Echocardiographic assessment of mitral stenosis

2. MITRAL STENOSIS

5. Most Favorite Lesion?
▪ Rheumatic Fever
▪ Examiners
▪ Atrial Fibrillation
▪ Echocardiographers

6. Objectives:
▪ Anatomy
▪ Etiology
▪ Assesment of Severity
▪ 2D
▪ Color Doppler
▪ Pulse wave
▪ Continous wave Doppler
▪ Consequences
▪ Role of Exercise Echo in MS

7. Role Of Echocardiography in MS
▪ Etiology
▪ Mechanism
▪ Severity of stenosis
▪ Upstream consequences
▪ Disease progression
▪ Decision regarding therapy

8. Anatomy Of Mitral valve
Two leaflets (thickness about 1 mm)
▪ Posterior leaflet
Quadrangular shape
Three individual scallops (P1–P2–P3)
 Anterior leaflet
Semi-circular shape
Artificially divided into three portions
(A1–A2–A3)

9. DIAGNOSTIC TESTING (INITIAL DIAGNOSIS)
RECOMMENDATIONS
TTE is indicated in patients with signs or symptoms of MS to establish
the diagnosis, quantify hemodynamic severity, assess concomitant
valvular lesions, and demonstrate valve morphology
(Level of Evidence: B)
TEE should be performed in patients considered for percutaneous mitral
balloon commissurotomy to assess the presence or absence of left atrial
thrombus and to further evaluate the severity of MR
(Level of Evidence: B)
CLASS I
CLASS I

10. DIAGNOSTIC TESTING (INITIAL DIAGNOSIS)
RECOMMENDATIONS
Exercise testing with Doppler or invasive hemodynamic
assessment is recommended to evaluate the response of the
mean mitral gradient and pulmonary artery pressure in patients
with MS when there is a discrepancy between resting Doppler
echocardiographic findings and clinical symptoms or signs.
(Level of Evidence: C)
CLASS I

11. Frequency?
Nishimura et al. JACCVol. 63, No. 22, 2014
2014AHA/ACCValvular Heart DiseaseGuideline

12. Summary of Recommendations for MS Intervention
Nishimura et al. JACCVol. 63, No. 22, 2014
2014AHA/ACCValvular Heart DiseaseGuideline

13. Etiology
Primary MS (morphological changes of the MV)
▪ Rheumatic disease (predominant cause of MS,
commissural fusion, multivalve involvement),
▪ Degenerative (calcifications),
▪ Congenital (very rare in adults),
▪ Others: malignant carcinoid disease,
mucopolysaccharidoses, systemic lupus
erythematosus, rheumatoid arthritis, methysergide
therapy, post-radiation therapy

14. Etiology
Secondary/functional MS
▪ LV inflow obstruction related to extrinsic
compression of the MV (usually in the presence of a
nondiseased valve),
▪ Intermittent flow obstruction created by a
voluminous LA mass (myxoma/LA thrombus)

15. Morphology Assessment In Rheumatic MS
▪ Thickening of leaflets edges—first change
in RMS, significant if ≥ 5 mm
▪ Fusion of commissures—pathognomonic
▪ Chordae shortening and fusion—
contributes less to MS,
▪ Systolic apical displacement of the leaflet
closure line in relation to the mitral
annular plane
▪ Calcific deposits

16. Reduced Leaflet Mobility
▪ Diastolic doming of anterior mitral leaflet (AML)
▪ 'fish-mouth' appearance of the MV in diastole
▪ ‘hockey-stick' appearance of the AML created by the
leaflet edges thickening + the diastolic doming of the
AML
▪ ‘funnel shape' complete loss of mobility, in the late
stages of RMS

17. Degenerative Mitral Stenosis

18. Assessment of severity
1. Settings: Adjust 2D and color gain, ECG, B.P, HR
2. M-Mode
3. 2D /3D visual Assessment
4. Color flow Doppler
5. MVA by Planimetry
4. Pressure Gradients
5. MVA by PHT
6. Continuity Equation
7. PISA
8. MitralValve Resistance

19. Is It Easy?
Mild
Moderate
Severe
Trace
Mild
Mild to
Moderate
Moderate
Moderately
Severe
Progressive
Severe
Severe
M
R
MS

20. M-Mode
▪ 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

21. 2D and Color Doppler Assessment

22. MVA Planimetery (Level 1 Recommendation).
Planimetery has been shown to have the best correlation with Anatomical
valve area as assessed on explanted valves.
Real-time 3D echo and 3D-guided biplane imaging

23. MVA Planimetery
▪ 2D planimetery is the reference method
▪ Offers best correlations to Anatomic MV
area
▪ Less dependent on flow, heart rate,
chamber compliance
▪ Not influenced by concomitant MR
▪ The most reliable tool to estimate MS
severity after PMC

24. MVA Planimetery
▪ Zoom mode
▪ Lower gain to avoid underestimation
▪ Measurement in mid-diastole
▪ Tracing is made at the black–white interface
▪ Measure at least three cardiac cycles in sinus
rhythm
▪ Measure at least five cardiac cycles in atrial
fibrillation

25. 3D TTE planimetry
▪ Gold Standard now
▪ Allows optimization of the position of the
sagittal plane in relation to MV orifice, increasing
accuracy of measurement
▪ Image acquisition is done from the PTLAX view
and the lateral plane is adjusted to transect the
edges of the MV leaflets in diastole
▪ 3D zoom mode or full volume acquisition focused
on the MV

26. Limitations Of The Planimetry
• Over and underestimation
• 2D gain settings
• Poor acoustic access
• Deformed valve anatomy (i.e. post-valvuloplasty).

27. Should We Measure This?

28. Mitral Leaflet Separation Index
▪ Distance between the tips of the mitral leaflets
▪ Semiquantitative method for MS severity
▪ 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

29. Pressure Gradient (Level 1 Recommendation)
▪ Maximum pressure gradient (PPG) across the valve is related to the
high velocity jet in the stenosis through the simplified Bernoulli
equation: PPG = 4 ×V2
▪ Mean pressure gradient (MPG) is calculated by averaging the
instantaneous gradients over the flow period
▪ Pressure gradient depends on
– MVA
– LV–LA compliance
– Heart rate
– Transvalvular flow

30. Grading Of Mitral Stenosis

31. Trans-mitral Diastolic PG Acquisition

33. Pitfalls of PG method

35. Pressure Half-Time (Level 1 Recommendation)
▪ T1/2 is defined as the time interval in milliseconds between the
maximum mitral gradient in early diastole and the time point where
the gradient is half the maximum initial value.
PHT = 0.29x DT
MVA = 220/PHT

37. Question
All the following overestimate the mitral valve area
when measured by the pressure half-time method
except:
A. Acute severe aortic regurgitation
B. Restrictive LV function
C. Left to right shunt at atrial level
D. Severe mitral regurgitation

38. Pitfalls of PHT
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
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 shortened
If LV is stiff-low ventricular compliance
▪ LV pressure may rise more rapidly
▪ PHT shortened

39. Easy to Remember
▪ 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. Continuity Equation
▪ Time-consuming, more prone to error
measurements
▪ Recommended if discordance between other
methods
▪ Estimates Functional MV area (≠ anatomic valve
area)
▪ Doppler volumetric method cannot be applied if
more than mild AR or MR is present, but PISA
method is applicable

44. The Proximal Isovelocity Surface Area (PISA) method
Acquisition
Step 1: Obtain a Zoomed CFD of the MV in the mid esophageal view.
Step 2: Note the aliasing velocity.
Step 3: Obtain a CWD of the mitral valve.
Step 4: Obtain an angle of the PISA formation:
(The angle at the mitral valve is typically 120 degrees)
▪ MVA = 2πr2 ×Va/Vmax × (α/180)

45. MITRALVALVE RESISTANCE
▪ MVR=Mean mitral gradient/ transmitral diastolic flow rate
▪ Transmitral diastolic flow rate= SV/DFP
▪ It correlate well with pulmonary artery pressure
▪ No prognostic valvue, No grading of severity

46. 3D Echocardiography
▪ TEE andTTE
▪ Higher accuracy than 2D echo
▪ Detailed information of commissural
fusion and subvalvular involvement
▪ MVA measurement in calcified and
irregular valve
▪ MVA measurement after BMV

47. Stress Echocardiography
Exercise testing is indicated in
▪ Asymptomatic patients with significant MS (MVA < 1.5 cm2)
▪ Patients with equivocal symptoms or discordant symptoms with the
severity of MS (i.e. mild to moderate MS in a patient describing
exertional dyspnoea)
▪ Changes in trans-mitral pressure gradient and pulmonary pressure
during exercise help in selecting patients with significant MS at
higher risk for future cardiovascular events

48. Stress Echocardiography
▪ Mean mitral gradient and PASP to be assessed during exercise
▪ Mean gradient >15 mm/Hg with exercise is considered severe MS
▪ A PASP > 60 mm/Hg on exercise has been proposed as an
indication for BMV
▪ Dobutamine stress echo mean gradient >18 mm/Hg with
exercise is considered severe MS

49. Consequences of Mitral Stenosis

50. Consequences of Mitral Stenosis

51. Consequences of Mitral Stenosis

52. Wilkin’s Score

53. Wilkin’s Score

54. Wilkin’s Score

55. Cormier’s method

56. Other Scores
RT3DE score of MS severity Commissure score
NON
CALCIFIED
FUSION
ANTEROLATE
RAL
COMMISSURE
POSTEROMED
IAL
COMMISSURE
ABSENT 0 0
PARTIAL 1 1
EXTENSIVE 2 2
TOTAL SCORE OTO 4

57. Example 1

58. Example 1

59. Example 2

60. Example 2

61. Thanks for your patience listening