Mitral Stenosis

Emerson LiuEmerson LiuEcho conferenceEcho conference

Nov. 5, 2008Nov. 5, 2008

Rheumatic Fever Rheumatic Fever Congenital MSCongenital MS Rare complication of: Rare complication of:

carcinoid, SLE, RA,carcinoid, SLE, RA,

mucopolysaccharidoses,mucopolysaccharidoses,

Whipple, amyloid depositWhipple, amyloid deposit MAC – may extend onto leaflet basesMAC – may extend onto leaflet bases Obstructive physiology: myxoma, IE, cor triatriatumObstructive physiology: myxoma, IE, cor triatriatum Cafergot ToxicityCafergot Toxicity

Etiologies

NormalNormal 4 - 6 cm4 - 6 cm22

Mild stenosisMild stenosis 1.6 - 2.5 1.6 - 2.5 cmcm22

Mod (usu Asx at rest)Mod (usu Asx at rest) 1.1 - 1.1 - 1.5 cm1.5 cm22

SevereSevere ≤ ≤ 1.0 cm1.0 cm22

MV Orifice Area

First heart sound (S1) is accentuated and snapping

Opening snap (OS) after aortic valve closure Low pitch diastolic rumble at the apex Pre-systolic accentuation (esp. if in sinus

rhythm)

S1 S2 OS S1 S2 OS S1 S1

Pathophysiology

Right Heart Failure:

Hepatic Congestion

JVD

Tricuspid Regurgitation

RA Enlargement

Pulmonary HTN

Pulmonary Congestion

LA Enlargement

Atrial Fib

LA Thrombi

LA Pressure

RV Pressure Overload

RVH

RV Failure

LV Filling

DyspneaDyspnea

Clinical Presentation

HemoptysisHemoptysis Chest painChest pain Palpitations and embolic eventsPalpitations and embolic events Ortner syndrome – hoarseness due toOrtner syndrome – hoarseness due to

compression of the left recurrent compression of the left recurrent laryngeallaryngeal

by dilated LA, tracheobronchial LN, by dilated LA, tracheobronchial LN, and PAand PA

Role of Echocardiography Diagnose Mitral StenosisDiagnose Mitral Stenosis Assess valve morphology – thickness, Assess valve morphology – thickness,

mobility, degree of calcification, extent of mobility, degree of calcification, extent of subvalvular involvementsubvalvular involvement

Assess hemodynamic severity: mean Assess hemodynamic severity: mean gradient, MV area, PAPgradient, MV area, PAP

Assess RV size and function.Assess RV size and function. Assess suitability for percutaneous Assess suitability for percutaneous

valvuloplastyvalvuloplasty Diagnose / assess concomitant valvular Diagnose / assess concomitant valvular

lesionslesions Reevaluate pts with known MS with Reevaluate pts with known MS with

changing symptoms or signs, and F/U of changing symptoms or signs, and F/U of asx pts with mod-severe MS asx pts with mod-severe MS

M-Mode

1. Thickened Mitral leaflets1. Thickened Mitral leaflets2. Decreased E to F slope 2. Decreased E to F slope

(increased EPSS)(increased EPSS)3. Diastolic anterior motion 3. Diastolic anterior motion

of of posterior leafletposterior leaflet

4. Abnormal septal motion4. Abnormal septal motion5. Left Atrial enlargement5. Left Atrial enlargement6. Left Atrial thrombus6. Left Atrial thrombus7. RV dilatation7. RV dilatation8. Pulmonary hypertension8. Pulmonary hypertension9. Small LV9. Small LV

MildMild Moderate Moderate Severe Severe

Thickened Leaflets in Mitral Thickened Leaflets in Mitral Stenosis Stenosis

Increased Increased EPSSEPSS

MildMild Moderate Moderate Severe Severe

Continuity equation

Diastolic Anterior Motion of Posterior Diastolic Anterior Motion of Posterior LeafletLeaflet

2-D Echo Findings in MS

1. Thickened (> 3 mm) and calcified mitral 1. Thickened (> 3 mm) and calcified mitral leaflets and subvalvular apparatus.leaflets and subvalvular apparatus.

2. “Hockey-stick” appearance of the 2. “Hockey-stick” appearance of the anterior mitral leaflet in anterior mitral leaflet in diastole (long-axis view).diastole (long-axis view).

3. “Fish-mouth” orifice in short-axis view.3. “Fish-mouth” orifice in short-axis view.

4. Immobility of posterior leaflet. 4. Immobility of posterior leaflet.

5. Increased Left Atrial Size.5. Increased Left Atrial Size.

6. Small Left Ventricle. 6. Small Left Ventricle.

Rheumatic MS

Rheumatic MS

Pitfalls

Pressure GradientPressure Gradient Intercept angle Intercept angle beat to beat variability in AFbeat to beat variability in AF Dependence on transmitral volume flow Dependence on transmitral volume flow

raterate

(exercise, coexisting mitral regurgitation)(exercise, coexisting mitral regurgitation)

Mitral valve Area

2D planimetry

Pitfalls

2D planimetry2D planimetry Image orientationImage orientation Tomographic planeTomographic plane 2D gain settings2D gain settings Poor acoustic accessPoor acoustic access Deformed valve anatomy post-Deformed valve anatomy post-

valvuloplastyvalvuloplasty

220220 t½ t½

MVA = MVA =

Pitfalls

T½ Valve Area T½ Valve Area Definition of Vmax and early diastolic slopeDefinition of Vmax and early diastolic slope Nonlinear early diastolic velocity slopeNonlinear early diastolic velocity slope Sinus rhythm with a wave superimposed Sinus rhythm with a wave superimposed

on early diastolic slopeon early diastolic slope Afib: Hemodynamics averaged over 5-10 cyclesAfib: Hemodynamics averaged over 5-10 cycles Influence of coexisting AR Influence of coexisting AR Changing LV and LA compliances (post Changing LV and LA compliances (post

commisurotomy)commisurotomy)

Continuity equation

MVA x VTI (ms jet) = transmittal SVMVA x VTI (ms jet) = transmittal SV

= LVOT CSA x VTI*= LVOT CSA x VTI*

* in the absence of MR* in the absence of MR

PISA Method

Pitfalls

Continuity equationContinuity equation Accurate measurement of transmitral SVAccurate measurement of transmitral SV

parallel intercept angleparallel intercept angle

without significant MRwithout significant MR

TEEClass IIa:Class IIa:

1. Check for LA thrombus in patients 1. Check for LA thrombus in patients considered for PBV or cardioversion. considered for PBV or cardioversion.

2. Evaluate valve morphology and 2. Evaluate valve morphology and

hemodynamics when transthoracic hemodynamics when transthoracic echo is suboptimal. echo is suboptimal.

Guide trans-septal Guide trans-septal puncture, or positionpuncture, or positionof balloon, during PBVof balloon, during PBV

Natural History

Progressive, lifelong diseaseProgressive, lifelong disease Usually slow & stable in the early yearsUsually slow & stable in the early years Progressive acceleration in the later yearsProgressive acceleration in the later years 20-40 year latency from rheumatic fever to 20-40 year latency from rheumatic fever to

symptom onsetsymptom onset Additional 10 years before disabling Additional 10 years before disabling

symptomsymptomss

Exercise Hemodynamics

For patients who have exertional For patients who have exertional symptoms and in whom resting symptoms and in whom resting hemodynamics do not clearly indicate hemodynamics do not clearly indicate severe MS.severe MS.

With fixed valve area, With fixed valve area, ⇑ CO and HR ⇑ CO and HR will ⇑ transmitral gradient, LA pressure will ⇑ transmitral gradient, LA pressure an PA pressurean PA pressure

Percutaneous Mitral Balloon Valvotomy

Class 1 Indications:Class 1 Indications:

1.1. Symptoms (NYHA II, III, IV), MVA Symptoms (NYHA II, III, IV), MVA ≤≤1.5cm², and valve morphology 1.5cm², and valve morphology favorable for percutaneous balloon favorable for percutaneous balloon valvotomy, in the absence of left valvotomy, in the absence of left atrial thrombus or moderate to atrial thrombus or moderate to severe MR. severe MR.

Wilkins Score

Percutaneous Percutaneous CommissurotomyCommissurotomy

Mitral Valve Repair

1.1. Pts. with NYHA III-IV, MVA Pts. with NYHA III-IV, MVA ≤ ≤ 1.5 cm², and 1.5 cm², and valve morphology favorable for repair if PBV valve morphology favorable for repair if PBV is not available.is not available.

2.2. Pts. with NYHA III-IV, MVA Pts. with NYHA III-IV, MVA ≤ ≤ 1.5 cm², and 1.5 cm², and valve morphology favorable for repair if a valve morphology favorable for repair if a left atrial thrombus is present despite left atrial thrombus is present despite anticoagulation.anticoagulation.

3.3. Pts. with NYHA III-IV, MVA Pts. with NYHA III-IV, MVA ≤ ≤ 1.5 cm², and a 1.5 cm², and a nonpliable or calcified valve with decision to nonpliable or calcified valve with decision to repair or replace valve made at time of repair or replace valve made at time of surgery. surgery.

Pts. with NYHA III-IV, MVA Pts. with NYHA III-IV, MVA ≤≤ 1.5 cm², 1.5 cm²,

and are not candidates for PBV or MV repair. and are not candidates for PBV or MV repair.

Mitral Valve Replacement