- The document discusses mitral stenosis and echocardiography. It describes the anatomy, etiology, pathophysiology and grading of severity of mitral stenosis. - Echocardiography is outlined as the primary method for evaluating mitral stenosis, including 2D, Doppler and 3D imaging. Methods for measuring mitral valve area such as planimetry, pressure half-time and continuity equation are covered. Stress echocardiography is also discussed. - Scoring systems for predicting outcomes of percutaneous mitral balloon valvuloplasty are presented, including the Wilkins, Padial and Cormier scores. Treatment options for mitral stenosis are mentioned.

1. Instituto Mexicano del Seguro Social
Centro Médico Nacional del Bajío
Unidad Médica de Alta Especialidad
>> Departamento de Cardiología <<
Tema:
“Estenosis Mitral y Ecocardiograma”
Dr. Ricardo Mora Moreno
Médico Residente 1er Año de Cardiología (R1C)
León, Guanajuato
16 / Diciembre / 2016

2. Objetivos:
• Anatomía, Etiología, Características secundarias
(FA, Hipertensión pulmonar), Modo M
• Evaluación de la severidad de acuerdo a
consensos internacionales
• Ventajas y limitaciones de los métodos de
evaluación de área y gradientes
• Grados de severidad de la estenosis mitral;
Gradientes durante el ejercicio
• Score de Wilkins, Score de Padial, Score de
Cormier
• Candidatos a valvuloplastía mitral
EM y Ecocardiograma

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ETIOLOGÍA
- Fiebre Reumática
Deformación
Fusión
Engrosamiento
Acortamiento cuerdas
-Congénitas (VM en paracaídas, anillo SV)
- Enf. Sistémicas: Carcinoide
LES
Artritis Reumatoide
Endocarditis Curada

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• Fisiopatología
• Aumento de volumen de AI
• Arritmias supraventriculares
• Aumento de la presión hidrostática
• Aumento de la rigidez pulmonar y del trabajo
respiratorio
• Edema intersticial y EAP
• Aumento de la RVP
• Aumento de presiones de AP, VD y AD

8. EM y Ecocardiograma
CAMBIOS RETRÓGRADOS
• AI: Sobrecarga de Po/Vo
•Transmision retrógrada lecho venocapilar pulmonar
- Disminución distensibilidad
- Disnea
- > 35mmHg edema pulmonar
•Hipertension Venocapilar Pulmonar
- Hipertrofia endotelio arteriolas /capilares
- ( ) Resistencia Vascular Pulmonar
- Hipertensión Pulmonar

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Hipertension Pulmonar
Sobrecarga presión sistólica del VD
Dilatacion anillo tricuspideo
Insuficiencia funcional (tricuspidización)
Dilatación anillo pulmonar
Insuficiencia V. Pulmonar

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RITMO DE DUROZIEZ:
• S1 brillante (valvas móviles)
• Chasquido de apertura
• Soplo –retumbo- mesodiastólico (tono bajo, en posicion
lateral I, espiracion
• Soplo telediastólico (contracción auricular)

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13. Anatomía:
EM y Ecocardiograma
Blue lines: 5-chamber (0°)
and 4-chamber (20°) views.
Red lines: parallel 2-
chamber views (60°-90°)
Green lines: long axis (3-
chamber) views (90°- 150°)

14. EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58

15. EM y Ecocardiograma
ECO 2D
• Dilated LA
• LA and LA appendage
thrombus
• Paradoxical septal motion
• Dilated RV and RA

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ECO 2D
• 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

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ECO 2D
• Restricted mobility -PLAX
• Early diastolic doming
motion of the AML-
restriction of tip motion

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ECO 2D
• Leaflet thickening -PLAX

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ECO 2D
• Chordal thickening,
shortening and fusion –
PLAX and A4C

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ECO 2D
• Superimposed calcification

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ECO MODO “M”
• 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)

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ECO MODO “M”

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ECO MODO “M”

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ETE
• 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

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ETE

28. Grados Severidad EM:
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Baumgartber et al., 2009

29. Grados Severidad EM:
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Severidad de E. Mitral:
• Area NORMAL: 4.0 - 6.0 cm2

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AVM por Planimetria
ECO 2-d
• 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

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AVM por Planimetria
• 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

32. EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58

33. EM y Ecocardiograma
Tiempo de hemipresión
• 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

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Tiempo de hemipresión

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Tiempo de hemipresión

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Tiempo de hemipresión
• Less dependent on COP or coexistent MR
• Useful when mean transmitral gradient is misleading
• MR -transmitral gradient overesimated
• Low COP –mean transmitral gradient -underestimated

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Tiempo de hemipresión
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

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Tiempo de hemipresión
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

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Tiempo de hemipresión
• 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

40. EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58

41. EM y Ecocardiograma
Gradiente de presión
• 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

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Gradiente de presión
• 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

43. EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58

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

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PSAP
PSAP = 4 V2máx IT + Presión AD

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PSAP
Diámetro de vena
cava inferior
Colapso con la
inspiración
PAD estimada
≤2,1cms > 50% 0-5mmHg
≤2,1 cms < 50% 5-10mmHg
≥2,5 cms >50% 5-10mmHg
≥2,5 cms <50% 15mmHg

47. EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58

48. EM y Ecocardiograma
Ecuación continuidad
• 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

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Ecuación continuidad

50. EM y Ecocardiograma
Ecuación continuidad

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Ecocardiografía en estres
• 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

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Ecocardiografía en estres
• 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

53. Score Wilkins:
EM y Ecocardiograma
Wilkins GT, Weyman AE, Abascal VM, et al. Percutaneous balloon dilatation of the mitral valve: an analysis of
echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988; 60: 299-308
The Wilkins echocardiographic score, also known as
the Abascal’s echocardiographic score, is used to
determine the suitability of the mitral valve structure for
percutaneous mitral balloon valvuloplasty, a minimally
invasive procedure using a balloon to open the stenotic
mitral valve.

54. Score Wilkins:
EM y Ecocardiograma
Wilkins GT, Weyman AE, Abascal VM, et al. Percutaneous balloon dilatation of the mitral valve: an analysis of
echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988; 60: 299-308

55. Score Wilkins:
EM y Ecocardiograma
Wilkins GT, Weyman AE, Abascal VM, et al. Percutaneous balloon dilatation of the mitral valve: an analysis of
echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988; 60: 299-308

56. EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58

57. Score Padial:
EM y Ecocardiograma
The echocardiographic scoring system described by
Padial et al. has been successful in predicting the
development of severe MR following PBMV using the
double balloon technique.
L. R. Padial, N. Freitas, A. Sagie et al., “Echocardiography can predict which patients will develop severe
mitral regurgitation after percutaneous mitral valvulotomy,” Journal of the American College of Cardiology,
vol. 27, no. 5, pp. 1225–1231, 1996

58. Score Cormier:
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Lung, B., Cormier, B., Ducimetiere, P., et al. 1996. Immediate result of
percutaneous mitral commissurotomy. A predictive model on a
series of 1514 patients. 94:2124–30.

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ECO-3D
• 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

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ECO-3D
• From LA • From LV

61. EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58

62. EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58

63. EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58

64. EM y Ecocardiograma
• Tratamiento

65. EM y Ecocardiograma
• Tratamiento

66. EM y Ecocardiograma
• Tratamiento

67. EM y Ecocardiograma
• Tratamiento

68. GRACIAS!!!
EM y Ecocardiograma