids, calcium, cholesterol.
• White caseous paste like material surrounded by calcium shell.
• Amorphous eosinophils, macrophages, lymphocytes with scattered
areas of necrosis,calcification on histology.
• Cause is unknown.
• Posterior periannuluar region on ECHO.
• Central area of echoluceny, which represents liquefaction
necrosis,and the absence of acoustic shadowing help distinguish it
form true MAC.

• No clinical differences have been shown to exist between
patients with MAC and those with CCMA.
• Benign
• Can progress or resolute.
• Has been shown to cause stenosis or regurgitation by mass
effect at mitral valve,erosion into the left atrium,erosion into
the left circumflex artery.
Caseous Calcification of the Mitral Annulus
Harvinder Arora, et al.Tex Heart Inst J. 2008; 35(2): 211–213..

Presence of A wave more than E wave
rules out significant MS

Radiation assosciated calcific MS
• Hodgkin’s cancer,breast cancer.
• 70-80% prevalence of valve fibrosis in patients treated with chest
radiation exceeding 35 Gy.
• 6-15% of treated pts – valvular heart disease.
• More than 20 yrs after radiation exposure.
• Decreased population of endothelial progenitor cells.
• Severe MAC and THICKENING of AMC extending onto AML.
• PML is mobile – distinguishes from degenerative MAC.
• No commissural fusion,subvalvular apparatus is typically
unaffected.

MITRAL VALVULAR DYSFUNCTION
Mitral Regurgitation:
• MC form
A.Sphincter like action does not occur in systole.
• Size of the annulus is not decreased in systole,so MR occurs.
B. Leaflet elevation of PML.
Mitral stenosis:
• When MAC is heavy and extends onto leaflets.
• Degenerative MS.
• Limiting orifice area is at the base of the mitral leaflets.
• Well appreciated by real 3D TTE.
• Tubular geometry of the mitral orifice.

Quantifying the severity
• Planimetry to be avoided - limiting orifice is at the base of the
leaflets.
• Mean diastolic gradient
• PHT to be avoided – because of decreased LV compliance
(usually seen in pts with MAC). – overestimation of MVA.
• PISA method is acceptable(color line shifted in the opposite
direction).
• RT3DE derived MVA better than PHT derived MVA
compared to continuity equation – Chu et al.

Figure 5 Congenital mitral stenosis. Parachute-like congenital mitral stenosis with a circular
orifice and no commissures in (A) two-dimensional transthoracic echocardiography and (B)
three-dimensional transthoracic echocardiography.
Laura Krapf , Julien Dreyfus , Caroline Cueff , Laurent Lepage , Éric Brochet , Alec Vahanian,
David Messika-Zei...
Anatomical features of rheumatic and non-rheumatic mitral stenosis: Potential additional value
of three-dimensional echocardiography
Archives of Cardiovascular Diseases, Volume 106, Issue 2, 2013, 111 - 115
http://dx.doi.org/10.1016/j.acvd.2012.11.004

Three-dimensional transesophageal images, surgical view (live 3D zoom mode).

• nejmicm1310149_attach_1_nejmicm1310149_v01.mp4
• MAHARSHI
BALLVALVETHROMBUS20141220143245248.avi

Prosthetic Mitral Valve Stenosis
• Easier to visualize.
• Parasternal and apical windows.
• Stability of mitral prosthesis,dehiscence,motion of leaflets or
the occluding mechanism generally possible with transthoracic
imaging.
• Doppler beam as close to the direction of inflow.

• renukaRENUKA TEE20150110132342727.avi

Effect of Concurrent conditions
• 1.Tachycardia
• 2.Mitral Regurgitation
• 3.Aortic regurgitation decreases PHT
• 4.LV dysfunction
• 5.ASD
• 6.Tricuspid stenosis
• 7.organic TR.
• 8.pulmonic stenosis
• 9.CCP
Increased gradients

Left atrium in MS
• Dilated
• Giant LA > 6.5 cm
• LAA
• SEC
• Thrombus
• LA clot formation in SR 2.4-13.5%
• Incidence is as high as 33% in patients with AF.
Manjunath et al ,
Incidence and predictors of LA thrombus in patients with rheumatic MS and SR .
Echocardiography 2011;28(4)257-60

Conclusion
• Echocardiography is the primary modality for evlaution of mitral
valve disease.
• M mode,2D echo ,color doppler all to be correlated in estimating the
severity of mitral stenosis.
• Concurrent conditions should be kept in mind when the values don’t
correlate with the clinical findings.
• 3d echo adds additional information.

ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE

ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE

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