This document discusses the echocardiographic assessment of mitral stenosis (MS). It describes the causes and anatomical features of different types of MS and the use of 2D, M-mode, Doppler, and 3D echocardiography to evaluate the severity of MS. Key findings that can be assessed include mitral valve area, pressure gradients, flow velocities, and the effects of MS on cardiac chambers and function. Severity is graded based on parameters such as mitral valve area, mean gradient, and pulmonary artery pressure. Stress echocardiography may help unmask symptoms in questionable cases.

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

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

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

4. 2D ECHO
 Commissural fusion
PSAX echo scanning of valve
Important in distinguishing
degenerative from rheumatic
valve
Complete fusion indicate
severe MS
Narrow diastolic opening of
valve leaflets

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

6.  Leaflet thickening -PLAX

7.  Chordal thickening,
shortening and fusion –
PLAX and A4C

8.  Superimposed
calcification

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

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

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

13. Cormier’s method

14. 3D ECHO
 TEE and TTE
 Higher accuracy than 2D echo
 Detailed information of commissural fusion and
subvalvular involvement
 MVA measurement in calcified and irregular valve
 MVA measurement after BMV
 Restenosis after commissurotomy
commissural refusion
valve rigidity with persistent commissural opening

15. From LA From LV

16. RT3DE score of MS severity

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

18. 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)

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

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

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

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

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

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

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

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

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

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

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

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

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

41. AF avoid short cycles and average different
cardiac cycles

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

43. MS MS+MR MR

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

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

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

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

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

49. CONTINUITY EQATION
LVOT AREA

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

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

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

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

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

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

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

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

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

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

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

63. 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

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

67. THANK U

68. 1 Pressure half time in MS affected by all except
 A ASD
 B MR
 C AR
 D HOCM

69. 2 In case of a pure MS transmitral mean gradient is
14 mmhg and mitral area by planimetry is 1.1cm2 it is
graded as
 A severe
 B moderate
 C mild
 D indeterminate

70. 3 Commissural fusion is not a feature of MS in
 A RHD
 B Calcific MS
 C SLE
 D Carcinoid disease

71. 4 Not included in Wilkins score is
 A commissural fusion
 B restricted mobility
 C leafllet thickening
 D subvalvular fusion

72. 5 harmonic imaging useful in
 A 2D MVA
 B PHT
 C PISA
 D M mode

73. 6 mitral leaflet separation index less than ----cms
indicate severe MS
 A 0.4
 B 0.6
 C 0.8
 D 0.2

74. 7 continuity equation useful in MVA calculation in
 A AF
 B AR
 C MR
 D Calcific MS

75. 8 Mean gradient greater than ---- mmhg with exercise
echocardiography is considered severe MS
 A 10
 B 12
 C 15
 D 18

76. 9 In a case of severe AR with MS mitralPHT obtained
is 280 severity of MS is
 A mild
 B moderate
 C severe
 D none of the above

77. 10 Method to assess severity of MS in diastolic
dysfunction is
 A PHT
 B PISA
 C continuity equation
 D mitral valve resistance

78. 1 Pressure half time in MS affected by all except
 A ASD
 B MR
 C AR
 D HOCM

79. 2 In case of a pure MS transmitral mean gradient is
14 mmhg and mitral area by planimetry is 1.1cm2 it is
graded as
 A severe
 B moderate
 C mild
 D indeterminate

80. 3 Commissural fusion is not a feature of MS in
 A RHD
 B Calcific MS
 C SLE
 D Carcinoid disease

81. 4 Not included in Wilkins score is
 A commissural fusion
 B restricted mobility
 C leafllet thickening
 D subvalvular fusion

82. 5 harmonic imaging useful in
 A 2D MVA
 B PHT
 C PISA
 D M mode

83. 6 mitral leaflet separation index less than ----cms
indicate severe MS
 A 0.4
 B 0.6
 C 0.8
 D 0.2

84. 7 continuity equation useful in MVA calculation in
 A AF
 B AR
 C MR
 D Calcific MS

85. 8 Mean gradient greater than ---- mmhg with exercise
echocardiography is considered severe MS
 A 10
 B 12
 C 15
 D 18

86. 9 In a case of severe AR with MS mitralPHT obtained
is 280 severity of MS is
 A mild
 B moderate
 C severe
 D none of the above

87. 10 Method to assess severity of MS in diastolic
dysfunction is
 A PHT
 B PISA
 C continuity equation
 D mitral valve resistance

89. 3D echo planimetry
 Mitral valve area
measurement using
anyplane
echocardiography.

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

92. 9 Usual mitral valve angle in PISA method to assess
severity of MS is ----degree
 A 80
 B 100
 C 150
 D 180