Mitral stenosis can be evaluated using echocardiography. Key findings include measuring the mitral valve area using planimetry, pressure half-time, and continuity equation methods. Pressure gradients and pulmonary artery systolic pressure can also assess severity. Mild mitral stenosis is defined as a mitral valve area greater than 1.5 cm2, moderate as 1-1.5 cm2, and severe as less than 1 cm2. Stress echocardiography may reveal symptoms in borderline cases by monitoring pressures with exercise.

1. ECHOCARDIOGRAPHY IN MITRAL
STENOSIS

2. MITRAL VALVE/STENOSIS
Normal MV orifice area - 4 to 6 cm2
Symptoms do not usually occur until orifice area
less than 1.5cm2

3. Pathology
Rheumatic
• Commissural fusion
• Leaflet thickening
• Chordal shortening and fusion
• Superimposed calcification
• Annular calcification
Degenerative MS
• Rarely leaflet thickening and calcification at base

4. PATHOLOGY(UNCOMMON)
Congenital MS
• Subvalvular apparatus abnormalities
Inflammatory-SLE
Infiltrative
Carcinoid heart disease
Drug induced valve disease
• Leaflet thickening and restriction
• Rarely commissural fusion

5. 2D ECHO/PLAX/RHEUMATIC
• Valve domes in diastole
due to commissural fusion
• Leaflet thickening
beginning at the edges of
the leaflets
• Produces significant
narrowing of orifice

6. 2D ECHO/PLAX/RHEUMATIC
• Fibrosis, thickening
and shortening of
chordae common
• Calcification may also
progressively involve
chordae

7. 2DECHO/PSAX

8. 2D ECHO APICAL 4CH

9. 2D ECHO APICAL 2CH

10. COLOR DOPPLER/FOR MR

11. OTHER 2D FEATURES
• Dilated LA(20-60ml
normal)
• LA and LA appendage
thrombus
• Paradoxical septal
motion
• Dilated RV and RA

12. ASSESSMENT OF MS SEVERITY
M mode
2D ECHO
• MVA BY PLANIMETRY
DOPPLER
• PRESSURE GRADIENTS
• MVA BY PHT
• CONTINUITY EQUATION
• PISA
• MITRAL VALVE RESISTANCE

13. • Mitral Stenosis M-mode
1. Anterior motion of posterior leaflet in diastole
2. Decreased rate of diastolic closing of AML (decrease
E-F slope)
3. Loss of A wave
4. Maintenance of fixed relation of two leaflets
throughout diastole
5. Thickening and Calcification of mitral valve
6. Enlargement of left atrium
Mitral Stenosis

14. • Mitral stenosis M-mode
Mitral Stenosis

15. – Anterior motion of posterior leaflet in diastole
1. Diagnostic
2. Absent in 18% (body of posterior valve is pliable and doming)
– Decrease E-F slope
1. E-F slope is affected by mitral orifice size, severity of fibrosis,
calcification of leaflet , compliance of LV , rate and volume of filling
through MV, heart rate , diastolic motion of mitral annulus
2. not diagnostic
3. doesn’t correlate severity of stenosis
– Absence of “a” wave
1. With or with out AF
2. With out AF =correlates with severity of MS (<1.2)
Mitral Stenosis
Mitral stenosis M-mode

16. M MODE
NORMAL MITRAL STENOSIS

17. 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)

18. PLANIMETRYPLANIMETRY
• 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
METHOD

19. PLANIMETRY
• Exessive gain setting = underestimate
• Zoom mode
• Harmonic imaging
• Optimal time is mid diastole
• Multiple measurements in AF or incomplete
commissural fusion
• difficult in calcified valve and chest deformity

20. GRADIENTS
Pressure gradient = 4 v2

21. GRADIENTS
• Apical window
• CWD at or after tip of
mitral valve
• Maximal and mean
gradient
• Derived from
transmitral velocity
flow curve
• Heart rate to be
mentioned
• CD to identify mitral jet

22. POINTS
• Maximal gradient influenced by LA compliance
and LV diastolic function
• AF = average of 5 cycles with least variation of
R-R interval and as close possible to normal
HR
• MVG = HR,COP and associated MR
• Tachycardia, increased COP and associated MR
-overestimates gradient

23. Mitral Valve Area by
Pressure Half-Time (PHT)
Time for pressure to fall to half it’s original peak value
(in msec)
• calculated from deceleration slope

25. MVA BY PHT
MVA = 220/ pressure half-
time ()
PHT = 0.29 x Deceleration
time
MVA = 750 / Deceleration
time
• 220 is proportional to
the product of net
compliance of left
atrium and LV, and the
square root of
maximum transmitral
gradient

26. MVA BY PHT
• tracing deceleration
slope of E wave on
Doppler spectral
display

27. AF avoid short cycles and Average
different cardiac cycles

28. • deceleration slope is sometimes bimodal, the
decline of mitral flow velocity being more
rapid in early diastole than during the
following part of the E-wave.= deceleration
slope in mid-diastole rather than the early
deceleration slope be traced.
• rare patients with a concave shape of the
tracing- T1/2 measurement may not be
feasible.

30. Factors that may affect PHT by
influencing LA pressure
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

31. Factors affect PHT by influencing LV
pressure
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

32. PRACTICAL POINTS
• All factors affect PHT (ASD, AR, low LA or LV
compliance ) =Shorten PHT = overestimation
• PHT never under estimate
• if PHT >220 MS is severe
• If PHT is < 220 consider other methods to
assess severity
• Unreliable immediately post BMV, causes
under estimation of MVA.

33. • When gradient and compliance are subject to
important and abrupt changes.
• Immediately after balloon mitral
commissurotomy =discrepancies between the
decrease in mitral gradient and the increase in
net compliance.

34. CONTINUITY EQATION

35. CONTINUITY EQUATION
• 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
• Method not useful in AF,AR or MR

36. PISA
• hemispherical shape of
convergence of diastolic
mitral flow on atrial side
of mitral valve and flow
acceleration blood
towards mitral valve

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

38. METHOD
• 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
• fixed angle value of 100° =accurate MVA estimation
in MS.

41. METHOD
• used in presence of significant MR, AR,
differing heart rhythms
• Not affected by LA,LV compliance
• Multiple measurements required

42. Mitral leaflet separation (MLS) index
• Distance between the tips of the mitral
leaflets
• semiquantitative
• value of 1.2 cm or more = non severe MS
• <0.8 cm -severe MS.
• not accurate in heavy mitral valvular
calcification and post BMV

44. Mitral valve resistance
• ratio of mean mitral gradient to transmitral
diastolic flow rate
• dividing SV by diastolic filling period.
• less dependent on flow conditions.

45. • MVR = Mean MVG____
Trans Mitral D.F.R

46. PAH

47. STRESS ECHOCARDIOGRAPHY
• unmask symptoms in 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

48. • 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 Stress is considered severe MS but
is less physiological.

49. 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

50. 3D ECHO
Higher accuracy than 2D echo
Detailed information of commissural
fusion and subvalvular involvement
MVA measurement in calcified and
irregular valve
MVA measurement after BMV

51. MANAGEMENT OF MS-Mitral
Balloon Valvuloplasty
• May delay or avoid surgery
• 80% patients have long term relief of
symptoms
• 7% restenosis rate at 7 years
• ECHO to determine ‘pliability’,MR
• Wilkins score, cormier’s method

53. Wilkin’s score -Mitral valve score <8 are
excellent candidates for BMV

54. Limitations of wilkin’s score
• 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.

55. Cormier’s method (subvalvular
disease)

56. Guiding the Procedure and Detecting Acute
Complication
 guide the transeptal puncture.
 Atrial or ventricular perforation with
tamponade
 Acute mitral regurgitation
 Valvular disruption.

57. Evaluating the short- and long-term results of the
intervention.
 Assessment of valve area
– Planimetry ideal , half time shoudnt be used
 Long term results
– Assessment can be done by all methods with predictors
of restenosis being echo score and valve area following
procedure

60. GRADING OF SEVERITY OF
MS/SUMMARY
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

61. • pressure half time
• Expected normal half time is longer than native valve and
varies with type and size
• bioprosthetic valve, and for mechanical valves -220/t1/2
provides reasonable approximation
• Continuity equation
• Pressure gradient can also be used with gradients varying
with type and size of valve
In Prosthetic Mitral Valve Stenosis
Mitral Stenosis