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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
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
EM y Ecocardiograma
EM y Ecocardiograma
EM y Ecocardiograma
EM y Ecocardiograma
ETIOLOGÍA
- Fiebre Reumática
Deformación
Fusión
Engrosamiento
Acortamiento cuerdas
-Congénitas (VM en paracaídas, anillo SV)
- Enf. Sistémicas: Carcinoide
LES
Artritis Reumatoide
Endocarditis Curada
EM y Ecocardiograma
• 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
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
EM y Ecocardiograma
Hipertension Pulmonar
Sobrecarga presión sistólica del VD
Dilatacion anillo tricuspideo
Insuficiencia funcional (tricuspidización)
Dilatación anillo pulmonar
Insuficiencia V. Pulmonar
EM y Ecocardiograma
RITMO DE DUROZIEZ:
• S1 brillante (valvas móviles)
• Chasquido de apertura
• Soplo –retumbo- mesodiastólico (tono bajo, en posicion
lateral I, espiracion
• Soplo telediastólico (contracción auricular)
EM y Ecocardiograma
EM y Ecocardiograma
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°)
EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58
EM y Ecocardiograma
ECO 2D
• Dilated LA
• LA and LA appendage
thrombus
• Paradoxical septal motion
• Dilated RV and RA
EM y Ecocardiograma
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
EM y Ecocardiograma
ECO 2D
• Restricted mobility -PLAX
• Early diastolic doming
motion of the AML-
restriction of tip motion
EM y Ecocardiograma
ECO 2D
• Leaflet thickening -PLAX
EM y Ecocardiograma
ECO 2D
• Chordal thickening,
shortening and fusion –
PLAX and A4C
EM y Ecocardiograma
ECO 2D
• Superimposed calcification
EM y Ecocardiograma
EM y Ecocardiograma
EM y Ecocardiograma
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)
EM y Ecocardiograma
ECO MODO “M”
EM y Ecocardiograma
ECO MODO “M”
EM y Ecocardiograma
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
EM y Ecocardiograma
ETE
Grados Severidad EM:
EM y Ecocardiograma
Baumgartber et al., 2009
Grados Severidad EM:
EM y Ecocardiograma
Severidad de E. Mitral:
• Area NORMAL: 4.0 - 6.0 cm2
EM y Ecocardiograma
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
EM y Ecocardiograma
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
EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58
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
EM y Ecocardiograma
Tiempo de hemipresión
EM y Ecocardiograma
Tiempo de hemipresión
EM y Ecocardiograma
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
EM y Ecocardiograma
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
EM y Ecocardiograma
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
EM y Ecocardiograma
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
EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58
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
EM y Ecocardiograma
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
EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58
EM y Ecocardiograma
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
EM y Ecocardiograma
PSAP
PSAP = 4 V2máx IT + Presión AD
EM y Ecocardiograma
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
EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58
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
EM y Ecocardiograma
Ecuación continuidad
EM y Ecocardiograma
Ecuación continuidad
EM y Ecocardiograma
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
EM y Ecocardiograma
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
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.
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
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
EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58
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
Score Cormier:
EM y Ecocardiograma
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.
EM y Ecocardiograma
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
EM y Ecocardiograma
ECO-3D
• From LA • From LV
EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58
EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58
EM y Ecocardiograma
A. S. Omran Et Al; Echocardiography in mitral stenosis; Journal of the Saudi Heart
Association (2011) 23, 51-58
EM y Ecocardiograma
• Tratamiento
EM y Ecocardiograma
• Tratamiento
EM y Ecocardiograma
• Tratamiento
EM y Ecocardiograma
• Tratamiento
GRACIAS!!!
EM y Ecocardiograma

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Estenosis mitral y ecocardiograma

  • 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
  • 6. EM y Ecocardiograma ETIOLOGÍA - Fiebre Reumática Deformación Fusión Engrosamiento Acortamiento cuerdas -Congénitas (VM en paracaídas, anillo SV) - Enf. Sistémicas: Carcinoide LES Artritis Reumatoide Endocarditis Curada
  • 7. EM y Ecocardiograma • 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
  • 9. EM y Ecocardiograma Hipertension Pulmonar Sobrecarga presión sistólica del VD Dilatacion anillo tricuspideo Insuficiencia funcional (tricuspidización) Dilatación anillo pulmonar Insuficiencia V. Pulmonar
  • 10. EM y Ecocardiograma RITMO DE DUROZIEZ: • S1 brillante (valvas móviles) • Chasquido de apertura • Soplo –retumbo- mesodiastólico (tono bajo, en posicion lateral I, espiracion • Soplo telediastólico (contracción auricular)
  • 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
  • 16. EM y Ecocardiograma 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
  • 17. EM y Ecocardiograma ECO 2D • Restricted mobility -PLAX • Early diastolic doming motion of the AML- restriction of tip motion
  • 18. EM y Ecocardiograma ECO 2D • Leaflet thickening -PLAX
  • 19. EM y Ecocardiograma ECO 2D • Chordal thickening, shortening and fusion – PLAX and A4C
  • 20. EM y Ecocardiograma ECO 2D • Superimposed calcification
  • 23. EM y Ecocardiograma 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)
  • 24. EM y Ecocardiograma ECO MODO “M”
  • 25. EM y Ecocardiograma ECO MODO “M”
  • 26. EM y Ecocardiograma 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
  • 28. Grados Severidad EM: EM y Ecocardiograma Baumgartber et al., 2009
  • 29. Grados Severidad EM: EM y Ecocardiograma Severidad de E. Mitral: • Area NORMAL: 4.0 - 6.0 cm2
  • 30. EM y Ecocardiograma 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
  • 31. EM y Ecocardiograma 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
  • 34. EM y Ecocardiograma Tiempo de hemipresión
  • 35. EM y Ecocardiograma Tiempo de hemipresión
  • 36. EM y Ecocardiograma 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
  • 37. EM y Ecocardiograma 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
  • 38. EM y Ecocardiograma 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
  • 39. EM y Ecocardiograma 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
  • 42. EM y Ecocardiograma 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
  • 44. EM y Ecocardiograma 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
  • 45. EM y Ecocardiograma PSAP PSAP = 4 V2máx IT + Presión AD
  • 46. EM y Ecocardiograma 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
  • 51. EM y Ecocardiograma 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
  • 52. EM y Ecocardiograma 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: EM y Ecocardiograma 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.
  • 59. EM y Ecocardiograma 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
  • 60. EM y Ecocardiograma 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