The boy presented with symptoms of dyspnea, migratory joint pains, and fever. His echocardiogram showed features of mitral stenosis including thickened mitral valve leaflets, restricted mobility of the posterior leaflet, and a dome shape of the anterior mitral leaflet during diastole. The probable diagnosis is rheumatic mitral stenosis.

1. 15 year old boy Rahul came with symptoms
dyspnea ,migratory joint pains, fever. His
echocardiogram showed the following features,
What is your probable diagnosis ?

7. Echocardiographic evaluation of
mitral stenosis
Dr.Sruthi Meenaxshi MBBS,MD ,PDF

8. • Mitral stenosis (MS) is a mechanical
obstruction in blood flow from the left atrium
to the left ventricle.
• The normal area of the mitral valve orifice is
about 4–6 cm2
• Impediment to the flow of blood into left
ventricle creating pressure gradient occurs
when the mitral valve area goes below 2 cm2

10. Etiology
• Mitral stenosis consists of 12% of all valvular heart disease in Euro
Heart Survey.
• Rheumatic heart disease (90 %)
• Infective endocarditis, ball valve thrombosis , atrial myoxma
• Mitral annular calcification
• Congenital malformation ( parachute mitral valve)
• Systemic lupus erythematosis
• Carcinoid heart disease
• Endomyocardial fibrosis
• Radiation-associated valve disease, including MS, is increasingly
recognized as late manifestation in survivors of Hodgkin’s
lymphoma

11. • M-mode echocardiogram — The M-mode
examination is performed from the precordium
and guided from the 2D long and short axis
views.
• Normally, the anterior mitral leaflet exhibits a
motion pattern that reflects the phasic nature of
ventricular filling and produces a familiar M-
shaped pattern
• The posterior leaflet moves in a nearly mirror
image "W" pattern with a smaller excursion

14. M mode mitral valve

15. 2D of mitral stenosis
• The following parameters need to be assessed
about the valve morphology:
• Thickening
• Mobility
• Subvalvular fusion
• Commissural fusion
• Calcification.

16. Valvular thickening
• Normal mitral valve thickness is 2-4 mm
• 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.
• 1.4 to2.0 mild Thickening
• 2 to 5 moderate thickening
• >5 severe thicknening

17. Mobility of valve
• (PLAX) and apical four-chamber views
• Assessed by reid index by a line drawn from
posterior aortic root wall to the anterior mitral
leaflet tip
• H/L ratio (ab/xy ratio)
• <0.25 mild
• 0.25-0.44 moderate
• >0.45 severe

18. Reid index

19. Subvalvular apparatus
• Measuring chordal shortening
• Mild stenosis is if chordal length > 10 mm
• Severe disease chordal length < 10 mm

20. Calcification
• Bright echogenicity of the leaflets –
calcification
• Commisural calcification is absolute
contraindication for BMV

21. • Two-dimensional echocardiogram — The 2D
appearance of the normal mitral valve on TTE
depends somewhat upon the imaging plane
from which it is viewed.
• In the parasternal short axis plane, the valve
presents itself as an ovoid (fish mouth) orifice

23. • parasternal long axis and apical views, it
resembles clapping hands
• anterior hand longer and more mobile than
the posterior

26. • mitral valve leaflets are thin and translucent;
the rough attachment points of its chordae to
their free margins are thicker than their
smooth bellies. The chordae from each leaflet
connect to both papillary muscles.
• the valve appears homogeneous and thin, <4
mm in thickness.

27. What happens in mitral stenosis ?
• Anatomically, the commissural separation
between the anterior and posterior or mural
leaflets is
• subvalvular apparatus is altered by chordal
foreshortening

28. • Immobility of the posterior leaflet is a
common early finding with a "hockey
stick/knee bend" appearance to the anterior
mitral leaflet due to leaflet tethering.
• Doming of the anterior leaflet corresponds
temporally to the opening snap on
auscultation.

29. M Mode diagnosis for mitral stenosis
• severity of obstruction, a slope of less than
10 mm/sec (normal is >60 mm/sec) during
suspended respiration means severe mitral
stenosis
• Reversal of diastolic motion from the normal
pattern makes the M-mode of the posterior
leaflet one of the most valuable means of
identifying mitral stenosis

33. 2 D evaluation of mitral stenosis
• dome or bulge into the ventricle throughout
diastole

34. • "knee bend" appearance on the precordial
long axis view

35. Doming of AML

36. 2D Planimetry
• In the parasternal short axis plane, the
opening of the valve can be imaged just above
the tips of the papillary muscles.
• From this orientation, its maximum diastolic
opening area can be measured by direct
planimetry of the 2D image.
• A mitral valve area (MVA) of less than 1.5
cm2 is considered severe, regardless of the
method used to calculate its size.

37. Calculation of mitral valve area
• Pressure half time method
• Empirically, a pressure half-time of 220 msec
is equivalent to a valve area of 1.0 cm2;
therefore:
• MVA = 220 ÷ pressure half-time

40. Doppler methods
• Doppler methods can measure the velocity of mitral inflow.
• In mitral stenosis, this velocity increases at rest from a normal value
of less than 1 m/sec to greater than 1.5 m/sec.
• The algorithm to convert Doppler velocity into pressure gradient is
the modified Bernoulli equation.
Peak gradient, in mmHg = 4 x peak velocity2
• Thus, a peak velocity of 1 m/sec indicates a peak gradient of 4
mmHg; a peak velocity of 2 m/sec indicates a peak gradient of 16
mmHg; 3 m/sec indicates a peak gradient of 36 mmHg.[

41. • The mean transmitral gradient can be
measured by tracing the area-under-the-curve
of the mitral E and A waves obtained by
continuous wave Doppler.
• With severe mitral stenosis, the mean
transmitral gradient is >10 mmHg in sinus
rhythm at heart rates between 60 and 80 bpm

42. continous wave doppler in mitral valve
tips ( apical 4 chamber view )
Calculate the pressure gradient
value > 10 is severe mitral stenosis

43. Severity grading of mitral stenosis

44. Indirect methods to identify severity of
mitral stenosis
• degree of foreshortening of the chordae
tendineae
• leaflet calcification
• left atrial enlargement
• right ventricular and atrial dilatation
• measuring degree of tricuspid regurgitation
and pulmonary hypertension, as determined
by Doppler of tricuspid regurgitant jet.

45. • 2014 AHA/ACC guideline for valvular heart
disease defined severe mitral stenosis as
• MVA ≤1.5 cm2 (MVA ≤1.0 cm2 with very
severe MS) and diastolic pressure half-time
≥150 ms
• diastolic pressure half-time ≥220 ms with very
severe MS, along with severe left atrial
enlargement and pulmonary artery systolic
pressure >30 mmHg

47. Wilkins score

48. Mitral stenosis
• Assess valve doming / restriction / calcification
• 2D planimetry – Mitral valve area
• Assess Pressure gradient and TR jet velocity
associated Pulmonary artery hypertension
• Coexisting MR /LA thrombus
• Left ventricular and Right ventricular function

49. Assessment of mitral stenosis

51. • A 45 year old female came with dyspnoea on
exertion.Her echocardiogram showed the
following features. What is your
diagnosis,grade the lesion and advice on
further line of management?

61. • A 55 year old female presented dyspnoea and
orthopnea.The echocardiogram revealed
following features , what is your diagnosis and
further line of management?

71. THANKYOU
• Take Home Message
• ACC /AHA 2020
• For patients with valvular heart disease and atrial
fibrillation (except for patients with rheumatic mitral
stenosis or a mechanical prosthesis)the decision to use oral
anticoagulation to prevent thromboembolic events, with
either a vitamin K antagonist or a non–vitamin K antagonist
anticoagulant, should be made in a shared decision-making
process based on the CHA2DS2-VASc score.
• Patients with rheumatic mitral stenosis or a mechanical
prosthesis and atrial fibrillation should receive oral
anticoagulation with a vitamin K antagonist.