Mitral valve stenosis ,causes,investigations .

2. The embryologic development of the mitral
valve is a complex process that unfolds in
the endocardial cushion between the 5th
and 15th weeks of gestation .
The fully developed mitral apparatus
consists of an annulus, two valve leaflets,
chordae tendineae, and papillary muscles .

3. Normal anatomy of the mitral valve. Photographs of the left heart
from a 16-year-old boy in long-axis (two-chamber) view (a) and of
the mitral valve removed and cut open along the mid P2 segment
(b). All the components of the valve are visible: the annulus (curved
arrow in a), anterior leaflet (# in b), posterior leaflet (* in b), chordae
tendineae (straight arrows), and papillary muscles (arrowheads).
(Case courtesy of William D. Edwards, MD, Department of Pathology,
Mayo Clinic, Rochester, Minn.)

4. Photograph of a short-
axis section from the
base of a healthy
human heart with the
atria removed shows
normal appearances of
the aortic (AV), mitral
(MV), pulmonic (PV),
and tricuspid (TV)
valves during simulated
ventricular diastole.
(Courtesy of William D.
Edwards, MD,
Department of
Pathology, Mayo Clinic,
Rochester, Minn.)

5.  Anatomy of the mitral valve shown in a cross section during mid-
diastole. The three segments or scallops of the anterior mitral leaflet
are labeled A1, A2, and A3. The three segments or scallops of the
posterior mitral leaflet are labeled P1, P2, and P3

6.  CMR interrogation of the mitral valve. Using a cross-sectional view of the mitral valve as a
reference point (A), serial long-axis views are prescribed through the A1 to P1 scallops (B), the A2
to P2 scallops (C), or the A3 to P3 scallops (D) to produce long-axis cine views interrogating the
individual scallops and coaptation points of the mitral valve. In this example, there is adequate
coaptation of the A1 to P1 scallops (B) and the A3 to P3 scallops (D) but impaired coaptation of
the A2 to P2 scallops, demonstrating a flail P2 scallop (C). AO: aorta; LV: left ventricle.
Juan et al, Methodist Debakey Cardiovasc J. 2013 Jul-Sep; 9(3): 142–148

7. normal anterior (A1, A2, A3) and
posterior (P1, P2, P3) mitral valve
leaflets, which are composed of
lateral (A1, P1), middle (A2, P2),
and medial (A3, P3) segments. (5)
Axial diastolic images from
contrast-enhanced
Normal appearances of the
anterior (white arrow in a) and
posterior (arrowhead in a) mitral
leaflets, left ventricular outflow
tract (black arrow in a), and
anterolateral (arrow in b) and
posteromedial (arrowhead in b)
papillary muscles.
CT normal anatomy

8.  Mitral stenosis (MS) is the most common valvular
heart disease encountered in developing countries.
The cause of MS is almost always chronic rheumatic
heart disease.
 In developed countries, mitral stenosis is relatively
uncommon.
 In MS , increase left atrial pressure is necessary to
move blood across the stenotic mitral valve and into
the left ventricle. Chronic elevation of left atrial
pressure causes atrial dilatation and pulmonary
vascular hypertension.
 .

9.  Atrial fibrillation due to atrial dilatation and
dyspnea due to pulmonary vascular
hypertension are common symptoms of mitral
stenosis.
 Prolonged pulmonary vascular hypertension
may also lead to right ventricular dilatation
and failure, as well as tricuspid regurgitation

10.  The incidence of isolated MS is about
25%. Combined MS and mitral
regurgitation (MR) account for 40% of
cases. Associated aortic valve involvement
is seen in 35% of cases.

11. Patient susally remain asymptomatic until the stenosis
is < 2 cm2 area.
Breathlessness: reduced lung compliance , due to
chronic
pulmonary venous congestion.
Fatigue- low cardiac output.
Oedema and ascites (right heart failure).
Palpitation ( Atrial fibrillation)
Haemoptysis (pulmonary congestion, pulmonary
hypertension).
Cough ( pulmonary congestion).
Chest pain ( pulmonary hypertension).
Thromboembolic complications ( e.g; stroke, ischemic
limb).

12. *Atrial fibrillation
*Mitral facies (calcification)
*Auscultation
-Loud 1st heart sound
- Opening snap: may be audible and move closer to
S2 with increase in severity.
*Mid-diastolic murmur: turbulent flow produces
characteristic low pitched.
-Accentuated by exercise
- Inaudible if the valve is heavily calcified.
*Crepitating, pulmonary oedema, effusion (raised
pulmonary capillary pressure).

13.  Rheumatic disease , represent 99.8%
 Congenital mitral stenosis.
 Radiation exposure.
 Infective endocarditis
 Carcinoid tumor
 Valve calcification
 Nonvalvular disease
 Ball-valve thrombus
 Atrial myxoma
 Fabray’s Disease
 Hurler’s syndrome
 Whipple’s Disease

14. Rheumatic mitral stenosis : characterized by
* Restricted opening of the thickened valve
from commissural fusion.
*Valve calcification, or both results in a “fish-
mouth” appearance on short-axis images.
*Bowing of a thickened and fibrotic anterior
leaflet during diastole results in a “hockey-
stick” appearance that is best seen on two- or
four-chamber images .

15. Multiple episodes of
Acute Rheumatic
Fever (ARF)
first causing
Pancarditis`

16.  Acute phase subsides
 Fibrosis alters leaflet and cusp structure
 Results in leaflet or cuspal thickening along valvular
margins of closure.
 Valves affected
 Most often mitral valve alone.
 Then most often mitral and aortic together.
 Lastly aortic alone.

17. Normal MV
Stenotic MV
Fusion of
chordae
Thickening of cusps

18.  Mitral orifice becomes smaller
 Two circulatory changes
*To maintain LV filling across narrowed valve,
left atrial pressure ↑
Blood flow across mitral valve is ↓which to
↓cardiac output

19.  Clinical
 chest X ray *
 CT&MRI ***
 Angiography *
 Echocardiography ****.

20. Chest x ray findings on the heart
*Usually normal heart or slightly enlarged heart.
*Straightening of left heart border.
*Convexity along left heart border secondary to enlarged
left atrial appendage.
*small aortic knob from decreased COP.
*Double density of left atrial enlargement.
*Rarely , right atrial enlargement from tricuspid
insufficiency.

21. Convexity from enlarged left atrial appendage

22. Small aortic knob

23. Right atrial enlargement from tricuspid regurge and enlarged left
Atrial appendage from MS

24. -Calcification of the valve seen best in lateral view.
-Rarely calcification of left atrial wall due to fibrosis from
long standing disease.
-Rarely calcification of pulmonary arteries from PAH.

25. Calcification of mitral annulus does not signify presence of mitral valve disease, Occurs
in older women, Usually asymptomatic, Rarely associated with Mitral Stenosis

26. -Cephalization
-Elevation of left main stem bronchus
-Enlargement of main pulmonary artery
secondary to PAH in severe, chronic disease.
-Multiple small hemorrhage in the lung,
Pulmonary hemosiderosis and ossification.

27.  ↑pulmonary venous and capillary pressure
 Normal 5-10 mm Hg
 Cephalization 10-15 mm Hg
 Kerley B Lines 15-20 mmHg
 Pulmonary Interstitial Edema 20-25 mmHg
 Pulmonary Alveolar Edema > 25 mmHg

28. In mitral stenosis:
•Left atrial pressure ↑
•Left atrium enlarges
•Cephalization
•pulmo.I.edema
•PAH develops
•PVR increases
•RV enlarges
•Pulmonic regurg develops
•Tricuspid annulus dilates
•Tricuspid insufficiency
•RV failure

29. Cephalization

30. Enlarged MPA and straightening of left heart border due to enlarged left
atrium

31. PA chest X-ray of a patient with mitral stenosis in which a double right contour , an increase of the carina
angle, elevated left main bronchus, a peribronchial cuffing and bilateral perihilar haze (arrow head) are
also observed secondary to an acute pulmonary edema in intertitial stage B. Axial chest CT at mediastinal
window of another patient shows a calcification of the mitral valve (arrowhead) and cardiomegaly in a
patient with severe mitral stenosis.

32.  *Assessment of mitral valve leaflets
 *Detection of calcification.
 *Valve area planimetry.
 *Assessment of papillary muscles.
 *Assessment of cardiac chambers.
 *Detection of valve masses, thrombosis.

33. Mitral valve area
planimetry.
A- left ventricle
along horizontal and
vertical (B) long
heart axis and cross
sections (C and D)
along short heart
axis at level of mitral
valve leaflets.
Arrowheads indicate
minor stair-step
artifacts due to
arrhythmia in atrial
fibrillation.
56 y o with heavily calcified , severely stenosed MV
Alexander et al, 2011.AJR

34. 14.MDCT short axis for Middle age woman with rheumatic mitral stenosis shows thickening of
the mitral valve leaflets (arrows) with commissural fusion and calcification (arrowhead), features
that produce a characteristic “fish-mouth” appearance. (15) Photograph of a short-axis section
from the base of the heart of a 44-year-old woman with rheumatic mitral stenosis shows diffuse
fibrous leaflet thickening (arrow) and commissural fusion (arrowhead) that cause the valve to
resemble a fish mouth. A large antero septal myocardial infarction with associated mural
attenuation also is depicted. (Fig 15 courtesy of William D. Edwards, MD, Department of
Pathology, Mayo Clinic, Rochester, Minn.)

35. Axial diastolic image from contrast-enhanced ECG-gated dual-source
64- channel CT in an 80-year-old woman shows leaflet calcifications
(arrows), a cause of mitral stenosis.

36.  Mitral annular calcification on CT.
 Courtesy of M. Urena-Alcazar.

37. Presence of calcification
indicates MS.
Calcium usually deposited in
clumps on valve leaflets
Heavier calcific deposits in men
than women

39. (16)Two-chamber diastolic view from ECG-gated 1.5-T SSFP MR imaging in a 74-year-old
woman with rheumatic mitral stenosis shows anterior leaflet thickening and bowing (arrow),
which produces a “hockey-stick” appearance. The posterior leaflet is also thickened (arrowhead).
(17) Photograph of a long-axis section (three-chamber view) from the heart of a 55-year-old
woman with rheumatic mitral stenosis shows prominent thickening of the mitral leaflets
and chordae, with associated bowing of the anterior leaflet (arrow) producing the
characteristic hockey-stick appearance.

40.  Quantifiable parameters of the severity of mitral
stenosis include the valve area measured with
planimetry and the mean diastolic gradient across the
valve on velocity-encoded phase-contrast cine images
Short-axis diastolic view from
ECG-gated 1.5-T SSFP MR
imaging performed for planimetry
in a 67-year-old woman shows mild
mitral stenosis.

41. Caseous degeneration of the mitral annulus in a 72-year-old woman. Axial double-
inversion-recovery image (a) and two-chamber SSFP image (b) from ECG-gated
1.5-T MR imaging show a low-signal-intensity mass in the posterior aspect of the
annulus (arrow).

42. Three-chamber view from
ECG-gated 1.5-T SSFP MR
imaging in a 20-year-old
woman shows all the chordae
arising from the
posteromedial papillary
muscle (arrow), a finding that
represents a parachute mitral
valve.

43. Cine MRI in MS
Observable features include;
Mitral leaflet thickening.
Reduced diastolic opening.
Abnormal valve motion toward the left ventricular
outflow tract.

44. 1- Peak systolic velocity.
2- pressure gradient.
3- valve area.

45. Phase contrast images
 VEC-MRI
Velocity-encoded cine-magnetic resonance imaging (VEC-
MRI) is a relatively new method for quantitation of blood
flow with the potential to measure high-velocity jets
across stenotic valves.

46. SSFP images of abnormal mitral and aortic valves with the abnormal valve leaflets (A) closed and (B) at maximal
opening. Rheumatic mitral stenosis is shown in the 3-chamber and short-axis image plane. Note significant
thickening and calcification of both the mitral valve leaflets and chordae tendineae, along with chordal fusion, as
well as severe left atrial enlargement. At maximal opening of the mitral valve leaflets, the signal void seen within the
left ventricle represents turbulent diastolic filling of the left ventricle (arrow). A bicuspid aortic valve with significant
aortic stenosis is shown in a short-axis image plane. MR images courtesy of Raymond J. Kim, MD, Duke
Cardiovascular Magnetic Resonance Center, Durham, NC.
Peter et al, circulation 2009

47. (A) Diastolic image of the mitral valve showing the smallest orifice recorded as planimetry.
(B) Velocity encoded CMR sequences in the left ventricular short-axis plane.
Funda et al European Heart Journal - Cardiovascular Imaging,
Volume 15, Issue 2, February 2014

48. Degree of
stenosis
Valve area cm2 Mean gradient
mmHg
Normal 4-6 0
Mild 1.6-3.9 <5
Moderate 1.0-1.5 5-10
Severe <1.0 >10

49. Exists as isolated abnormality 25% of time.
Coexists with VSD 30% of time.
Coexists with another form of left ventricular outflow
obstruction 40% of time —SHONE’S Syndrome.

50.  A parachute mitral valve is a valvular congenital abnormality usually
identified in infants or young children, though it can present later, in
adulthood.
 Pathology
 Parachute mitral valves occur when all the chorda tendiae are attached to a
single papillary muscle origin, this single origin means the valve has
limited opening, thus causing a relative obstruction. When presenting in
infancy, the condition usually progresses to mitral stenosis.
 Associations
 It may occur as a single anomaly but is recognized as part of the Shone
complex.
 Other recognized associations include:
 Supravalvular ring.
 Subaortic stenosis.
 Aortic Coarcatation.

51.  Analysis of mitral valve should include
 –leaflet thickening, calcification, leaflet mobility,
subvalvular invovement.
 Diagnosis of mitral stenosis done by 2D echo , demonstrate
bowing, elbowing or hockey stick appearance of anterior
leaflet.

52. The following parameters need to be assessed about the
valve morphology.:
*Thickening.
*Mobility.
*Subvalvar fusion.
*Commissural fusion.
*Calcification.

53. *Two-dimensional planimetry.
*Mean pressure gradient.
*Pressure half-time.
*Continuity equation.
*Proximal isovelocity surface area assessment of mitral valve
area.

54.  Mitral valve area (MVA) measured by planimetry in short-axis
view of mitral valve correlates best with explanted valves and is
the reference standard.
 This measurement is not affected by flow conditions, compliance
of LA, and presence of associated valve lesions.
 This method is a very familiar technique by 2D and 3D
echocardiography en-face view of mitral valve.
Smallest orifice is the maximum opening in mid-diastole at the
tips of mitral leaflets. This is identified while scanning from LA
to left ventricular (LV) apex and frozen for planimetry in short
axis of mitral valve

55. Short axis view in mid diastole

56.  Echographic analysis of mitral stenosis. Transthoracic
echocardiography. Parasternal long-axis (left) and short-axis (right)
views showing MS. Note on the short-axis view the bilateral
commissural fusion without calcification. LA, left atrium; LAX,
long-axis view; LV, left ventricle; SAX, short-axis view.
 Courtesy of Dr E. Brochet.

57. Parasternal short axis view of the mitral valve at the level of the tips to measure mitral valve
area (MVA) by planimetry. (A) Prior to percutaneous balloon mitral valvuloplasty (PBMV),
showing fused both commissures with MVA = 1.2 cm2. (B) Same patient after PBMV, showing
complete opening of the anterolateral commissure and partial opening of the posteromedial
commissure. MVA = 2.0 cm2.
A S OMRAN et al J Saudi Heart Assoc. 2011 Jan;
23(1): 51–58

58. Fish mouth opening in short axis view

59. 3D TEE zoom-mode of mitral valve with severe rheumatic
MS.
A S OMRAN et al J Saudi Heart Assoc. 2011 Jan;
23(1): 51–58

60. Calculation of mitral valve area (MVA) by QLAB software implemented in the 3D echo
machine. (A) Two orthogonal views of mitral valve are derived from a 3D zoom-mode
acquisition of the mitral valve. After proper alignment of lines representing x, y and z axis,
mitral valve orifice will appear and MVA can be traced. (B) MVA was 1.1 cm2. this software
still needs validation.
A S OMRAN et al J Saudi Heart Assoc. 2011 Jan;
23(1): 51–58

61. Planimetry in 2D short axis view

62. leaflets separation is measured in PLAX view and apical
four-chamber view. The distance between the tips of both
leaflets when widely separated in diastole is measured for
at least three cardiac cycles, and then, the average is taken.
An index of 0.8 cm or less predicts severe MS. 1.1–1.2 or
more indicates mild MS.

63. Parasternal long axis view in diastole, showing diastolic doming (hockey-stick
shape) of anterior mitral valve leaflet (AMVL) and thickened, restricted posterior
mitral valve leaflet (PMVL). RV = right ventricle, LV = left ventricle, LA = left
atrium.
A S OMRAN et al J Saudi Heart Assoc. 2011 Jan;
23(1): 51–58

64. (a) Measuring thickness of the tip of anterior leaflet in diastole. (b)
Objective measurement of leaflet mobility (ab/xy)
Gnanavelu Ganesan 2017
C- MV leaflet thickness and mobility

65.  The normal thickness of mitral leaflet is 2–4 mm. Usually,
thickness of mitral leaflets increases at the margins in MS
and extend toward body and whole leaflet is thickened in
severe cases. Depending on the thickness, four grades are
given in Wilkins score.
 Mitral leaflet thickness can be compared to posterior aortic
wall thickness, and the ratio gives an objective assessment.
Normally, the ratio of valve thickness/posterior aortic wall
thickness is <1.4. The ratio between 1.4 and 2.0 indicates
mild thickening, the ratio between 2 and 5 indicates
moderate thickening, and ratio >5 indicates severe
thickening.

66. Objective grading of mobility of mitral valve - Reid system
H/L ratio ab/xy Grade Score
<0.25 Mild 0
0.25-0.44 Moderate 1
>0.44 Severe 2

67. MODERATE SUBVALVULAR THICKENING
D- Other changes with MS, subvalvular thickening

68. Calcification is identified by bright echogenic spots over the
leaflets. The presence of calcium over commissures is an
absolute contraindication for BMV; however, some
experienced operators do perform BMV when only one
commissure is calcified. Calcium restricted to the body of the
leaflets is not a contraindication for BMV.

69. A-Doppler gradient
Continuous wave Doppler and color-guided parallel alignment of
Doppler beam in apical four-chamber view are necessary to
achieve maximum velocity across mitral valve. Pulse wave
Doppler or high pulse repetition frequency can be of value and
give better spectral Doppler waveform because of better signal to
noise ratio.
Maximum and mean gradients are calculated by tracing the
diastolic flow waveform. Mean gradient is hemodynamically more
relevant than peak gradient because maximal gradient depends on
LA compliance, LV diastolic function, and associated MR. Mean
gradient more than 10 mmHg indicates severe MS.

70. (a) Measuring peak, mean gradients, and
pressure half time. Mean gradient measures 14
mmHg and P1/2t of 264 ms suggesting severe
mitral stenosis. (b) In this spectral Doppler
waveform, only gradients can be measured.
P1/2 t cannot be measured.

71. B-Pressure half time
Pressure half time (P1/2t) is the time interval between the
maximum mitral gradient in early diastole and the time point
where the gradient becomes half of the peak initial value,
expressed in milliseconds.
Normal P1/2time is 20-40 ms
Valve area is inversely related to the decline of the velocity of
diastolic transmitral blood flow. MVA is derived using an
empirical formula: MVA = 220/P1/2t cm2. P1/2t is derived by
tracing the slope of deceleration of E wave on Doppler spectral
display of transmitral flow, and the valve area is calculated
automatically by the software.
Grades of MS according to PHT(ms), mild (<150), moderate (150-
220), severe (>220).

72. Calculation of the mitral valve area (MVA) by the method of
pressure half-time (P1/2t).
A S OMRAN et al J Saudi Heart Assoc. 2011 Jan;
23(1): 51–58

73. C- Mean pressure gradient across the mitral valve can be
measured in apical views. Modal Doppler (most dense portion
of the Doppler curve) should be used for calculation .
 The gradient can be measured by tracing the dense outline of
mitral diastolic inflow and the mean pressure gradient is
automatically calculated.
 The severity can be assessed as mild (<5), moderate (5–10)
and severe (>10).


74. Continuous wave Doppler parallel to the mitral inflow in apical 4 chamber view to
measure mean peak gradient (Mean PG) across the mitral valve. Measurements should be
done in 3–5 consecutive beats and averaged.
A S OMRAN et al J Saudi Heart Assoc. 2011 Jan;
23(1): 51–58

75. D- MVA by continuity equation
Continuity equation is based on the law of conservation of
mass and assumes that volume of blood flow through the
mitral annulus should be equal to flow across the mitral
orifice. LV outflow tract (LVOT) can be substituted for
mitral annulus. This substitution is valid only if there is no
significant AR.

76. Flow across LVOT =
LVOT area (LVOT
diameter2 × 0.785) ×
LVOT velocity time
integral (VTI).
Then MVA = LVOT
flow/MS VTI.

78. Mitral valve area by continuity equation (a) parasternal
long-axis view to measure the left ventricular outflow
tract diameter (b) A4C view to measure mitral stenosis
velocity time integral (c) A5C view to measure left
ventricular outflow tract velocity time integral. Left
ventricular outflow tract diameter = 1.96 cm, left
ventricular outflow tract velocity time integral = 17.4
cm, mitral stenosis velocity time integral = 74.9 cm,
mitral valve area = 1.96 × 1.96 × 0.785 × 17.4/74.9 =
0.7 cm2

79. LA size should be assessed in PLAX view. The widest
dimension antero-posteriorly is measured. Although the
American Society of Echocardiography does not
recommend this dimension as a standard measure of LA, it
is an important parameter for BMV. LA size <5 cm predicts
better procedural success of BMV. Aneurysmally dilated LA
(>6 cm), however, predicts unfavorable results after BMV
and procedural failure.
Spontaneous echo contrast (SEC) may be present within
LA. Objective assessment of SEC is available and may be
used. LA should be carefully examined along its free wall,
roof, near appendage, and near pulmonary veins for the
presence of thrombus.

80. Very dense SEC in both atria imaged on transesophageal
echocardiography from a patient with prior mitral valve replacement
surgery. LA, left atrium; PV, prosthetic valve; RA, right atrium.

81. Mitral stenosis as demonstrated with 2-dimensional (2D)
echocardiography.

82. (a) Ball valve thrombus (Type V). (b) Transesophageal echocardiography mid esophageal 90° 2 chamber view –
pectinate muscle in the left atrial appendage. (c) Transesophageal echocardiography mid esophageal 60° short-
axis view showing clear left atrial appendage. (d) Transesophageal echocardiography mid esophageal 60° short-
axis view showing spontaneous echo contrast in the left atrial appendage. (e) Transesophageal echocardiography
mid esophageal 60° short-axis view showing Type IIb thrombus in the left atrial appendage

83. Interatrial septum should be carefully assessed for the
presence of patent foramen ovale or ASD (Lutembacher's
syndrome). Interatrial septal aneurysm or bulging septum
toward the right atrium should be noted and reported because
this feature may give rise to difficulty in septal puncture. The
presence of thrombus over interatrial septum is a
contraindication to BMV.

84. Mitral stenosis, 4 chamber view video

85. Candle flame appearance

86. Estimation of pulmonary artery systolic pressure and the
right ventricular systolic pressure (RVSP) is necessary.
It can be measured from tricuspid regurgitation velocity by
Bernoulli equation . RVSP can also be assessed during
exercise in borderline cases.

87. (A) Estimation of pulmonary artery systolic pressure (right ventricular systolic
pressure) using TR velocity and gradient in short axis view in a patient with severe MS
and severe pulmonary hypertension (B) Calculation of left atrial volume using method
of discs (MOD) in apical 4 chamber view in same patient, showing severe increase of
LA volume.
A S OMRAN et al J Saudi Heart Assoc. 2011 Jan;
23(1): 51–58

88.  In grading the severity of MS based on echocardiographic
evaluation, the following recommendations by the EAE/ASE
(Baumgartber et al., 2009) are the used standards of practice.

89. mild moderate severe
Specific finding
Valve area cm2 >1.5 1.0-1.5 <1.0
Supportive finding
Mean pressure gradient (mmHg)a <5 5-10 >10
PHT ms <150 150-220 >220
Pulmonary artery pressure
(mmHg)
<30 30-50 >50
a -At heart rates 60-80 bpm in regular rhythm

90. 3D echocardiography, especially 3D TEE is a merging tool and is
very promising to assess anatomy of mitral valve due to excellent
location of mitral valve in relation with esophagus. 3D TEE can
show en-face view of the mitral valve from left atrial and left
ventricular side.
Morphology of the mitral valve, degree of fusion of the
commissures, area of mitral valve by QLAB software, result of
the balloon valvuloplasty and mechanism of possible post
balloon mitral regurgitation are the information which can be
driven from 3D TEE.
This technique can be used in Catheterization Laboratory during
PBMV and in the operation room during surgical correction of
mitral stenosis.

91. 3D TEE zoom-mode acquisition of a patient with severe rheumatic mitral stenosis,
viewing from LV side. (A) Prior to balloon valvuloplasty, mitral valve area (MVA)
calculated by the grid and 3D QLAB was 0.7–0.8 cm2. (B) Same view, 2 days after
successful PBMV, both commissures are fully split. MVA calculated by same methods
showed increasing to 2.1 cm2.
A S OMRAN et al J Saudi Heart Assoc. 2011 Jan;
23(1): 51–58

92. 6-M Mode ECHO

93. M mode changes in MS
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 (increased in LV
filling pressure).
*Decrease in amplitude of the A wave (decreased atrial
contraction).

94. DE amplitude , normal 17-30 mm
DE slope =240-380 mm/s
EF slope= 50-180 mm/s

95. On M mode in patient with MS specifically rheumatic
origin , PML moves anteriorly and in parallel with the
AML rather than in usual posterior direction, this is highly
specific for MS.
Segal et al Echocardiography clinical application in mitral stenosis JAMA 1966, Ticzon et
al 1975.

96. M mode echo of mitral valve in normal, MS and false MS

97. E- F slope
The slower and flatter the slope of E wave, the more severe the MS.
A slow slope of 10-20 mm/s with a valve area less than 1.0 cm2.
Flattening of E-F slope is due to;
*increase in LV filling pressure.
*poor LV compliance.
*pulmonary hypertension.
A wave is absent in atrial fibrillation.

98. Grading of MS according to E-F slope
E-F slope MS
>35 mm/s Normal
26-35 mm/s mild
15-26 mm/s Moderate
<15 mm/s severe
Winter and associates emphasized that a correlation between E-F slope and
valve area could only be seen with an amplitude greater than 10 mm.

99. Moderate MS

100. Severe MS

101. Moderate MS

103. Elucidating the B bump on the mitral valve echogram in patients with severe left
Ventricular systolic dysfunction.
1-mitral B bump is essentially a late diastolic phenomina in which the leaflets
Keep a semi-opened 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 generated the bump.
3-DR is caused by LVEDP higher than LA pressure and coexists with B bump
without a cause effect relationship.
May 2004, 96:1:7-12

106. Mitral Masses; causes
1-Nonneoplastic causes.
 Mitral annular calcification.
 Vegetation (usually infective).
 Caseous degeneration of mitral annulus.
 Thrombus.
2-Benign neoplasms.
 Papillary fibroelastoma
 Myxoma
3-Malignant neoplasms
 Lymphoma
 Sarcoma
 Metastasis
CT SCAN IS SUPERIOR DUE
TO HIGH SPATIAL
RESOLUTION AND
LESS ARTIFACTS

107. (19) Axial diastolic image from contrast-enhanced 16-channel CT in a 71- year-old woman
shows a left atrial myxoma (arrow) obstructing mitral inflow. (20) Photograph of a long-
axis cardiac section (three-chamber view) shows a large myxoma arising from the left
atrial septum and blocking the mitral orifice (arrow). (Fig 20 courtesy of William D.
Edwards, MD, Department of Pathology, Mayo Clinic, Rochester, Minn.)

108. Mitral vegetation in a 78-year-
old man with infective
endocarditis. (a) Axial image
from contrast-enhanced 64-
channel CT shows a hypo
attenuating mass (arrow)
adhering to the mitral valve. (b)
Intraoperative photograph shows
a large vegetation (arrow)
adhering to the posterior mitral
leaflet (arrowhead).

109. Caseous degeneration of the mitral
annulus in an 86-year-old woman.
Four-chamber view from contrast-
enhanced ECG-gated 64- channel
multidetector CT shows a mass in the
posterior aspect of the annulus
(arrow). The mass is demarcated by a
peripheral enhancing rim of
calcification and contains a central
region of lesser hyper attenuation.

110.  Great thanks for your attention
Great thanks for your attention