Echocardiography in mitral_stenosis

D R R A J E S H K F
ECHOCARDIOGRAPHY IN
MITRAL STENOSIS

CAUSES AND ANATOMIC PRESENTATION
Rheumatic
 Commissural fusion
 Leaflet thickening
 Chordal shortening and fusion
 Superimposed calcification
Degenerative MS
 Annular calcification
 Rarely leaflet thickening and calcification at base

Congenital MS
 Subvalvular apparatus abnormalities
Inflammatory-SLE
Infiltrative
Carcinoid heart disease
Drug induced valve disease
 Leaflet thickening and restriction
 Rarely commissural fusion

2D ECHO
 Commissural fusion
PSAX echo scanning of valve
Important in distinguishing
degenerative from rheumatic
valve
Complete fusion indicate
severe MS
Narrow diastolic opening of
valve leaflets

 Restricted mobility -
PLAX
 Early diastolic doming
motion of the AML-
restriction of tip motion

 Chordal thickening,
shortening and fusion –
PLAX and A4C

 Superimposed
calcification

 Dilated LA
 LA and LA appendage
thrombus
 Paradoxical septal
motion
 Dilated RV and RA

Wilkins score -Mitral valve score <8 are
excellent candidates for BMV

Limitations of wilkin score
 Assessment of commissural involvement is not
included
 Limited in ability to differentiate nodular fibrosis
from calcification.
 Doesn’t account for uneven distribution of
pathologic abnormalities.
 Frequent underestimation of subvalvular disease.
 Doesn’t use results from TEE or 3D echo

3D ECHO
 TEE and TTE
 Higher accuracy than 2D echo
 Detailed information of commissural fusion and
subvalvular involvement
 MVA measurement in calcified and irregular valve
 MVA measurement after BMV
 Restenosis after commissurotomy
commissural refusion
valve rigidity with persistent commissural opening

 Total RT3DE score ranging from 0 to 31 points
 Total score of mild MV involvement was defined as
<8 points
 Moderate MV involvement 8–13
 Severe MV involvement >14

M MODE ECHO
 Decreased E-F Slope
 >80 mm/s MVA=4-6cm²
<15mm/s⇒ MVA <1.3cm²
 Thickened Mitral Leaflets
 Anterior Motion or
Immobility of Posterior
Mitral Leaflet-tethering at
tips
 Diastolic Posterior Motion
of Ventricular Septum
(severity of stenosis)

TEE
 For diagnosis and
quantification little yield
 Spontaneous echo contrast
 LA and LA appendage
thrombus
 Use of transgastric plane
90 -1200 for evaluation of
chordal structures
 Assessment of commissural
calcification and fusion to
predict procedural outcome
after BMV

Commissure score
NON CALCIFIED
FUSION
ANTEROLATERAL
COMMISSURE
POSTEROMEDIAL
COMMISSURE
ABSENT 0 0
PARTIAL 1 1
EXTENSIVE 2 2
TOTAL SCORE O TO 4

 Scores for anterolateral and posteromedial
commissures were combined such that each valve
had an overall commissure score ranging from 0–4
 A high score indicated extensively fused,
non‐calcified commissures that were therefore more
likely to split
 A low score indicated either minimal fusion or the
presence of resistant commissural calcification

ASSESSMENT OF MS SEVERITY
2D OR 3D ECHO
 MVA BY PLANIMETRY
DOPPLER
 PRESSURE GRADIENTS
 MVA BY PHT
 CONTINUITY EQATION
 PISA
 MITRAL VALVE RESISTANCE
 PASP

MVA BY PLANIMETRY
2D Echo
 Best correlation with anatomical area
 Scanning method to avoid overestimation
 measured at leaflet tips in a plane perpendicular to
mitral orifice
 Elliptical in shape
 Direct measure of mitral orifice including opened
commissures in PSAX

 Excessive gain setting may underestimate valve area
 Zoom mode is better for delineation
 Harmonic imaging can improve planimetry
measurement
 Optimal time is mid diastole obtained by cine loop
mode on a frozen image
 Multiple measurements in AF or incomplete
commissural fusion
 difficult in calcified valve,chest deformity and
previous commissurotomy

Real time 3D echocardiography
 identify true smallest orifice independent of its
orientation
 most accurate ultrasound technique for measuring
MVA, with a superior pre- and postprocedural
agreement with the Gorlin’s derived MVA
 Less experience dependent and more reproducible

Mitral leaflet separation (MLS) index
 Distance between the tips of the mitral leaflets in
parasternal long-axis and four-chamber views
 it can be used as a semiquantitative method for the
assessment of MS severity
 A value of 1.2 cm or more provided a good specificity
and PPV for the diagnosis of non severe MS
 less than 0.8 cm -severe MS.
 It is not accurate in patients with heavy mitral
valvular calcification and post BMV

PRESSURE GRADIENT
 Apical window
 CWD /PWD at or after tip of mitral valve
 Maximal and mean gradient
 Bernoulli equation( P =4V2)
 Derived from transmitral velocity flow curve
 Heart rate to be mentioned
 CD to identify eccentric mitral jet

 Maximal gradient influenced by LA compliance and
LV diastolic function
 In AF average of 5 cycles with least variation of R-R
interval and as close possible to normal HR
 MVG dependent on HR,COP and associated MR
 Tachycardia, increased COP and associated MR
overestimates gradient
 Maximal gradient is markedly affected

PRESSURE HALF TIME
 T1/2 is time interval in msecs between max mitral
gradient in early diastole and time point where
gradient is half max gradient
 Or it is the time when velocity falls to 1/1.414 peak
 PHT related to decceleration time
 PHT =.29x DT
 MVA=220/PHT

 The empirically determined constant of 220 is
proportional to the product of net compliance of left
atrium and LV, and the square root of maximum
transmitral gradient in a model that does not take
into account active relaxation of LV

 Obtained by tracing deceleration slope of E wave on
Doppler spectral display
 Concave not feasible
 If slope is bimodal deceleration slope in mid diastole
rather than early diastole is traced

AF avoid short cycles and average different
cardiac cycles

 Less dependent on COP or coexistent MR
 Useful when mean transmitral gradient is misleading
 MR -transmitral gradient overesimated
 Low COP –mean transmitral gradient -
underestimated

Factors that may affect PHT by influencing LA
pressure decline
More rapid LA pressure decline shorten PHT
LA draining to second chamber –ASD
 LA pressure drop rapidly
 PHT shortened
Stiff LA –low LA compliance
 LA pressure drop rapidly
 PHT shortened

Factors affect PHT by influencing LV pressure
rise
More rapid LV pressure rise shorten PHT
If LV fills from a second source PHT –AR
 LV pressure rise more rapidly
 PHT will be shortened
If LV is stiff-low ventricular compliance
 LV pressure may rise more rapidly
 PHT will be shortened

 All factors affect PHT (ASD, AR, low LA or LV
compliance )
 shorten PHT
 Leads to overestimation of MVA
 Therefore PHT never under estimate MVA
 Therefore if PHT >220 MS is severe
 If PHT is < 220 consider other methods to assess
severity

 Prosthetic MVA
 Not been validated
 Affected mainly by DD
 More accurate method is continuity equation

Not reliable
After BMV
 Normally LA and LV compliance counteract each
other
 when gradient and compliance are subject to
important and abrupt changes alter relation between
PHT and MVA
 Upto 48 hrs post BMV

 MVA X VTI mitral= LVOT area X VTI aortic
 MVA = LVOT area X VTI aortic
VTI mitral
 MVA= p D2 X VTI aortic
4 VTI mitral
 D is diameter of LVOT in CM and VTI in CM
 SV can be estimated from PA
 Method not useful in AF,AR or MR
 Useful in degenerative calcific MS

PISA
 Based on hemispherical
shape of convergence of
diastolic mitral flow on
atrial side of mitral valve
and flow acceleration
blood towards mitral
valve

MVA x MV = PISA x AV
MVA = PISA x AV
MV
PISA = 2pr2 x a
180
MVA = 2pr2 x AV x a
MV 180

 Zoom on the flow convergence
 Upshift the baseline velocity and use an aliasing
velocity of 20–30 cm/s
 Measure the radius of the flow convergence region
and the transmitral velocity at the same time in early
diastole
 Measure the α angle formed by the mitral leaflets
 Use of a fixed angle value of 100° can provide an
accurate MVA estimation in patients with MS.

 Can be used in presence of significant MR, AR,
differing heart rhythms
 Not affected by LA,LV compliance
 Multiple measurements required
 M mode improves accuracy

Colour M-mode PISA
 Instantaneous measurement of MVA throughout
diastole
 Under guidance of magnified 2D colour imaging,
colour M-mode tracings were recorded by placing
the M-mode cursor line through the centre of the
flow convergence.
 Diastole was divided into four phases of equal
duration: early, mid, mid-late, and late diastole.
 Peak radius of flow convergence was measured
during each phase to calculate mitral flow rate

 Each radius was measured from the red–blue
aliasing level to the tip of the leaflet at the orifice
 Colour M-mode analysis was then paired with
continuous wave Doppler
 Three to five measurements of each variable (on
matched cycle for colour M-mode and Doppler
methods) were averaged, depending on the patient's
rhythm.
 MVA was then calculated separately for each phase
of diastole

MITRAL VALVE RESISTANCE
 MVR=Mean mitral gradient/ transmitral diastolic
flow rate
 Transmitral diastolic flow rate= SV/DFP
 It correlate well with pulmonary artery pressure

PASP
 CWD
 Estimation of the systolic gradient between RV and
RA
 Multiple acoustic windows to optimize intercept
angle
 Estimation of RAP according to IVC diameter

STRESS ECHOCARDIOGRAPHY
 Useful to unmask symptoms in patients with
MVA<1.5cm2 and no or doubtful complaints
 Discrepancy between resting doppler and clinical
findings
 Semi-supine echocardiography exercise (30 to 60
secs of leg lifts) is now preferred to post exercise
echocardiography
 Allows monitoring gradient and pulmonary pressure
in each step of increasing workload

 Mean mitral gradient and PASP to be assessed
during exercise
 Mean gradient >15 mmhg with exercise is considered
severe MS
 A PASP > 60 mmHg on exercise has been proposed
as an indication for BMV
 Dobutamine stress echo mean gradient >18 mmhg
with exercise is considered severe MS

Associated lesions
 Quantitation of LAE
 Associated MR and its mechanism
 Severity AS (underestimated)
 AR- t1/2 method to assess MS is not valid
 TR ,tricuspid annulus
 Secondary pulmonary HTN-TR

GRADING OF SEVERITY OF MS
MILD MODERATE SEVERE
SPECIFIC
VALVE AREA(cm2) >1.5 1-1.5 <1
NONSPECIFIC
MEAN GRADIENT
(mmHg)
<5 5-10 >10
PASP (mmHg) <30 30-50 >50

1 Pressure half time in MS affected by all except
 A ASD
 B MR
 C AR
 D HOCM

2 In case of a pure MS transmitral mean gradient is
14 mmhg and mitral area by planimetry is 1.1cm2 it is
graded as
 A severe
 B moderate
 C mild
 D indeterminate

3 Commissural fusion is not a feature of MS in
 A RHD
 B Calcific MS
 C SLE
 D Carcinoid disease

4 Not included in Wilkins score is
 A commissural fusion
 B restricted mobility
 C leafllet thickening
 D subvalvular fusion

5 harmonic imaging useful in
 A 2D MVA
 B PHT
 C PISA
 D M mode

6 mitral leaflet separation index less than ----cms
indicate severe MS
 A 0.4
 B 0.6
 C 0.8
 D 0.2

7 continuity equation useful in MVA calculation in
 A AF
 B AR
 C MR
 D Calcific MS

8 Mean gradient greater than ---- mmhg with exercise
echocardiography is considered severe MS
 A 10
 B 12
 C 15
 D 18

9 In a case of severe AR with MS mitralPHT obtained
is 280 severity of MS is
 A mild
 B moderate
 C severe
 D none of the above

10 Method to assess severity of MS in diastolic
dysfunction is
 A PHT
 B PISA
 C continuity equation
 D mitral valve resistance

3D echo planimetry
 Mitral valve area
measurement using
anyplane
echocardiography.

 allows on-line assessment of the mitral valve area.
 Images are displayed as two simultaneous
intersecting orthogonal long-axis scans (B-mode
scans) and two perpendicular short-axis scans (C-
mode scans)
 These C-mode scans allow the display of short-axis
views of the mitral valve from an apical transducer
position

9 Usual mitral valve angle in PISA method to assess
severity of MS is ----degree
 A 80
 B 100
 C 150
 D 180

Echocardiography in mitral_stenosis

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (18)

Similar to Echocardiography in mitral_stenosis

Similar to Echocardiography in mitral_stenosis (20)

Recently uploaded

Recently uploaded (20)

Echocardiography in mitral_stenosis