Mitral Stenosis 2

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Echo Conference

April 6, 2011

Frances Canet, MD


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Causes andAnatomy

Assessment of

Mitral Stenosis How to Grade

Mitral Stenosis

Cases andApplication

Outline


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Rheumatic MSCommissural fusion

Degenerative MS

Annular calcificationAssociated with elderly, hypertension,atherosclerosis and aortic stenosis

Congenital MS

Abnormalities of subvalvular apparatus

Other: Systemic lupus, infiltrative disease, carcinoidheart disease, drug-induced valve disease

Causes and Anatomy


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Level 1 Recommendations:Pressure gradient

MVA Planimetry

Pressure half-time

Level 2 Recommendations:

Continuity equation

Proximal isovelocity surface area method (PISA)

Stress echocardiography

How to Assess Mitral Stenosis


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Continuous wave doppler is preferred

Gradient is measured in the apical window

Color doppler is used to identify eccentric diastolic mitral jets

Doppler beam is guided by the highest flow velocity zoneidentified by color doppler

Mean gradient is the relevant hemodynamic finding

Measure heart rate at which gradients are obtainedIf patient is in atrial fibrillation, the mean gradient should be anaverage of five cycles with the least variation of R-R intervals

Pressure Gradient


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Mitral Valve Area Planimetry

Direct tracing of the mitral orifice including opened commissures in theparasternal short-axis view at mid-diastole

Advantages:- Direct measure of MVA- Does not involve hypothesis regarding flow conditions, cardiac chamber

compliance or associated valvular lesions- Best correlation with anatomic valve area of explanted valves


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Obtaining and measuring the image:

-Scan apex to the base of the LV to ensure the cross-sectional area is measured at the leaflet tips.

-Plane should be perpendicular to the mitral orifice,elliptical shape.

-Gain, sufficient to see contour of the mitral orifice.

- If too excessive, may cause under estimation of the valve area.

-Perform several measurements if the patient has atrialfibrillation or incomplete commissural fusion

Mitral Valve Area Planimetry


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T1/2= time intervalin milliseconds

between the

maximum mitral

gradient in early

diastole and the

time point where

the gradient is

half the maximum

initial value

MVA = 220/ T1/2

Pressure half-time


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Measuring T1/2 with a bimodal, non-linear decreasing slope of the E-wave


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Based on assumption that the filling volume of diastolic mitral flow is equalto aortic SV.

MVA = pi (D2/4) (VTIAortic / VTIMitral)

D is the diameter of the LVOT in cm

VTI is in cm.

Accuracy and reproducibility is hampered by the number of measurements

increasing the impact of errors of measurements.Cannot be used in atrial fibrillation or associated significant MR or AR

Continuity equation Level 2


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MVA = pi (r2) (Valiasing) / Peak Vmitralx

alpha/1800

R is the radius of the convergencehemisphere in cm

Valiasing is the aliasing velocity in cm/s

Peak Vmitralis the peak CWD velocity of

mitral inflow in cm/salpha is the opening angle of mitralleaflets relative to flow direction

Proximal isovelocity surface areamethod Level 2


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Parasternal short-axis view

valve thickness (maximum and heterogeneity)

commissural fusion

extension and location of localized bright zones (fibrous nodules orcalcification)

Parasternal long-axis view

valve thickness

extension of calcification

valve pliabilitysubvalvular apparatus (chordal thickening, fusion, or shortening)

Apical two-chamber view

subvalvular apparatus (chordal thickening, fusion, or shortening)

Detail each component and summarize in a score

Valve Anatomy


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Enables measurement of mean

mitral gradient and systolic

pulmonary artery pressure during

effort.

Semi-supine exercise

echocardiography allows

monitoring of gradient.

Useful in patients with equivocal or

discordant with the severity of MS.

Stress Echocardiography Level 2


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How to Grade Mitral Stenosis

Normal MVA is 4.0-5.0 cm2

MVA >1.5 cm2 does not produce symptomsAs severity increases, cardiac output decreases and fails toincrease during exercise.


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Grades morphological changes in the MV during echo:

Leaflet mobility

Leaflet thickening

Valve calcification

Involvement of the subvalvular apparatus

Each characteristic is graded from 0-4, with a total of 16points total.

A score >8 is predictive of low success post percutaneousmitral valvuloplasty.

Wilkins (Valvotomy )Score


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72-year-old man with known moderate aortic stenosis,mitral regurgitation, hypertension, diabetes, COPD, TIAand severe pulmonary hypertension based on cardiaccatheterization results is referred for echocardiogram to

assess severity of mitral valve regurgitation.

How severe is his mitral regurgitation? Does he havemitral stenosis? What are his options for repair calculate

valvotomy score?

Case 1


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PSL MV


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PSL Zoom


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PSL MV Color


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4C AP


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4C AP Color


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MV Planimetry


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PSS MV Planimetry Still


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MV VTI for Pressure Gradient


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MV half time 3


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LVOT Diameter is 2.1

VTI aortic is 87

VTI mitral is 87.2

MVA = pi (D2/4) (VTIAortic / VTIMitral)

MVA = 3.89 cm2 (Not accurate compared to MVA of 1.15 cm 2calculatedfrom pressure gradient. Remember, it is not accurate in patient with severe

mitral regurgitation or atrial fibrillation.)

Less accurate calculation of MVA as it relies on several other measurementsto be accurate.

Continuity equation


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Valvotomy Score = 12Mobility valve

moves forward in

diastole, moves

mainly from base

3 points

Subvalvular

Thickening

thickening of chordal

structures extending

into 1/3rdof the

chordal length3 points

Thickening extends

through the entire

leaflet

3 points

Calcification

Brightness extending

into the mid-portion

of the leaflets

3 points

Total score = 12


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56-year-old woman with a history of rheumatic mitralvalve stenosis, respiratory failure, heart failure, atrialfibrillation, recent stroke, COPD, sarcoidosis,schizophrenia was transferred from an outside hospital

for a second opinion on mitral valve replacement. She haspoor functional and neurologic status at present.

Evaluate the grade of her mitral stenosis and calculate her

valvotomy score.

Case 2


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PSL MV


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PSL MV Zoom


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PSL MV Color


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4C AP MV


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PSS Planimetry Loop


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Planimetry Still

This is not acutally the area of

the MV orfiice. Look at the

small sliver of black area justbelow the tracing.


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Pressure gradient


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Pressure half-time


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Resting mean pressure gradient: 16mmHg(severe is >10mmHg)

Mitral valve area using half time: 0.77cm2(severe

is


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Valvotomy score:


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Mobility: 4

No or minimalforward movement of theleaflets.

Subvalvular Thickening: 2-3-

Thickening of chordal

structures up to one-third ofthe chordal length possibly todistal third of the chords.

Thickening: 4 Considerablethickening of all leaflet tissue

(>8-10mm).

Calcification: 4 Extensivebrightness throughout muchof the leaflet tissue.

Valvotomy score: 14 out of 16

Mitral Stenosis 2

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