Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
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 Feige...
Introduction
• Echocardiography is the primary diagnostic tool for evaluating
patients with known or suspected mitral valv...
Mitral Valve Apparatus (MVA)
• Mitral annulus
• Mitral valve leaflets
• Commissures
• Chordae tendinae
• Papillary muscles...
Mitral Annulus
• Dynamic,anatomically ill defined structure.
• Enface – kidney bean, 3D – nonplanar saddle shape.
• Anteri...
Mitral Leaflets
• Anterior and posterior leaflets.
• Leaflet – MA ratio of 1.5 to 2.0 is sufficient to prevent significant...
(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic
valve, this comprises ...
ANTERIOR MITRAL
LEAFLET
POSTERIOR MITRAL
LEAFLET
• AORTIC or SEPTAL
• Trapezoid shaped or dome shaped
• Anchored to fibrou...
• Anterior leaflet is twice the height of the posterior leaflet but
has half its annular length.
• Mitral leaflets thicken...
Structures behind PML
• Left circumflex coronary artery, which courses within the
leftatrioventricular groove near the ant...
Commissural leaflet,Accessory or junctional
leaflet
• Anterolateral (A1-P1)
• Posteromedial (A3-P3)
• Tissue length measur...
• Mitral leaflet tissue is trilaminar
• Fibrosa/ventricularis – dense collagen fibers – mechanical stability.
• Spongiosa ...
Carpentiers nomenclature
Anterior leaflet is
termed as “A”.
 A1 scallop:- lateral third.
 A2 scallop:- middle third.
 ...
• Middle scallop is the largest of the three in more than 90% of
normal hearts.
• Either the anterolateral or posteromedia...
Chordae Tendinae
• Fibrous strings that originate with highly variable branching from the PM
tips(heads) and insert fanlik...
View of the ventricular surface of an adult mitral valve.
McCarthy K P et al. Eur J Echocardiogr 2010;11:i3-i9
Published o...
Commissures
• Cleft like splits in the leaflet tissue that represent the sites of
separation of the leaflets.
• Beneath th...
Papillary muscles
• Lateral and medial
• Originate from the apical one third of LV
• Finger like projection into LV.
• Lat...
View of the ventricular surface of an adult mitral valve.
McCarthy K P et al. Eur J Echocardiogr 2010;11:i3-i9
Published o...
Papillary muscle head orientation and distribution.
McCarthy K P et al. Eur J Echocardiogr 2010;11:i3-i9
Published on beha...
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 va...
Echocardiography helps in early detection of RHD
• Marijon and colleagues demonstrated a prevalence of 2.3cases/1000
by au...
(A) Specimen demonstrating rheumatic mitral valve.
McCarthy K P et al. Eur J Echocardiogr 2010;11:i3-i9
Published on behal...
Echo evaluation done for
• Assessing the severity of stenosis.
• Assosciated mitral regurgitation
• Assosciated valve lesi...
M mode
• Parasternal long axis and short axis.
• High temporal resolution – leaflet motion is beautifully illustrated.
• M...
Mitral Valve M mode
• Posterior mitral leaflet has a less exaggerated independent pattern of
motion, with a W shape.
• In rheumatic MS there i...
Mitral Valve
Rheumatic Mitral Stenosis
On M mode in patient with Mitral Stenosis specifically
Rheumatic Etiology,
PML moves anteriorly and in parallel with the A...
• 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 hei...
Winters and associates emphasized that a correlation between E-F slope
and valve area could only be seen in patients with ...
MVA =1.46cm2
MVA = 0.675cm²
• 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.
...
• 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 ...
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
Thickened leaflets > 4mm
Leaflet separation remains constant through
out diastole
Assessment of Severity of Mitral Stenosis by Echocardiographic
Leaflet Separation
Michael L. Fisher, Charles E. DeFelice, ...
DE/MAIC
• Mitral echogram measured at the onset of left ventricular isovolumic
contraction(MAIC). (R wave on ECG ,C wave o...
Shiu’s index(Mitral Valve Closure Index)
• Distance between anterior and posterior mitral leaflet echoes is
measured at ea...
Left Atrial emptying index
(Strunk et al ,Circulation 1976:54:744)
• Ratio of the amplitude of the posterior aortic wall d...
Gerald V Naccarelli et al Chest ,76:6,December 1979.
• Close relation between the AEI and MVA ( r =0.93).
• Not correlated...
Two Dimensional Echocardiography
• The normal mitral valve leaflets are thin <4mm,translucent and
highly mobile structures...
Assessment of severity of
Mitral Stenosis
Severity is quantified by
• Doppler transmitral pressure gradient
• Pulmonary hy...
Transmitral Pressure Gradient
• Mean transmitral gradient is extremely important for grading the
severity of MS
<5 mmHg – ...
Estimation of
Pulmonary Artery Pressure
• The obstruction of flow at the mitral orifice results in pulmonary
hypertension ...
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
valv...
Methods to estimate the MVA
• 1.2D planimetry
• 2.Pressure Half Time (PHT)
• 3.Continuity method
• 4.Proximal Isovelocity ...
• Valve area indexed to body surface area has not been validated.
• Planimetry and PHT methods are the most widely used an...
2D Planimetry
• Based on direct visualization of the mitral valve orifice.
• Not limited by hemodynamic loading conditions...
limitations
• Irregular orifice difficult to measure.
• A calcified object appears larger than it is actually on echo,as
c...
• Pressure gradient is dependent on volume status,stroke volume
and heart rate,which affects filling time.
• Transmitral g...
Hatle and colleagues
• Concept of PHT as a relatively flow independent assessment of MS
severity.
• PHT – the time taken f...
• Hatle and colleagues proposed a derivation of MVA by using the
empirical formula
MVA = 220/PHT
• The PHT can also be cal...
Caveats to the blanket use of PHT method
• Unreliable in the presence of tachycardia and AF.
• Post valvotomy period (24-7...
Determination of Doppler pressure half-time (T1/2) with a bimodal, non-linear decreasing
slope of the E-wave.
Baumgartner ...
Imp points
• If a line drawn above and not within then PHT will be longer.
• In atrial fibrillation use long R-R intervals...
• Mean pressure gradient is directly related to the average area
of the restrictive orifice and cardiac output.
• The peak...
Deceleration time
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 ...
Limitations
• Most accurate in patients without significant mitral regurgitation.
• Accurate pulmonary artery diameter mea...
PISA method
• Principle of flow convergence.
• Multiple hemispheric shells of increasing velocity and decreasing
radius – ...
• 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...
3D Echo
• Can visualize the mitral valve enface.
• 3D Planimetry has the closest agreement with invasive gorlin derived
MV...
Stress Echocardiography
• Class I indication for exercise echocardiography in patients with
discordant clinical features a...
• Both exercise and dobutamine stress echocardiography have been
studied.
• Supine bike exercise is preferred to dobutamin...
Ideal echo scoring system
CRITERIA:
• Global and segmental evaluation (qualitative and quantitative) of each
MV apparatus ...
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 comm...
• CHENNAIAH20150128182116596.avi
• GOVIND CRHD20150127113838630.avi
• PSax view for commissural calcification.
• High intensity bright echoes extending across the commissure
were taken to be...
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 le...
Reid score
It includes
• leaflet motion,
• leaflet thickness,
• subvalvular disease, and
• commissural calcium.
• Leaflet ...
Nobuyoshi score
• Leaflet pliability,
• Commissural disease, and
• Subvalvular apparatus
Nobuyoshi M, Hamasaki N, Kimura T...
Cormier score
• Cormier score divided the patients into three groups depending on
leaflets mobility ,calcification and sub...
3D Echo score
Anwar AM, Attia WM, Nosir YF, et al. Validation of a new score for the assessment of mitral stenosis
using r...
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. V...
2. Leaflet calcification. Scoring of leaflet calcification using Wilkins
score depends on the bright areas and the extensi...
• Both chordal thickness and separation are scored at three levels by
dividing their length into three parts (proximal, mi...
Limitations
• Not available in all cardiac centers.
• Operator dependent.
• Analysis based on software .
• Complex and tim...
TEE
• The standard midesophageal (ME) views (four-chamber,
commissural, two-chamber, and long-axis) assist in evaluating t...
LA thrombus classification
Follow up
Vijaya’s echo criteria
S. NO ECHO FEATURE SCORE
1 Mitral valve and aortic valve thickness >4 mm 2
2 Increased echogenicity...
Calcific Mitral Stenosis
• Saddle shaped annulus plays an active role in mitral valve
leaflet coaptation and in LA,LV systole and diastole.
• Annul...
Mitral Annular Calcification
• MC cardiac findings at autopsy.
• Calcium deposited between posterior LV wall and PML.
• TT...
• Assosciated with female age, advanced age, diabetes, hypertension.
• Patients with MVP.
• 9% of women,3% of men with > 6...
CCMA
• Caseous Calcification of Mitral Annulus
• Rare variant.
• Misinterpreted as tumor, abscesses or thrombus on echo.
•...
• No clinical differences have been shown to exist between
patients with MAC and those with CCMA.
• Benign
• Can progress ...
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 trea...
MITRAL VALVULAR DYSFUNCTION
Mitral Regurgitation:
• MC form
A.Sphincter like action does not occur in systole.
• Size of t...
Quantifying the severity
• Planimetry to be avoided - limiting orifice is at the base of the
leaflets.
• Mean diastolic gr...
Congenital Mitral Stenosis
Figure 5 Congenital mitral stenosis. Parachute-like congenital mitral stenosis with a circular
orifice and no commissures ...
Three-dimensional transesophageal images, surgical view (live 3D zoom mode).
McCarthy K P et al. Eur J Echocardiogr 2010;1...
LA Myxoma
• nejmicm1310149_attach_1_nejmicm1310149_v01.mp4
• MAHARSHI
BALLVALVETHROMBUS20141220143245248.avi
Prosthetic Mitral Valve Stenosis
• Easier to visualize.
• Parasternal and apical windows.
• Stability of mitral prosthesis...
• renukaRENUKA TEE20150110132342727.avi
Effect of Concurrent conditions
• 1.Tachycardia
• 2.Mitral Regurgitation
• 3.Aortic regurgitation decreases PHT
• 4.LV dys...
Left atrium in MS
• Dilated
• Giant LA > 6.5 cm
• LAA
• SEC
• Thrombus
• LA clot formation in SR 2.4-13.5%
• Incidence is ...
Conclusion
• Echocardiography is the primary modality for evlaution of mitral
valve disease.
• M mode,2D echo ,color doppl...
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE
Upcoming SlideShare
Loading in …5
×

ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE

8,587 views

Published on

MITRAL VALVE ANATOMY , M MODE FINDINGS IN MITRAL STENOSIS,EVALUATION OF THE SEVERITY OF LESION,CALCIFIC MS,CCMA,CONGENITAL LESIONS,GUIDELINES ALL IN DETAIL....

Published in: Education

ECHOCARDIOGRAPHIC EVALUATION OF MITRAL VALVE DISEASE

  1. 1. Echocardiographic evaluation of Mitral Valve Disease Dr.Nagula Praveen, Second yr PG2/8/2015
  2. 2. Inge Edler Carl Hellmuth Hertz Father of Echocardiography 1953
  3. 3. 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
  4. 4. 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).
  5. 5. Mitral Valve Apparatus (MVA) • Mitral annulus • Mitral valve leaflets • Commissures • Chordae tendinae • Papillary muscles • LV wall Bishop Mitre
  6. 6. 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.
  7. 7. 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.
  8. 8. (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
  9. 9. 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.
  10. 10. • 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.
  11. 11. 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.
  12. 12. Commissural leaflet,Accessory or junctional leaflet • Anterolateral (A1-P1) • Posteromedial (A3-P3) • Tissue length measured from annular insertion is 0.5-1.0cm.
  13. 13. • 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.
  14. 14. 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.
  15. 15. • 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.
  16. 16. 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.
  17. 17. View of the ventricular surface of an adult mitral valve. 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
  18. 18. 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.
  19. 19. 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.
  20. 20. View of the ventricular surface of an adult mitral valve. 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
  21. 21. Papillary muscle head orientation and distribution. 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
  22. 22. Rheumatic Mitral Stenosis Echocardiographic Assessment of Mitral Stenosis
  23. 23. 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).
  24. 24. 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).
  25. 25. (A) Specimen demonstrating rheumatic mitral valve. 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
  26. 26. 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
  27. 27. 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
  28. 28. Mitral Valve M mode
  29. 29. • 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).
  30. 30. Mitral Valve
  31. 31. Rheumatic Mitral Stenosis
  32. 32. 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
  33. 33. • 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
  34. 34. 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.
  35. 35. MVA =1.46cm2
  36. 36. MVA = 0.675cm²
  37. 37. • B bump indicates increased LVEDP. • EPSS normal is <0.6cm.or 6 mm
  38. 38. 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
  39. 39. • 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 .
  40. 40. DE amplitude is reduced <15 mm DE amplitude Normal 17-30 mm DE slope = 240-380 mm/sec EF slope = 50-180 mm/sec
  41. 41. Absent A peak in patients not in Atrial fibrillation
  42. 42. Rapid AC slope 350 mm/sec or 35 cm /sec
  43. 43. Thickened leaflets > 4mm
  44. 44. Leaflet separation remains constant through out diastole
  45. 45. 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
  46. 46. 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)
  47. 47. 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
  48. 48. 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
  49. 49. 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.
  50. 50. 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.
  51. 51. Assessment of severity of Mitral Stenosis Severity is quantified by • Doppler transmitral pressure gradient • Pulmonary hypertension • Mitral valve area (MVA)
  52. 52. 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.
  53. 53. 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
  54. 54. RVSP (mmHg)  PAP = Transtricuspid gradient +RAP
  55. 55. 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
  56. 56. 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.
  57. 57. • 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.
  58. 58. 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.
  59. 59. 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.
  60. 60. • 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.
  61. 61. 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
  62. 62. • 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.
  63. 63. 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
  64. 64. 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 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
  65. 65. 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) .
  66. 66. • 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.
  67. 67. Deceleration time
  68. 68. DT= 216/0.29= 744 msec DT Normal <220 msec. Normal PHT < 60 msec
  69. 69. 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
  70. 70. 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.
  71. 71. 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
  72. 72. • Color flow doppler assessment of the mitral inflow in the Apical 4 chamber window.
  73. 73. • 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.
  74. 74. 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.
  75. 75. 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.
  76. 76. • 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.
  77. 77. 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.
  78. 78. Wilkins score • Also called Boston, Abascal score. • 1988 Gerard T. Wilkins,Arthur E.Weyman,Vivian M Abascal et al.
  79. 79. 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.
  80. 80. • CHENNAIAH20150128182116596.avi • GOVIND CRHD20150127113838630.avi
  81. 81. • 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.
  82. 82. Significance of commissural calcification on outcome of mitral balloon valvotomy N Sutaria, et al.,Heart 2000.84:398-402.
  83. 83. 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.
  84. 84. 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.
  85. 85. 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
  86. 86. 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.
  87. 87. 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
  88. 88. Scallops in 2D Echocardiographic views
  89. 89. 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.
  90. 90. 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.
  91. 91. • 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.
  92. 92. Limitations • Not available in all cardiac centers. • Operator dependent. • Analysis based on software . • Complex and time consuming.
  93. 93. 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.
  94. 94. LA thrombus classification
  95. 95. Follow up
  96. 96. 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
  97. 97. Calcific Mitral Stenosis
  98. 98. • 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.
  99. 99. 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.
  100. 100. • 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.
  101. 101. 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.
  102. 102. • 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..
  103. 103. Presence of A wave more than E wave rules out significant MS
  104. 104. 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.
  105. 105. 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.
  106. 106. 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.
  107. 107. Congenital Mitral Stenosis
  108. 108. 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
  109. 109. Three-dimensional transesophageal images, surgical view (live 3D zoom mode). 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
  110. 110. LA Myxoma
  111. 111. • nejmicm1310149_attach_1_nejmicm1310149_v01.mp4 • MAHARSHI BALLVALVETHROMBUS20141220143245248.avi
  112. 112. 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.
  113. 113. • renukaRENUKA TEE20150110132342727.avi
  114. 114. 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
  115. 115. 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
  116. 116. 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.

×