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Echocardiography Mitral stenosis
This document discusses mitral stenosis, including its etiology, assessment of severity, and role of echocardiography. It provides details on: - Rheumatic fever is the most common cause of mitral stenosis. - Echocardiography is used to determine etiology, severity, consequences, and guide treatment decisions. Methods include 2D, Doppler, and exercise echocardiography. - Severity is assessed by methods like planimetry, pressure gradients, and pressure half-time, with each method having strengths and limitations. - Consequences of severe mitral stenosis include atrial fibrillation, pulmonary hypertension, and heart failure. Scores like Wilkin's are used to
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Echocardiography Mitral stenosis
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- 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 Echocardiographyin MS ▪ Etiology ▪ Mechanism ▪ Severity of stenosis ▪ Upstream consequences ▪ Disease progression ▪ Decision regarding therapy
- 8. Anatomy Of Mitralvalve 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 (INITIALDIAGNOSIS) 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 (INITIALDIAGNOSIS) 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 Recommendationsfor MS Intervention Nishimura et al. JACCVol. 63, No. 22, 2014 2014AHA/ACCValvular Heart DiseaseGuideline
- 13. Etiology Primary MS (morphologicalchanges 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 ▪ LVinflow 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 InRheumatic 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
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- 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 Mildto Moderate Moderate Moderately Severe Progressive Severe Severe M R MS
- 20. M-Mode ▪ Decreased E-FSlope ▪ >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 ColorDoppler Assessment
- 22. MVA Planimetery (Level1 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 ▪ 2Dplanimetery 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 ▪ Zoommode ▪ 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 ThePlanimetry • Over and underestimation • 2D gain settings • Poor acoustic access • Deformed valve anatomy (i.e. post-valvuloplasty).
- 27. Should We MeasureThis?
- 28. Mitral Leaflet SeparationIndex ▪ 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 (Level1 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 MitralStenosis
- 31. Trans-mitral Diastolic PGAcquisition
- 33. Pitfalls of PGmethod
- 35. Pressure Half-Time (Level1 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 followingoverestimate 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 Factorsthat 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 IsovelocitySurface 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=Meanmitral 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 ▪ TEEandTTE ▪ 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 testingis 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 ▪ Meanmitral 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 MitralStenosis
- 50. Consequences of MitralStenosis
- 51. Consequences of MitralStenosis
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- 56. Other Scores RT3DE scoreof 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
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- 61. Thanks for yourpatience listening
Editor's Notes
- #38 Severe aortic regurgitation increases the LV volume precipitously. This in turn leads to early equalization of LA-LV pressures. Similarly, a stiff ventricle due to severe diastolic dysfunction leads to rapid increase in the LV diastolic pressure. In cases of left to right atrial shunts, the left atrium empties more rapidly than normal due to the shunt ow. This leads to a decrease in driving pressure from LA to LV and early pressure equalization. Severe mitral regurgitation leads to volume overload of the left atrium. This will lead to increased early diastolic peak gradient (elevated E), but mean gradient and deceleration slope do not change. Therefore, P t½ should be unaltered.