Echocardiographic evaluation of

Mitral Valve Disease

DrNagula Praveen

Second yr PG282015

Inge Edler

Carl Hellmuth Hertz

Father of

Echocardiography

1953

Kennedy J W Circulation 20001012552-2553

Copyright copy American Heart Association Inc All rights reserved

Harvey Feigenbaum Harold T Dodge

Used M mode echocardiography for measuring ventricular volumes

Coined the term Echocardiography

Introduction

bull Echocardiography is the primary diagnostic tool for evaluating

patients with known or suspected mitral valve disease

bull Mitral valve was the first of the four cardiac valves to be evaluated

with echocardiography(high prevalence of RHD large excursion of

the mitral valve leaflets ndash easier target for M mode techniques)

Mitral Valve Apparatus (MVA)

bull Mitral annulus

bull Mitral valve leaflets

bull Commissures

bull Chordae tendinae

bull Papillary muscles

bull LV wallBishop Mitre

Mitral Annulus

bull Dynamicanatomically ill defined structure

bull Enface ndash kidney bean 3D ndash nonplanar saddle shape

bull Anterior flatter portion is continuous with aortic annulus ndash parallel

collagen fibers

bull Posterior is loosely anchored helps in systolic apical bending along

a medio lateral commissure axis increase in saddle height decrease

in circumferential area

bull Normal mitral annular orifice is 4 to 6 cmsup2

bull Dilatation primarily affects the PML

bull MA area significantly increases in patients with dilated LVs cause

being MA flattening decrease and delay of systolic sphincter like

mitral annular area

Mitral Leaflets

bull Anterior and posterior leaflets

bull Leaflet ndash MA ratio of 15 to 20 is sufficient to prevent significant

mitral regurgitation

bull Atrial surface of the leaflets is smooth leaflet body is translucent

rough zone starts approx 1cm from the distal leaflet edge

bull Irregular rough zone helps to maintain a seal when leaflets coapt

bull Ventricular surface of leaflet ndash basket weave of criss crossed collagen

strands

bull Primary chordae insert at the free leaflet tips

bull Secondary chordae insert close to the rough zone

(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic

valve this comprises the clear zone of the leaflet

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

ANTERIOR MITRAL

LEAFLETPOSTERIOR MITRAL

LEAFLET

bull AORTIC or SEPTAL

bull Trapezoid shaped or dome shaped

bull Anchored to fibrous portion of the MA

bull Encircles on 13rd of annulus but covers 23rd of valve orifice area

bull Fibrous continuity with non coronary cusp of aortic valve

bull Larger longer thicker than the posterior leaflet

bull 3 cm base

bull A1(lateral)A2(middle)A3(medial) nomenclature does not represent anatomically distinct structures

bull MURAL

bull Crescentric

bull Long circumferential base

bull Short radial length

bull Occupies 23rd of the annulus but

covers only 13rd of the valve area

bull 5cm base

bull Posterior portion of MA

bull P1(lateral)P2(middle)P3(medial)

bull Slits and indentations within PML

demarcate these scallops

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Inge Edler

Carl Hellmuth Hertz

Father of

Echocardiography

1953

Kennedy J W Circulation 20001012552-2553

Copyright copy American Heart Association Inc All rights reserved

Harvey Feigenbaum Harold T Dodge

Used M mode echocardiography for measuring ventricular volumes

Coined the term Echocardiography

Introduction

bull Echocardiography is the primary diagnostic tool for evaluating

patients with known or suspected mitral valve disease

bull Mitral valve was the first of the four cardiac valves to be evaluated

with echocardiography(high prevalence of RHD large excursion of

the mitral valve leaflets ndash easier target for M mode techniques)

Mitral Valve Apparatus (MVA)

bull Mitral annulus

bull Mitral valve leaflets

bull Commissures

bull Chordae tendinae

bull Papillary muscles

bull LV wallBishop Mitre

Mitral Annulus

bull Dynamicanatomically ill defined structure

bull Enface ndash kidney bean 3D ndash nonplanar saddle shape

bull Anterior flatter portion is continuous with aortic annulus ndash parallel

collagen fibers

bull Posterior is loosely anchored helps in systolic apical bending along

a medio lateral commissure axis increase in saddle height decrease

in circumferential area

bull Normal mitral annular orifice is 4 to 6 cmsup2

bull Dilatation primarily affects the PML

bull MA area significantly increases in patients with dilated LVs cause

being MA flattening decrease and delay of systolic sphincter like

mitral annular area

Mitral Leaflets

bull Anterior and posterior leaflets

bull Leaflet ndash MA ratio of 15 to 20 is sufficient to prevent significant

mitral regurgitation

bull Atrial surface of the leaflets is smooth leaflet body is translucent

rough zone starts approx 1cm from the distal leaflet edge

bull Irregular rough zone helps to maintain a seal when leaflets coapt

bull Ventricular surface of leaflet ndash basket weave of criss crossed collagen

strands

bull Primary chordae insert at the free leaflet tips

bull Secondary chordae insert close to the rough zone

(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic

valve this comprises the clear zone of the leaflet

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

ANTERIOR MITRAL

LEAFLETPOSTERIOR MITRAL

LEAFLET

bull AORTIC or SEPTAL

bull Trapezoid shaped or dome shaped

bull Anchored to fibrous portion of the MA

bull Encircles on 13rd of annulus but covers 23rd of valve orifice area

bull Fibrous continuity with non coronary cusp of aortic valve

bull Larger longer thicker than the posterior leaflet

bull 3 cm base

bull A1(lateral)A2(middle)A3(medial) nomenclature does not represent anatomically distinct structures

bull MURAL

bull Crescentric

bull Long circumferential base

bull Short radial length

bull Occupies 23rd of the annulus but

covers only 13rd of the valve area

bull 5cm base

bull Posterior portion of MA

bull P1(lateral)P2(middle)P3(medial)

bull Slits and indentations within PML

demarcate these scallops

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Kennedy J W Circulation 20001012552-2553

Copyright copy American Heart Association Inc All rights reserved

Harvey Feigenbaum Harold T Dodge

Used M mode echocardiography for measuring ventricular volumes

Coined the term Echocardiography

Introduction

bull Echocardiography is the primary diagnostic tool for evaluating

patients with known or suspected mitral valve disease

bull Mitral valve was the first of the four cardiac valves to be evaluated

with echocardiography(high prevalence of RHD large excursion of

the mitral valve leaflets ndash easier target for M mode techniques)

Mitral Valve Apparatus (MVA)

bull Mitral annulus

bull Mitral valve leaflets

bull Commissures

bull Chordae tendinae

bull Papillary muscles

bull LV wallBishop Mitre

Mitral Annulus

bull Dynamicanatomically ill defined structure

bull Enface ndash kidney bean 3D ndash nonplanar saddle shape

bull Anterior flatter portion is continuous with aortic annulus ndash parallel

collagen fibers

bull Posterior is loosely anchored helps in systolic apical bending along

a medio lateral commissure axis increase in saddle height decrease

in circumferential area

bull Normal mitral annular orifice is 4 to 6 cmsup2

bull Dilatation primarily affects the PML

bull MA area significantly increases in patients with dilated LVs cause

being MA flattening decrease and delay of systolic sphincter like

mitral annular area

Mitral Leaflets

bull Anterior and posterior leaflets

bull Leaflet ndash MA ratio of 15 to 20 is sufficient to prevent significant

mitral regurgitation

bull Atrial surface of the leaflets is smooth leaflet body is translucent

rough zone starts approx 1cm from the distal leaflet edge

bull Irregular rough zone helps to maintain a seal when leaflets coapt

bull Ventricular surface of leaflet ndash basket weave of criss crossed collagen

strands

bull Primary chordae insert at the free leaflet tips

bull Secondary chordae insert close to the rough zone

(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic

valve this comprises the clear zone of the leaflet

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

ANTERIOR MITRAL

LEAFLETPOSTERIOR MITRAL

LEAFLET

bull AORTIC or SEPTAL

bull Trapezoid shaped or dome shaped

bull Anchored to fibrous portion of the MA

bull Encircles on 13rd of annulus but covers 23rd of valve orifice area

bull Fibrous continuity with non coronary cusp of aortic valve

bull Larger longer thicker than the posterior leaflet

bull 3 cm base

bull A1(lateral)A2(middle)A3(medial) nomenclature does not represent anatomically distinct structures

bull MURAL

bull Crescentric

bull Long circumferential base

bull Short radial length

bull Occupies 23rd of the annulus but

covers only 13rd of the valve area

bull 5cm base

bull Posterior portion of MA

bull P1(lateral)P2(middle)P3(medial)

bull Slits and indentations within PML

demarcate these scallops

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Introduction

bull Echocardiography is the primary diagnostic tool for evaluating

patients with known or suspected mitral valve disease

bull Mitral valve was the first of the four cardiac valves to be evaluated

with echocardiography(high prevalence of RHD large excursion of

the mitral valve leaflets ndash easier target for M mode techniques)

Mitral Valve Apparatus (MVA)

bull Mitral annulus

bull Mitral valve leaflets

bull Commissures

bull Chordae tendinae

bull Papillary muscles

bull LV wallBishop Mitre

Mitral Annulus

bull Dynamicanatomically ill defined structure

bull Enface ndash kidney bean 3D ndash nonplanar saddle shape

bull Anterior flatter portion is continuous with aortic annulus ndash parallel

collagen fibers

bull Posterior is loosely anchored helps in systolic apical bending along

a medio lateral commissure axis increase in saddle height decrease

in circumferential area

bull Normal mitral annular orifice is 4 to 6 cmsup2

bull Dilatation primarily affects the PML

bull MA area significantly increases in patients with dilated LVs cause

being MA flattening decrease and delay of systolic sphincter like

mitral annular area

Mitral Leaflets

bull Anterior and posterior leaflets

bull Leaflet ndash MA ratio of 15 to 20 is sufficient to prevent significant

mitral regurgitation

bull Atrial surface of the leaflets is smooth leaflet body is translucent

rough zone starts approx 1cm from the distal leaflet edge

bull Irregular rough zone helps to maintain a seal when leaflets coapt

bull Ventricular surface of leaflet ndash basket weave of criss crossed collagen

strands

bull Primary chordae insert at the free leaflet tips

bull Secondary chordae insert close to the rough zone

(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic

valve this comprises the clear zone of the leaflet

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

ANTERIOR MITRAL

LEAFLETPOSTERIOR MITRAL

LEAFLET

bull AORTIC or SEPTAL

bull Trapezoid shaped or dome shaped

bull Anchored to fibrous portion of the MA

bull Encircles on 13rd of annulus but covers 23rd of valve orifice area

bull Fibrous continuity with non coronary cusp of aortic valve

bull Larger longer thicker than the posterior leaflet

bull 3 cm base

bull A1(lateral)A2(middle)A3(medial) nomenclature does not represent anatomically distinct structures

bull MURAL

bull Crescentric

bull Long circumferential base

bull Short radial length

bull Occupies 23rd of the annulus but

covers only 13rd of the valve area

bull 5cm base

bull Posterior portion of MA

bull P1(lateral)P2(middle)P3(medial)

bull Slits and indentations within PML

demarcate these scallops

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Mitral Valve Apparatus (MVA)

bull Mitral annulus

bull Mitral valve leaflets

bull Commissures

bull Chordae tendinae

bull Papillary muscles

bull LV wallBishop Mitre

Mitral Annulus

bull Dynamicanatomically ill defined structure

bull Enface ndash kidney bean 3D ndash nonplanar saddle shape

bull Anterior flatter portion is continuous with aortic annulus ndash parallel

collagen fibers

bull Posterior is loosely anchored helps in systolic apical bending along

a medio lateral commissure axis increase in saddle height decrease

in circumferential area

bull Normal mitral annular orifice is 4 to 6 cmsup2

bull Dilatation primarily affects the PML

bull MA area significantly increases in patients with dilated LVs cause

being MA flattening decrease and delay of systolic sphincter like

mitral annular area

Mitral Leaflets

bull Anterior and posterior leaflets

bull Leaflet ndash MA ratio of 15 to 20 is sufficient to prevent significant

mitral regurgitation

bull Atrial surface of the leaflets is smooth leaflet body is translucent

rough zone starts approx 1cm from the distal leaflet edge

bull Irregular rough zone helps to maintain a seal when leaflets coapt

bull Ventricular surface of leaflet ndash basket weave of criss crossed collagen

strands

bull Primary chordae insert at the free leaflet tips

bull Secondary chordae insert close to the rough zone

(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic

valve this comprises the clear zone of the leaflet

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

ANTERIOR MITRAL

LEAFLETPOSTERIOR MITRAL

LEAFLET

bull AORTIC or SEPTAL

bull Trapezoid shaped or dome shaped

bull Anchored to fibrous portion of the MA

bull Encircles on 13rd of annulus but covers 23rd of valve orifice area

bull Fibrous continuity with non coronary cusp of aortic valve

bull Larger longer thicker than the posterior leaflet

bull 3 cm base

bull A1(lateral)A2(middle)A3(medial) nomenclature does not represent anatomically distinct structures

bull MURAL

bull Crescentric

bull Long circumferential base

bull Short radial length

bull Occupies 23rd of the annulus but

covers only 13rd of the valve area

bull 5cm base

bull Posterior portion of MA

bull P1(lateral)P2(middle)P3(medial)

bull Slits and indentations within PML

demarcate these scallops

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Mitral Annulus

bull Dynamicanatomically ill defined structure

bull Enface ndash kidney bean 3D ndash nonplanar saddle shape

bull Anterior flatter portion is continuous with aortic annulus ndash parallel

collagen fibers

bull Posterior is loosely anchored helps in systolic apical bending along

a medio lateral commissure axis increase in saddle height decrease

in circumferential area

bull Normal mitral annular orifice is 4 to 6 cmsup2

bull Dilatation primarily affects the PML

bull MA area significantly increases in patients with dilated LVs cause

being MA flattening decrease and delay of systolic sphincter like

mitral annular area

Mitral Leaflets

bull Anterior and posterior leaflets

bull Leaflet ndash MA ratio of 15 to 20 is sufficient to prevent significant

mitral regurgitation

bull Atrial surface of the leaflets is smooth leaflet body is translucent

rough zone starts approx 1cm from the distal leaflet edge

bull Irregular rough zone helps to maintain a seal when leaflets coapt

bull Ventricular surface of leaflet ndash basket weave of criss crossed collagen

strands

bull Primary chordae insert at the free leaflet tips

bull Secondary chordae insert close to the rough zone

(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic

valve this comprises the clear zone of the leaflet

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

ANTERIOR MITRAL

LEAFLETPOSTERIOR MITRAL

LEAFLET

bull AORTIC or SEPTAL

bull Trapezoid shaped or dome shaped

bull Anchored to fibrous portion of the MA

bull Encircles on 13rd of annulus but covers 23rd of valve orifice area

bull Fibrous continuity with non coronary cusp of aortic valve

bull Larger longer thicker than the posterior leaflet

bull 3 cm base

bull A1(lateral)A2(middle)A3(medial) nomenclature does not represent anatomically distinct structures

bull MURAL

bull Crescentric

bull Long circumferential base

bull Short radial length

bull Occupies 23rd of the annulus but

covers only 13rd of the valve area

bull 5cm base

bull Posterior portion of MA

bull P1(lateral)P2(middle)P3(medial)

bull Slits and indentations within PML

demarcate these scallops

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Mitral Leaflets

bull Anterior and posterior leaflets

bull Leaflet ndash MA ratio of 15 to 20 is sufficient to prevent significant

mitral regurgitation

bull Atrial surface of the leaflets is smooth leaflet body is translucent

rough zone starts approx 1cm from the distal leaflet edge

bull Irregular rough zone helps to maintain a seal when leaflets coapt

bull Ventricular surface of leaflet ndash basket weave of criss crossed collagen

strands

bull Primary chordae insert at the free leaflet tips

bull Secondary chordae insert close to the rough zone

(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic

valve this comprises the clear zone of the leaflet

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

ANTERIOR MITRAL

LEAFLETPOSTERIOR MITRAL

LEAFLET

bull AORTIC or SEPTAL

bull Trapezoid shaped or dome shaped

bull Anchored to fibrous portion of the MA

bull Encircles on 13rd of annulus but covers 23rd of valve orifice area

bull Fibrous continuity with non coronary cusp of aortic valve

bull Larger longer thicker than the posterior leaflet

bull 3 cm base

bull A1(lateral)A2(middle)A3(medial) nomenclature does not represent anatomically distinct structures

bull MURAL

bull Crescentric

bull Long circumferential base

bull Short radial length

bull Occupies 23rd of the annulus but

covers only 13rd of the valve area

bull 5cm base

bull Posterior portion of MA

bull P1(lateral)P2(middle)P3(medial)

bull Slits and indentations within PML

demarcate these scallops

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

(A) The aortic leaflet of the mitral valve is in fibrous continuity with the leaflets of the aortic

valve this comprises the clear zone of the leaflet

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

ANTERIOR MITRAL

LEAFLETPOSTERIOR MITRAL

LEAFLET

bull AORTIC or SEPTAL

bull Trapezoid shaped or dome shaped

bull Anchored to fibrous portion of the MA

bull Encircles on 13rd of annulus but covers 23rd of valve orifice area

bull Fibrous continuity with non coronary cusp of aortic valve

bull Larger longer thicker than the posterior leaflet

bull 3 cm base

bull A1(lateral)A2(middle)A3(medial) nomenclature does not represent anatomically distinct structures

bull MURAL

bull Crescentric

bull Long circumferential base

bull Short radial length

bull Occupies 23rd of the annulus but

covers only 13rd of the valve area

bull 5cm base

bull Posterior portion of MA

bull P1(lateral)P2(middle)P3(medial)

bull Slits and indentations within PML

demarcate these scallops

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

ANTERIOR MITRAL

LEAFLETPOSTERIOR MITRAL

LEAFLET

bull AORTIC or SEPTAL

bull Trapezoid shaped or dome shaped

bull Anchored to fibrous portion of the MA

bull Encircles on 13rd of annulus but covers 23rd of valve orifice area

bull Fibrous continuity with non coronary cusp of aortic valve

bull Larger longer thicker than the posterior leaflet

bull 3 cm base

bull A1(lateral)A2(middle)A3(medial) nomenclature does not represent anatomically distinct structures

bull MURAL

bull Crescentric

bull Long circumferential base

bull Short radial length

bull Occupies 23rd of the annulus but

covers only 13rd of the valve area

bull 5cm base

bull Posterior portion of MA

bull P1(lateral)P2(middle)P3(medial)

bull Slits and indentations within PML

demarcate these scallops

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Anterior leaflet is twice the height of the posterior leaflet but

has half its annular length

bull Mitral leaflets thicken with advanced age particularly along

their closing edges

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Structures behind PML

bull Left circumflex coronary artery which courses within the

leftatrioventricular groove near the anterolateral commissure and the

coronary sinus which courses within the left atrioventricular groove

adjacent to the annulus of the posterior mitral leaflet

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Commissural leafletAccessory or junctional

leaflet

bull Anterolateral (A1-P1)

bull Posteromedial (A3-P3)

bull Tissue length measured from annular insertion is 05-10cm

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Mitral leaflet tissue is trilaminar

bull Fibrosaventricularis ndash dense collagen fibers ndash mechanical stability

bull Spongiosa ndash less organized collagen water absorbent proteins at the tips

bull Atrialis layers ndash network of collagen and elastin leaflet remodellingand adaptation

bull AML ndash dominant fibrosa ndash high tensile strength

bull PML ndash thinner more flexible

bull AML ndash dense innervation

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Carpentiers nomenclature

Anterior leaflet is termed as ldquoArdquo

A1 scallop- lateral third

A2 scallop- middle third

A3 scallop- medial third

Posterior leaflet is termed as ldquoPrdquo

P1 scallop- lateral third

P2 scallop- middle third

P3 scallop- medial third

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Middle scallop is the largest of the three in more than 90 of

normal hearts

bull Either the anterolateral or posteromedial scallop is larger

bull Rarely there are accessory scallops

bull PML prolapse usually involves the middle scallop and can be

assosciated with chordal rupture

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Chordae Tendinae

bull Fibrous strings that originate with highly variable branching from the PM tips(heads) and insert fanlike into the ventricular aspects of the anterior posterior and commissural leaflets

bull Chordae from the basal posterior myocardium insert directly into the posterior leaflet

bull Interfacing tightly linked collagen

bull Primary marginal chordae ndash leaflet free edges

bull Secondary basal chordae ndash AML rough zone PMLndash through out body

bull Strut chordae ndash pair of thick secondary chordae ndash 4 and 8 PM into ventricular aspect of AML

bull Basket woven collagen fibers distribute chordal force from insertion to the annulus

Primary chordae prevent flail leaflet

bull Average length of chordae -20 mm

bull Thickness of 1-2 mm

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Commissures

bull Cleft like splits in the leaflet tissue that represent the sites of

separation of the leaflets

bull Beneath the two comissures lie the anterolateral and psoteromedial

papillary muscles which arise from the LV free wall

bull Commissural chords ndash free edge of the leaflets adjacent to the major

commissures or into two adjacent scallops of the PMLminor

commissures

bull In contrast to congenital cleft a true commissure is always

assosciated with an underlying papillary muscle and an intervening

array of chordae tendinae

bull Seldom elongated

bull Proper closing plane for the leaflets during the surgical repair

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Papillary muscles

bull Lateral and medial

bull Originate from the apical one third of LV

bull Finger like projection into LV

bull Lateral PM has a single head and dual blood supply from the LCX

LAD artery

bull Medial PM most commonly has 2 heads ndashsupplied by RCA or LCX

bull Acts as Shock absorber

bull Small left atrial branches supply the most basal aspects of the mitral

leaflets

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

View of the ventricular surface of an adult mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Papillary muscle head orientation and distribution

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Rheumatic Mitral Stenosis

Echocardiographic Assessment of

Mitral Stenosis

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Introduction

bull MS is characterized by pathologic thickening and narrowing of the valve resulting in a reduction in the valve orifice area

Effect

bull 1Obstruction to transmitral flow in diastole

bull 2An increase in upstream pressures

bull 3Pulmonary hypertension

bull 4A decrease in cardiac output

Rheumatic Heart Disease (RHD)is the most common cause of Mitral

Stenosis(MS)

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Echocardiography helps in early detection of RHD

bull Marijon and colleagues demonstrated a prevalence of 23cases1000

by auscultation alone and a 10 fold higher prevalence of 304 cases

per 1000 by echocardiography screening of school age children in

Cambodia and MozambiquePrevalence of RHD detected by echocardiographic screening NEJM 2007357470-6

bull As many as 54 of patients with echocardiographic features of

RHD can be missed by auscultation alone Carapetis et al(2008)

bull Focused screening of mitral and aortic valves is needed for detection

bull Echocardiography is highly specific for RHD with a positive

predictive value of 94 Minich et al (1997)

bull WHO recommends echocardiographic screening of endemic

populations(2005)

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

(A) Specimen demonstrating rheumatic mitral valve

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Echo evaluation done for

bull Assessing the severity of stenosis

bull Assosciated mitral regurgitation

bull Assosciated valve lesions

bull PA pressure estimation from TR

bull Valve suitability for BMV

bull Restenosis

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

M mode

bull Parasternal long axis and short axis

bull High temporal resolution ndash leaflet motion is beautifully illustrated

bull Movement of the normal anterior mitral leaflet has 4 distinct phases

giving it the characteristic M shape during diastole

bull 1Early Diastole a brisk rapid opening or anterior excursion (E wave)

at the onset of the diastole resulting in rapid filling of the left

ventricle

bull 2Mid diastole or diastasis near closure during passive filling of LV

bull 3Late diastole a smaller anterior excursion caused by left atrial

contraction (A wave)

bull 4Early systoleisovolumic contraction valve closure

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Mitral Valve M mode

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Posterior mitral leaflet has a less exaggerated independent pattern of

motion with a W shape

bull In rheumatic MS there is a distinct and easily recognizable

distortion of this M mode pattern

Thickening of leaflets

Delay in amplitude and slope of the E wave (delayed valve opening)

A slow descent or flattening of the E-F slope (increase in LV filling

pressures)

Decrease in amplitude of the A wave (decreased atrial contraction)

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Mitral Valve

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Rheumatic Mitral Stenosis

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

On M mode in patient with Mitral Stenosis specifically

Rheumatic Etiology

PML moves anteriorly and in parallel with the AML

rather than in usual posterior direction

ndash highly specific for MS

Segal et alEchocardiography clinical application in mitral stenosis JAMA 1966195-161-6

Ticzon et al1975

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull The slower and flatter the slope of the E wave the more severe the

MS

bull A slow slope of 10-30 mmsec and an E wave height of 20 mm

indicate severe MS with a valve area of less than 10 cm2

bull Segal et alJAMA 1966195161-6

Flattening of the E-F slope is due to

1increase in left ventricular filling pressure

2poor left ventricular compliance

3pulmonary hypertension

A wave is absent in patients with AF

1 E F slope

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Winters and associates emphasized that a correlation between E-F slope

and valve area could only be seen in patients with an amplitude greater

than 10 mm

Winters et al reported the relationship between E-F slope and amplitude

of excursion

Correlation of EF slope with MVA was poor (r=020) Naccarelli et al

Cope et al (r = 049)Wann et al (r = 051)

Grading of Mitral stenosis based on EF slope

E- F slope Mitral Stenosis

lt 15 mmsec Severe

15-25 mmsec Moderate

26-35 mmsec Mild

gt35 mmsec Normal

Winters et al

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

MVA =146cm2

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

MVA = 0675cmsup2

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull B bump indicates increased LVEDP

bull EPSS normal is lt06cmor 6 mm

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Elucidating the B bump on the mitral valve M-mode echogram in

patients with severe left ventricular systolic dysfunction

Aloir Queiroz Araujo Alaor Queiroz Araujo

bull (1) Mitral B bump is essentially a late diastolic phenomenon in which

the leaflets keep a semi-open position without LV inflow

effectiveness

bull (2) The resultant LA pressure which prolongates the duration of AR

wave beyond A wave analogously work over mitral leaflets pushing

them toward LV generating the bump

bull (3) DR is caused by LVEDP higher than LA pressure and coexists

with B bump without a causendasheffect relationship

bull May 20049517-12

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull The plane of M-mode cut will change the mitral valve motion (May be this is most

common M-mode at tip of mitral valve may be trifid however a little beyond may

record a bifid-M pattern

bullRedundant mitral valve

bullMid diastolic AML drag

bullSigns of elevated LVEDP

bullFinally it could be a sign of mitral valve fatigue after exercise Some of these

persons revert back to M pattern after a brief period of Trifid motion following

exercise

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

DE amplitude is reduced lt15 mm

DE amplitude Normal 17-30 mm

DE slope = 240-380 mmsec

EF slope = 50-180 mmsec

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Absent A peak in patients not in Atrial

fibrillation

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Rapid AC slope 350 mmsec or 35 cm sec

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Thickened leaflets gt 4mm

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Leaflet separation remains constant through

out diastole

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Assessment of Severity of Mitral Stenosis by Echocardiographic

Leaflet Separation

Michael L Fisher Charles E DeFelice Nathan H Carlineret al

Arch Intern Med 1979139(4)402-406 doi101001archinte197903630410012009

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

DEMAIC

bull Mitral echogram measured at the onset of left ventricular isovolumic

contraction(MAIC) (R wave on ECG C wave on ACG)

bull DE represents the opening amplitude of the mitral valve in early

diastole

bull DEMAIC ratio used avoid other conditions causing reduced diastolic

closure rate

bull Correlation (r=084)

Pavlos Toutouzas et al British Heart Journal19773973-79

MAIC DEMAIC

NORMAL 2-4 mm (27 mm average) 33 -65 (51)

AS and HOCM 2-4 mm (29 mm average) 27 -65 (42)

MS 6-17 mm (113 mm average) 07 -15 (11)

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Shiursquos index(Mitral Valve Closure Index)

bull Distance between anterior and posterior mitral leaflet echoes is

measured at early (X1) and at end diastole(X2)

bull MVCI is obtained as follows

X1-X2

t X1

bull MVCI of 20 is assosciated with severe MS and

bull MVCI of 80 excludes significant mitral stenosis

100

MVA (cmsup2) MVCI

lt 13 13

13-18 49

gt 18 74

British heart Journal 197739839

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Left Atrial emptying index

(Strunk et al Circulation 197654744)

bull Ratio of the amplitude of the posterior aortic wall diastolic motion

during the first third of this interval to the total posterior excursion of

the aortic root during the whole of this interval

In severe MS AEI is less than 04

In moderate MS it is 05 or 06

In mild MS it is 07

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Gerald V Naccarelli et al Chest 766December 1979

bull Close relation between the AEI and MVA ( r =093)

bull Not correlated well with the left atrial size (r = 010 ) or the EF

slope of the mitral valve (r = 020)

bull Useful in categorizing the patients with mitral stenosis

bull overall predictive value is 86

bull Sensitive index in estimating mitral stenosis

bull AEI = 05 ndashMVA from 13 -18 sq cm

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Two Dimensional Echocardiography

bull The normal mitral valve leaflets are thin lt4mmtranslucent and

highly mobile structures with the AML exhibiting the greater

mobility

bull Maximum mobility is seen in the leaflet tips

bull In rheumatic MS the leaflet thickening is most pronounced at the tips

with relative sparing of the midportion giving the characteristic

ldquobent kneerdquo or ldquohockey stickrdquo appearance

bull The leaflets open and close suddenly

bull Appearance of convexity into the LV in diastole (doming)

bull Convexity into LA during systole

bull PML is thickened and restricted paradoxically pulled forward by

the AML in diastole

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Assessment of severity of

Mitral Stenosis

Severity is quantified by

bull Doppler transmitral pressure gradient

bull Pulmonary hypertension

bull Mitral valve area (MVA)

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Transmitral Pressure Gradient

bull Mean transmitral gradient is extremely important for grading the severity of MS

lt5 mmHg ndash mild

5-10 mm Hg ndash moderate

gt10mm Hg ndash severe

bull Correlates well with invasive measurements and is easily reproducible

Apical four chamber view

bull Mean gradient is highly sensitive to alterations in mitral flow atrioventricular compliance and heart rate

bull With tachycardia there is a decrease in diastolic filling resulting in elevation of the mean gradient

bull In the presence of AF atleast 5 and usually 10 cycles have to be averaged to obtain an accurate mean gradient

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Estimation of

Pulmonary Artery Pressure

bull The obstruction of flow at the mitral orifice results in pulmonary

hypertension and increased pulmonary vascular resistance

bull The degree of pulmonary hypertension is a measure of the

hemodynamic burden

bull Pulmonary artery systolic pressure(PAP) is incorporated in grading

the severity of MS

lt30 mm Hg ndash mild

30-50mmHg ndash moderate

gt50 mm Hg - severe

bull Echocardiographically estimated RVSP is used as a surrogate for

PAP in absence of PS

bull RAP is estimated from size of IVC and respiratory collapsibilityBonow RO et al 2008 ACCAHA guidelines

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

RVSP (mmHg) PAP =

Transtricuspid gradient +RAP

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Mitral valve area

bull The normal MVA is 40 - 60cm2

bull Typically patients with MS do not experience symptoms until the

valve area is less than 25cm2

bull Based on mitral valve area stenosis is classified as

Severe lt 15 cmsup2

Very severe lt 10 cmsup2

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Methods to estimate the MVA

bull 12D planimetry

bull 2Pressure Half Time (PHT)

bull 3Continuity method

bull 4Proximal Isovelocity Surface area (PISA)method

bull 53D planimetry

bull 6Color Doppler method

Good correlation with invasively derived area and surgical

anatomic sizing there are inherent limitations

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Valve area indexed to body surface area has not been validated

bull Planimetry and PHT methods are the most widely used and easily

applicable

Planimetry is considered the reference method

No single method should be solely relied on and data from multiple

methods should be interpretated in the appropriate clinical setting

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

2D Planimetry

bull Based on direct visualization of the mitral valve orifice

bull Not limited by hemodynamic loading conditions

bull Excellent correlation with direct sizing at surgery (r =092)and

invasively derived area using the Gorlin hydraulic formula (r =095)

bull Mitral inflow is funnel shaped with the narrowest orifice at the level

of the leaflet tips

Parasternal short axis view

bull The inner rim of the orifice including opened commissures is traced

in mid diastole to calculate the MVA

bull Several measurements to be averaged in patients with HR variability

and AF

bull Can be challenging in setting of poor image quality heavily

calcified or distorted valves

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

limitations

bull Irregular orifice difficult to measure

bull A calcified object appears larger than it is actually on echoas

calcium reflects ultrasound very wellhence the orifice will

appear smaller (Blooming of echoes)

bull If chordae are thickenedthey can be mistaken for one of the

leaflet

bull Gain should be kept minimal

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Pressure gradient is dependent on volume statusstroke volume

and heart ratewhich affects filling time

bull Transmitral gradient plus the anticipated LVDP = LAP

bull LAP =PVP =PCWP = hydrostatic pressure

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Hatle and colleagues

bull Concept of PHT as a relatively flow independent assessment of MS

severity

bull PHT ndash the time taken for the transmitral pressure gradient to decay to

half the value at the onset of diastole

bull Time required for the peak velocity to decrease to V2 or V 14

bull PHT across isolated MS can be between 90 and 383 msec

In stenotic mitral valves there is a linear and inverse relationship

between MVA and PHT

The more severe the MS the longer the PHTHatle et al Noninvasive assessment of AVPHT by doppler Ultrasound

Circulation 1979601096-1104

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Hatle and colleagues proposed a derivation of MVA by using the

empirical formula

MVA = 220PHT

bull The PHT can also be calculated by multiplying the deceleration time

(time required for the peak velocity to decrease to the zero baseline)

by 029

bull PHT is directly proportional to left atrial and ventricular

chamber compliance and the square root of the initial peak gradient

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Caveats to the blanket use of PHT method

bull Unreliable in the presence of tachycardia and AF

bull Post valvotomy period (24-72 hrs) - abrupt changes in the

atrioventricular pressure compliance relationships and

transmitral gradient Thomas et alCirculation 198878980-93

bull Increased LV stiffness ndash aortic valve disease or CAD ndash may

overestimate MVA Karp et al JACC 198913594-9

bull Concomitant AR ndash shortening of PHT - overestimation of

MVA Gillam et al JACC 199016396-404

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Determination of Doppler pressure half-time (T12) with a bimodal non-linear decreasing

slope of the E-wave

Baumgartner H et al Eur J Echocardiogr

2008ejechocardjen303

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2008 For permissions please email journalspermissionsoxfordjournalsorg

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Imp points

bull If a line drawn above and not within then PHT will be longer

bull In atrial fibrillation use long R-R intervals

bull Severe AR shortens the PHT and so understimates the severity

bull In patients with LVHrelaxation can be slowerthe PHT will be longer

bull PHT can be used in patients with mitral regurgitation(but not

continuity equation)

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Mean pressure gradient is directly related to the average area

of the restrictive orifice and cardiac output

bull The peak instantaneous early pressure gradient between the

LA and LV is also related to the early transmitral flow volume

bull Early flow volume is dependent on cardiac output and by high

left atrial volumes ndash MR high output states

bull There is disproportionate increases in the early vs mean

gradient

bull This discrepancy can be a clue to concomitant MR especially

eccentric jets or paravalvular leaks

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Deceleration time

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

DT= 216029= 744 msec

DT Normal lt220 msec

Normal PHT lt 60 msec

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

MVA by continuity method

bull Principle of conservation of mass

bull Stroke volumes proximal and distal to the stenotic mitral valve must

be equal

SV = Valve area VTI

MVA = LVOT SV VTI MS

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Limitations

bull Most accurate in patients without significant mitral regurgitation

bull Accurate pulmonary artery diameter measurement for SV

calculations can be difficult in adult patients because of poor

acoustic access

bull Some degree of ARMR present in patients wit MS so transaortic

stroke volume dose not equal transmitral stroke volume

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

PISA method

bull Principle of flow convergence

bull Multiple hemispheric shells of increasing velocity and decreasing

radius ndash as flow accelerates towards an orifice

bull All blood cells at a particular hemisphere must have the same

velocity and radius

bull To conserve mass flow rate at a given hemispheric shell must be

equal to the flow across the stenotic mitral valve

Diastolic flow rate at stenotic mitral valve = flow rate

at PISA

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Color flow doppler assessment of the mitral inflow in the

Apical 4 chamber window

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull PISA method has been shown to have a good correlation with

other methods of MVA estimation

bull In the presence of AF the correlation is decreased but is

reasonable

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

3D Echo

bull Can visualize the mitral valve enface

bull 3D Planimetry has the closest agreement with invasive gorlin derived

MVA

bull Can be useful immediate postop of PBMV for accurate valve area

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Stress Echocardiography

bull Class I indication for exercise echocardiography in patients with

discordant clinical features and stenosis severity by resting ECHO

bull Intervention can be considered in patients with a mean gradient

greater than 15 mm Hg or PAP greater than 60 mmHg with

exercise

bull Gorlin and colleagues ndash patients with MS experience a significant

increase in HRLAPPAP during supine bike exercise

bull In patients with poor left atrial compliance can have substantial

elevations in PAP during exercise

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull Both exercise and dobutamine stress echocardiography have been

studied

bull Supine bike exercise is preferred to dobutamine

bull Exercise is a more physiological stressor and results in greater

elevations of HRLVFPPAP

bull In patients who are unable to exercise DSE can be performed

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Ideal echo scoring system

CRITERIA

bull Global and segmental evaluation (qualitative and quantitative) of each

MV apparatus component separately to localize the deformity in a

specific portion of MV apparatus

bull Inclusion of all points that proved to predict and affect the PMV

outcome via large study

bull Validation in large studies that include patients with different age

groups (not only young)

bull Easily applicable and interpretable by most cardiologists within a

reasonable time

bull High reproducibility and reliability

bull Unified for both transthoracic and transesophageal approaches

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Wilkins score

bull Also called Boston Abascal score

bull 1988 Gerard T WilkinsArthur EWeymanVivian M Abascal et al

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

Drawbacks of Wilkins score

bull Limited in ability to differentiate nodular fibrosis from

calcification

bull Assessment of commissural involvement is not included or

underestimated

bull Doesnrsquot account for uneven distribution of pathologic

abnormalities

bull Doesnrsquot account for relative contribution of each variable (no

weighting of variables)

bull Frequent underestimation of sub valvular disease

bull Doesnrsquot use results from TEE or 3D echocardiography

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull CHENNAIAH20150128182116596avi

bull GOVIND CRHD20150127113838630avi

bull PSax view for commissural calcification

bull High intensity bright echoes extending across the commissure

were taken to be areas of commissural calcification

bull Each half commissure with such echoes score of 1

bull Grade 0 -4

Significance of commissural calcification on outcome of mitral balloon valvotomy

N Sutaria et alHeart 200084398-402

Chen et al

bull A modified Wilkins score parameter for subvalvular thickening

according to the involved segment of chordal length

bull (1) if less than 13

bull (2) if more than 13

bull (3) if more than 23 and

bull (4) if involved the whole chordal length with no separation

Chen CG Wang X Wang Y et al Value of two-dimensional echocardiography in selecting

patients and balloon sizes for percutaneous balloon mitral valvuloplasty

J Am Coll Cardiol 198914(7)1651ndash8

Reid score

It includes

bull leaflet motion

bull leaflet thickness

bull subvalvular disease and

bull commissural calcium

bull Leaflet motion was expressed as a slope by dividing the height (H) by

the length (L) of doming of anterior leaflet

bull Leaflet thickness was expressed as the ratio between the thickness of

the tip of MV and thickness of posterior wall of aortic root

bull The score was assigned as

0 for mild affection

1 for moderate and

2 for severe affection

Reid CL et al Influence of mitral valve morphology on double-balloon

catheter balloon valvuloplasty in patients with mitral stenosis Analysis

of factors predicting immediate and 3-month results

Circulation 198980 (3)515ndash24

Nobuyoshi score

bull Leaflet pliability

bull Commissural disease and

bull Subvalvular apparatus

Nobuyoshi M Hamasaki N Kimura T et al Indications complications and short-term

clinical outcome of percutaneous transvenous mitral commissurotomy

Circulation 198980 (4)782ndash92

Cormier score

bull Cormier score divided the patients into three groups depending on

leaflets mobility calcification and subvalvular affection

bull Group 1 pliable noncalcified AML and mild subvalvular

disease (ie thin chordae gt10 mm long)

bull Group 2 pliable noncalcified AML and severe subvalvular

disease (ie thickened chordae lt10 mm long) and

bull Group 3 calcification of MV of any extent as assessed by

fluoroscopy whatever the state of subvalvular apparatus

Iung B Cormier B Ducimetiere P et al Immediate results of percutaneous mitral commissurotomy

A predictive model on a series of 1514 patients

Circulation 199694(9)2124-30

3D Echo score

Anwar AM Attia WM Nosir YF et al Validation of a new score for the assessment of mitral stenosis

using real-time threedimensional echocardiography

J Am Soc Echocardiogr Official Publication of the American Society of Echocardiography

201023(1)13ndash22

Mild mitral valve lt 8

Moderate 8-13

Severe gt14

Scallops in 2D Echocardiographic views

Advantages of 3D Echo score

bull The 3D score has many potential benefits that help for a detailed

assessment of the MV

1 Visualization of leaflets By RT3DE visualization and assessment of

the whole length of both leaflets is possible through single image

plane especially in sinus rhythm Leaflet mobility could be well

assessed

bull RT3DE could detect the thickness of each leaflet scallop

bull The whole leaflet length could not be evaluated by a single 2DE

image especially for the posterior leaflet which is short and

naturally less mobile than the anterior one

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Significance of commissural calcification on outcome of mitral balloon valvotomy

N Sutaria et alHeart 200084398-402

Chen et al

bull A modified Wilkins score parameter for subvalvular thickening

according to the involved segment of chordal length

bull (1) if less than 13

bull (2) if more than 13

bull (3) if more than 23 and

bull (4) if involved the whole chordal length with no separation

Chen CG Wang X Wang Y et al Value of two-dimensional echocardiography in selecting

patients and balloon sizes for percutaneous balloon mitral valvuloplasty

J Am Coll Cardiol 198914(7)1651ndash8

Reid score

It includes

bull leaflet motion

bull leaflet thickness

bull subvalvular disease and

bull commissural calcium

bull Leaflet motion was expressed as a slope by dividing the height (H) by

the length (L) of doming of anterior leaflet

bull Leaflet thickness was expressed as the ratio between the thickness of

the tip of MV and thickness of posterior wall of aortic root

bull The score was assigned as

0 for mild affection

1 for moderate and

2 for severe affection

Reid CL et al Influence of mitral valve morphology on double-balloon

catheter balloon valvuloplasty in patients with mitral stenosis Analysis

of factors predicting immediate and 3-month results

Circulation 198980 (3)515ndash24

Nobuyoshi score

bull Leaflet pliability

bull Commissural disease and

bull Subvalvular apparatus

Nobuyoshi M Hamasaki N Kimura T et al Indications complications and short-term

clinical outcome of percutaneous transvenous mitral commissurotomy

Circulation 198980 (4)782ndash92

Cormier score

bull Cormier score divided the patients into three groups depending on

leaflets mobility calcification and subvalvular affection

bull Group 1 pliable noncalcified AML and mild subvalvular

disease (ie thin chordae gt10 mm long)

bull Group 2 pliable noncalcified AML and severe subvalvular

disease (ie thickened chordae lt10 mm long) and

bull Group 3 calcification of MV of any extent as assessed by

fluoroscopy whatever the state of subvalvular apparatus

Iung B Cormier B Ducimetiere P et al Immediate results of percutaneous mitral commissurotomy

A predictive model on a series of 1514 patients

Circulation 199694(9)2124-30

3D Echo score

Anwar AM Attia WM Nosir YF et al Validation of a new score for the assessment of mitral stenosis

using real-time threedimensional echocardiography

J Am Soc Echocardiogr Official Publication of the American Society of Echocardiography

201023(1)13ndash22

Mild mitral valve lt 8

Moderate 8-13

Severe gt14

Scallops in 2D Echocardiographic views

Advantages of 3D Echo score

bull The 3D score has many potential benefits that help for a detailed

assessment of the MV

1 Visualization of leaflets By RT3DE visualization and assessment of

the whole length of both leaflets is possible through single image

plane especially in sinus rhythm Leaflet mobility could be well

assessed

bull RT3DE could detect the thickness of each leaflet scallop

bull The whole leaflet length could not be evaluated by a single 2DE

image especially for the posterior leaflet which is short and

naturally less mobile than the anterior one

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Chen et al

bull A modified Wilkins score parameter for subvalvular thickening

according to the involved segment of chordal length

bull (1) if less than 13

bull (2) if more than 13

bull (3) if more than 23 and

bull (4) if involved the whole chordal length with no separation

Chen CG Wang X Wang Y et al Value of two-dimensional echocardiography in selecting

patients and balloon sizes for percutaneous balloon mitral valvuloplasty

J Am Coll Cardiol 198914(7)1651ndash8

Reid score

It includes

bull leaflet motion

bull leaflet thickness

bull subvalvular disease and

bull commissural calcium

bull Leaflet motion was expressed as a slope by dividing the height (H) by

the length (L) of doming of anterior leaflet

bull Leaflet thickness was expressed as the ratio between the thickness of

the tip of MV and thickness of posterior wall of aortic root

bull The score was assigned as

0 for mild affection

1 for moderate and

2 for severe affection

Reid CL et al Influence of mitral valve morphology on double-balloon

catheter balloon valvuloplasty in patients with mitral stenosis Analysis

of factors predicting immediate and 3-month results

Circulation 198980 (3)515ndash24

Nobuyoshi score

bull Leaflet pliability

bull Commissural disease and

bull Subvalvular apparatus

Nobuyoshi M Hamasaki N Kimura T et al Indications complications and short-term

clinical outcome of percutaneous transvenous mitral commissurotomy

Circulation 198980 (4)782ndash92

Cormier score

bull Cormier score divided the patients into three groups depending on

leaflets mobility calcification and subvalvular affection

bull Group 1 pliable noncalcified AML and mild subvalvular

disease (ie thin chordae gt10 mm long)

bull Group 2 pliable noncalcified AML and severe subvalvular

disease (ie thickened chordae lt10 mm long) and

bull Group 3 calcification of MV of any extent as assessed by

fluoroscopy whatever the state of subvalvular apparatus

Iung B Cormier B Ducimetiere P et al Immediate results of percutaneous mitral commissurotomy

A predictive model on a series of 1514 patients

Circulation 199694(9)2124-30

3D Echo score

Anwar AM Attia WM Nosir YF et al Validation of a new score for the assessment of mitral stenosis

using real-time threedimensional echocardiography

J Am Soc Echocardiogr Official Publication of the American Society of Echocardiography

201023(1)13ndash22

Mild mitral valve lt 8

Moderate 8-13

Severe gt14

Scallops in 2D Echocardiographic views

Advantages of 3D Echo score

bull The 3D score has many potential benefits that help for a detailed

assessment of the MV

1 Visualization of leaflets By RT3DE visualization and assessment of

the whole length of both leaflets is possible through single image

plane especially in sinus rhythm Leaflet mobility could be well

assessed

bull RT3DE could detect the thickness of each leaflet scallop

bull The whole leaflet length could not be evaluated by a single 2DE

image especially for the posterior leaflet which is short and

naturally less mobile than the anterior one

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Reid score

It includes

bull leaflet motion

bull leaflet thickness

bull subvalvular disease and

bull commissural calcium

bull Leaflet motion was expressed as a slope by dividing the height (H) by

the length (L) of doming of anterior leaflet

bull Leaflet thickness was expressed as the ratio between the thickness of

the tip of MV and thickness of posterior wall of aortic root

bull The score was assigned as

0 for mild affection

1 for moderate and

2 for severe affection

Reid CL et al Influence of mitral valve morphology on double-balloon

catheter balloon valvuloplasty in patients with mitral stenosis Analysis

of factors predicting immediate and 3-month results

Circulation 198980 (3)515ndash24

Nobuyoshi score

bull Leaflet pliability

bull Commissural disease and

bull Subvalvular apparatus

Nobuyoshi M Hamasaki N Kimura T et al Indications complications and short-term

clinical outcome of percutaneous transvenous mitral commissurotomy

Circulation 198980 (4)782ndash92

Cormier score

bull Cormier score divided the patients into three groups depending on

leaflets mobility calcification and subvalvular affection

bull Group 1 pliable noncalcified AML and mild subvalvular

disease (ie thin chordae gt10 mm long)

bull Group 2 pliable noncalcified AML and severe subvalvular

disease (ie thickened chordae lt10 mm long) and

bull Group 3 calcification of MV of any extent as assessed by

fluoroscopy whatever the state of subvalvular apparatus

Iung B Cormier B Ducimetiere P et al Immediate results of percutaneous mitral commissurotomy

A predictive model on a series of 1514 patients

Circulation 199694(9)2124-30

3D Echo score

Anwar AM Attia WM Nosir YF et al Validation of a new score for the assessment of mitral stenosis

using real-time threedimensional echocardiography

J Am Soc Echocardiogr Official Publication of the American Society of Echocardiography

201023(1)13ndash22

Mild mitral valve lt 8

Moderate 8-13

Severe gt14

Scallops in 2D Echocardiographic views

Advantages of 3D Echo score

bull The 3D score has many potential benefits that help for a detailed

assessment of the MV

1 Visualization of leaflets By RT3DE visualization and assessment of

the whole length of both leaflets is possible through single image

plane especially in sinus rhythm Leaflet mobility could be well

assessed

bull RT3DE could detect the thickness of each leaflet scallop

bull The whole leaflet length could not be evaluated by a single 2DE

image especially for the posterior leaflet which is short and

naturally less mobile than the anterior one

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Nobuyoshi score

bull Leaflet pliability

bull Commissural disease and

bull Subvalvular apparatus

Nobuyoshi M Hamasaki N Kimura T et al Indications complications and short-term

clinical outcome of percutaneous transvenous mitral commissurotomy

Circulation 198980 (4)782ndash92

Cormier score

bull Cormier score divided the patients into three groups depending on

leaflets mobility calcification and subvalvular affection

bull Group 1 pliable noncalcified AML and mild subvalvular

disease (ie thin chordae gt10 mm long)

bull Group 2 pliable noncalcified AML and severe subvalvular

disease (ie thickened chordae lt10 mm long) and

bull Group 3 calcification of MV of any extent as assessed by

fluoroscopy whatever the state of subvalvular apparatus

Iung B Cormier B Ducimetiere P et al Immediate results of percutaneous mitral commissurotomy

A predictive model on a series of 1514 patients

Circulation 199694(9)2124-30

3D Echo score

Anwar AM Attia WM Nosir YF et al Validation of a new score for the assessment of mitral stenosis

using real-time threedimensional echocardiography

J Am Soc Echocardiogr Official Publication of the American Society of Echocardiography

201023(1)13ndash22

Mild mitral valve lt 8

Moderate 8-13

Severe gt14

Scallops in 2D Echocardiographic views

Advantages of 3D Echo score

bull The 3D score has many potential benefits that help for a detailed

assessment of the MV

1 Visualization of leaflets By RT3DE visualization and assessment of

the whole length of both leaflets is possible through single image

plane especially in sinus rhythm Leaflet mobility could be well

assessed

bull RT3DE could detect the thickness of each leaflet scallop

bull The whole leaflet length could not be evaluated by a single 2DE

image especially for the posterior leaflet which is short and

naturally less mobile than the anterior one

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Cormier score

bull Cormier score divided the patients into three groups depending on

leaflets mobility calcification and subvalvular affection

bull Group 1 pliable noncalcified AML and mild subvalvular

disease (ie thin chordae gt10 mm long)

bull Group 2 pliable noncalcified AML and severe subvalvular

disease (ie thickened chordae lt10 mm long) and

bull Group 3 calcification of MV of any extent as assessed by

fluoroscopy whatever the state of subvalvular apparatus

Iung B Cormier B Ducimetiere P et al Immediate results of percutaneous mitral commissurotomy

A predictive model on a series of 1514 patients

Circulation 199694(9)2124-30

3D Echo score

Anwar AM Attia WM Nosir YF et al Validation of a new score for the assessment of mitral stenosis

using real-time threedimensional echocardiography

J Am Soc Echocardiogr Official Publication of the American Society of Echocardiography

201023(1)13ndash22

Mild mitral valve lt 8

Moderate 8-13

Severe gt14

Scallops in 2D Echocardiographic views

Advantages of 3D Echo score

bull The 3D score has many potential benefits that help for a detailed

assessment of the MV

1 Visualization of leaflets By RT3DE visualization and assessment of

the whole length of both leaflets is possible through single image

plane especially in sinus rhythm Leaflet mobility could be well

assessed

bull RT3DE could detect the thickness of each leaflet scallop

bull The whole leaflet length could not be evaluated by a single 2DE

image especially for the posterior leaflet which is short and

naturally less mobile than the anterior one

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

3D Echo score

Anwar AM Attia WM Nosir YF et al Validation of a new score for the assessment of mitral stenosis

using real-time threedimensional echocardiography

J Am Soc Echocardiogr Official Publication of the American Society of Echocardiography

201023(1)13ndash22

Mild mitral valve lt 8

Moderate 8-13

Severe gt14

Scallops in 2D Echocardiographic views

Advantages of 3D Echo score

bull The 3D score has many potential benefits that help for a detailed

assessment of the MV

1 Visualization of leaflets By RT3DE visualization and assessment of

the whole length of both leaflets is possible through single image

plane especially in sinus rhythm Leaflet mobility could be well

assessed

bull RT3DE could detect the thickness of each leaflet scallop

bull The whole leaflet length could not be evaluated by a single 2DE

image especially for the posterior leaflet which is short and

naturally less mobile than the anterior one

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Scallops in 2D Echocardiographic views

Advantages of 3D Echo score

bull The 3D score has many potential benefits that help for a detailed

assessment of the MV

1 Visualization of leaflets By RT3DE visualization and assessment of

the whole length of both leaflets is possible through single image

plane especially in sinus rhythm Leaflet mobility could be well

assessed

bull RT3DE could detect the thickness of each leaflet scallop

bull The whole leaflet length could not be evaluated by a single 2DE

image especially for the posterior leaflet which is short and

naturally less mobile than the anterior one

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Advantages of 3D Echo score

bull The 3D score has many potential benefits that help for a detailed

assessment of the MV

1 Visualization of leaflets By RT3DE visualization and assessment of

the whole length of both leaflets is possible through single image

plane especially in sinus rhythm Leaflet mobility could be well

assessed

bull RT3DE could detect the thickness of each leaflet scallop

bull The whole leaflet length could not be evaluated by a single 2DE

image especially for the posterior leaflet which is short and

naturally less mobile than the anterior one

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

2 Leaflet calcification Scoring of leaflet calcification using Wilkins

score depends on the bright areas and the extension of calcification

along the leaflet length Multiple cut planes are needed for detecting

calcification in all scallops of both MV leaflets

bull RT3DE could predict the extent and distribution of calcification in

each scallop from a single short axis cut plain

bull The new RT3DE score described calcification at the commissural

parts of leaflet by a higher score than the middle leaflets calcification

because it was proved that calcification of commissures is one of the

strong predictors of outcome after PMV the degree of commissural

splitting

3 Subvalvular apparatus RT3DE score included the chordal thickness

and separation which is a good independent predictor for BMV

outcome

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

bull Both chordal thickness and separation are scored at three levels by

dividing their length into three parts (proximal middle and distal)

This detailed information especially for chordal separation was not

obtained by most 2D scoring systems including Wilkins score

4 Score applicability Compared to Wilkins score the RT3DE score is

simple and more helpful particularly for less experienced operators as

it provides a simple number for each leaflet scallop and subvalvular

apparatus segment separately This was evident by good interobserver

and intraobserver agreements for most of the score components

5 Score approach The score can be applied using both transthoracic

and transesophageal approaches because the image orientation and

interpretation are not different

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Limitations

bull Not available in all cardiac centers

bull Operator dependent

bull Analysis based on software

bull Complex and time consuming

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

TEE

bull The standard midesophageal (ME) views (four-chamber

commissural two-chamber and long-axis) assist in evaluating the

extent of disease

bull The chordal tendons can display varying degrees of thickening and

contracture

bull The transgastric (TG) long-axis imaging plane provides the best

information with regard to the extent of subvalvular involvement in

the rheumatic process

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

LA thrombus classification

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Follow up

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Vijayarsquos echo criteria

S NO ECHO FEATURE SCORE

1 Mitral valve and aortic valve thickness gt4 mm 2

2 Increased echogenicity of submitral structures 2

3 Rheumatic nodules (beaded appearance) 2

4 MVPAVPTVP 2

5 Mitral regurgitation and aortic regurgitationtricuspid

regurgitation

2

6 Reduced mobility of the valves 2

7 Chordal tear 2

8 Pericardial effusion 2

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Calcific Mitral Stenosis

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

bull Saddle shaped annulus plays an active role in mitral valve

leaflet coaptation and in LALV systole and diastole

bull Annulus is susceptible to disease processes that are distinct

from those that affect the mitral valve leaflets

bull The calcification may extend onto the posterior leaflet thereby

increasing the diastolic gradients across the mitral valve

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Mitral Annular Calcification

bull MC cardiac findings at autopsy

bull Calcium deposited between posterior LV wall and PML

bull TTE ndashPLAX viewPSAX

bull Anterior involvement ndash advanced casesrare

bull Calcification of the aortic valvepapillary muscleschordae

tendinae frequently coexist with MAC

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

bull Assosciated with female age advanced age diabetes hypertension

bull Patients with MVP

bull 9 of women3 of men with gt 60 yrs of age

bull ESRD requiring dialysis

bull Framingham Heart Study ndash CKD pts with e GFR lt

60mlmin173m2 were 19 times more likely to have MAC compared

to those without CKD after age and sex matching

bull Deranged calcium and phosphorus metabolism

bull MAC is marker for atherosclerotic burden and is assosciated with an

increased risk of atrial arrhythmias stroke and CV morbidity and

mortality

bull For each mm increase in size of the MACthe event rate increased by

approx10

bull Increased burden of aortic atherosclerosis is seen in pts with MAC

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

CCMA

bull Caseous Calcification of Mitral Annulus

bull Rare variant

bull Misinterpreted as tumor abscesses or thrombus on echo

bull Combination of fatty acids calcium cholesterol

bull White caseous paste like material surrounded by calcium shell

bull Amorphous eosinophils macrophages lymphocytes with scattered

areas of necrosiscalcification on histology

bull Cause is unknown

bull Posterior periannuluar region on ECHO

bull Central area of echoluceny which represents liquefaction

necrosisand the absence of acoustic shadowing help distinguish it

form true MAC

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

bull No clinical differences have been shown to exist between

patients with MAC and those with CCMA

bull Benign

bull Can progress or resolute

bull Has been shown to cause stenosis or regurgitation by mass

effect at mitral valveerosion into the left atriumerosion into

the left circumflex artery

Caseous Calcification of the Mitral Annulus

Harvinder Arora et alTex Heart Inst J 2008 35(2) 211ndash213

Presence of A wave more than E wave

rules out significant MS

Radiation assosciated calcific MS

bull Hodgkinrsquos cancerbreast cancer

bull 70-80 prevalence of valve fibrosis in patients treated with chest

radiation exceeding 35 Gy

bull 6-15 of treated pts ndash valvular heart disease

bull More than 20 yrs after radiation exposure

bull Decreased population of endothelial progenitor cells

bull Severe MAC and THICKENING of AMC extending onto AML

bull PML is mobile ndash distinguishes from degenerative MAC

bull No commissural fusionsubvalvular apparatus is typically

unaffected

MITRAL VALVULAR DYSFUNCTION

Mitral Regurgitation

bull MC form

ASphincter like action does not occur in systole

bull Size of the annulus is not decreased in systoleso MR occurs

B Leaflet elevation of PML

Mitral stenosis

bull When MAC is heavy and extends onto leaflets

bull Degenerative MS

bull Limiting orifice area is at the base of the mitral leaflets

bull Well appreciated by real 3D TTE

bull Tubular geometry of the mitral orifice

Quantifying the severity

bull Planimetry to be avoided - limiting orifice is at the base of the

leaflets

bull Mean diastolic gradient

bull PHT to be avoided ndash because of decreased LV compliance

(usually seen in pts with MAC) ndash overestimation of MVA

bull PISA method is acceptable(color line shifted in the opposite

direction)

bull RT3DE derived MVA better than PHT derived MVA

compared to continuity equation ndash Chu et al

Congenital Mitral Stenosis

Figure 5 Congenital mitral stenosis Parachute-like congenital mitral stenosis with a circular

orifice and no commissures in (A) two-dimensional transthoracic echocardiography and (B)

three-dimensional transthoracic echocardiography

Laura Krapf Julien Dreyfus Caroline Cueff Laurent Lepage Eacuteric Brochet Alec Vahanian

David Messika-Zei

Anatomical features of rheumatic and non-rheumatic mitral stenosis Potential additional value

of three-dimensional echocardiography

Archives of Cardiovascular Diseases Volume 106 Issue 2 2013 111 - 115httpdxdoiorg101016jacvd201211004

Three-dimensional transesophageal images surgical view (live 3D zoom mode)

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

LA Myxoma

bull nejmicm1310149_attach_1_nejmicm1310149_v01mp4

bull MAHARSHI

BALLVALVETHROMBUS20141220143245248avi

Radiation assosciated calcific MS

bull Hodgkinrsquos cancerbreast cancer

bull 70-80 prevalence of valve fibrosis in patients treated with chest

radiation exceeding 35 Gy

bull 6-15 of treated pts ndash valvular heart disease

bull More than 20 yrs after radiation exposure

bull Decreased population of endothelial progenitor cells

bull Severe MAC and THICKENING of AMC extending onto AML

bull PML is mobile ndash distinguishes from degenerative MAC

bull No commissural fusionsubvalvular apparatus is typically

unaffected

MITRAL VALVULAR DYSFUNCTION

Mitral Regurgitation

bull MC form

ASphincter like action does not occur in systole

bull Size of the annulus is not decreased in systoleso MR occurs

B Leaflet elevation of PML

Mitral stenosis

bull When MAC is heavy and extends onto leaflets

bull Degenerative MS

bull Limiting orifice area is at the base of the mitral leaflets

bull Well appreciated by real 3D TTE

bull Tubular geometry of the mitral orifice

Quantifying the severity

bull Planimetry to be avoided - limiting orifice is at the base of the

leaflets

bull Mean diastolic gradient

bull PHT to be avoided ndash because of decreased LV compliance

(usually seen in pts with MAC) ndash overestimation of MVA

bull PISA method is acceptable(color line shifted in the opposite

direction)

bull RT3DE derived MVA better than PHT derived MVA

compared to continuity equation ndash Chu et al

Congenital Mitral Stenosis

Figure 5 Congenital mitral stenosis Parachute-like congenital mitral stenosis with a circular

orifice and no commissures in (A) two-dimensional transthoracic echocardiography and (B)

three-dimensional transthoracic echocardiography

Laura Krapf Julien Dreyfus Caroline Cueff Laurent Lepage Eacuteric Brochet Alec Vahanian

David Messika-Zei

Anatomical features of rheumatic and non-rheumatic mitral stenosis Potential additional value

of three-dimensional echocardiography

Archives of Cardiovascular Diseases Volume 106 Issue 2 2013 111 - 115httpdxdoiorg101016jacvd201211004

Three-dimensional transesophageal images surgical view (live 3D zoom mode)

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

LA Myxoma

bull nejmicm1310149_attach_1_nejmicm1310149_v01mp4

bull MAHARSHI

BALLVALVETHROMBUS20141220143245248avi

MITRAL VALVULAR DYSFUNCTION

Mitral Regurgitation

bull MC form

ASphincter like action does not occur in systole

bull Size of the annulus is not decreased in systoleso MR occurs

B Leaflet elevation of PML

Mitral stenosis

bull When MAC is heavy and extends onto leaflets

bull Degenerative MS

bull Limiting orifice area is at the base of the mitral leaflets

bull Well appreciated by real 3D TTE

bull Tubular geometry of the mitral orifice

Quantifying the severity

bull Planimetry to be avoided - limiting orifice is at the base of the

leaflets

bull Mean diastolic gradient

bull PHT to be avoided ndash because of decreased LV compliance

(usually seen in pts with MAC) ndash overestimation of MVA

bull PISA method is acceptable(color line shifted in the opposite

direction)

bull RT3DE derived MVA better than PHT derived MVA

compared to continuity equation ndash Chu et al

Congenital Mitral Stenosis

Figure 5 Congenital mitral stenosis Parachute-like congenital mitral stenosis with a circular

orifice and no commissures in (A) two-dimensional transthoracic echocardiography and (B)

three-dimensional transthoracic echocardiography

Laura Krapf Julien Dreyfus Caroline Cueff Laurent Lepage Eacuteric Brochet Alec Vahanian

David Messika-Zei

Anatomical features of rheumatic and non-rheumatic mitral stenosis Potential additional value

of three-dimensional echocardiography

Archives of Cardiovascular Diseases Volume 106 Issue 2 2013 111 - 115httpdxdoiorg101016jacvd201211004

Three-dimensional transesophageal images surgical view (live 3D zoom mode)

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

LA Myxoma

bull nejmicm1310149_attach_1_nejmicm1310149_v01mp4

bull MAHARSHI

BALLVALVETHROMBUS20141220143245248avi

Quantifying the severity

bull Planimetry to be avoided - limiting orifice is at the base of the

leaflets

bull Mean diastolic gradient

bull PHT to be avoided ndash because of decreased LV compliance

(usually seen in pts with MAC) ndash overestimation of MVA

bull PISA method is acceptable(color line shifted in the opposite

direction)

bull RT3DE derived MVA better than PHT derived MVA

compared to continuity equation ndash Chu et al

Congenital Mitral Stenosis

Figure 5 Congenital mitral stenosis Parachute-like congenital mitral stenosis with a circular

orifice and no commissures in (A) two-dimensional transthoracic echocardiography and (B)

three-dimensional transthoracic echocardiography

Laura Krapf Julien Dreyfus Caroline Cueff Laurent Lepage Eacuteric Brochet Alec Vahanian

David Messika-Zei

Anatomical features of rheumatic and non-rheumatic mitral stenosis Potential additional value

of three-dimensional echocardiography

Archives of Cardiovascular Diseases Volume 106 Issue 2 2013 111 - 115httpdxdoiorg101016jacvd201211004

Three-dimensional transesophageal images surgical view (live 3D zoom mode)

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

LA Myxoma

bull nejmicm1310149_attach_1_nejmicm1310149_v01mp4

bull MAHARSHI

BALLVALVETHROMBUS20141220143245248avi

Congenital Mitral Stenosis

Figure 5 Congenital mitral stenosis Parachute-like congenital mitral stenosis with a circular

orifice and no commissures in (A) two-dimensional transthoracic echocardiography and (B)

three-dimensional transthoracic echocardiography

Laura Krapf Julien Dreyfus Caroline Cueff Laurent Lepage Eacuteric Brochet Alec Vahanian

David Messika-Zei

Anatomical features of rheumatic and non-rheumatic mitral stenosis Potential additional value

of three-dimensional echocardiography

Archives of Cardiovascular Diseases Volume 106 Issue 2 2013 111 - 115httpdxdoiorg101016jacvd201211004

Three-dimensional transesophageal images surgical view (live 3D zoom mode)

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

LA Myxoma

bull nejmicm1310149_attach_1_nejmicm1310149_v01mp4

bull MAHARSHI

BALLVALVETHROMBUS20141220143245248avi

Figure 5 Congenital mitral stenosis Parachute-like congenital mitral stenosis with a circular

orifice and no commissures in (A) two-dimensional transthoracic echocardiography and (B)

three-dimensional transthoracic echocardiography

Laura Krapf Julien Dreyfus Caroline Cueff Laurent Lepage Eacuteric Brochet Alec Vahanian

David Messika-Zei

Anatomical features of rheumatic and non-rheumatic mitral stenosis Potential additional value

of three-dimensional echocardiography

Archives of Cardiovascular Diseases Volume 106 Issue 2 2013 111 - 115httpdxdoiorg101016jacvd201211004

Three-dimensional transesophageal images surgical view (live 3D zoom mode)

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

LA Myxoma

bull nejmicm1310149_attach_1_nejmicm1310149_v01mp4

bull MAHARSHI

BALLVALVETHROMBUS20141220143245248avi

Three-dimensional transesophageal images surgical view (live 3D zoom mode)

McCarthy K P et al Eur J Echocardiogr 201011i3-i9

Published on behalf of the European Society of Cardiology All rights reserved copy The Author

2010 For permissions please email journalspermissionsoxfordjournalsorg

LA Myxoma

bull nejmicm1310149_attach_1_nejmicm1310149_v01mp4

bull MAHARSHI

BALLVALVETHROMBUS20141220143245248avi

LA Myxoma

bull nejmicm1310149_attach_1_nejmicm1310149_v01mp4

bull MAHARSHI

BALLVALVETHROMBUS20141220143245248avi

bull nejmicm1310149_attach_1_nejmicm1310149_v01mp4

bull MAHARSHI

BALLVALVETHROMBUS20141220143245248avi

Prosthetic Mitral Valve Stenosis

bull Easier to visualize

bull Parasternal and apical windows

bull Stability of mitral prosthesisdehiscencemotion of leaflets or

the occluding mechanism generally possible with transthoracic

imaging

bull Doppler beam as close to the direction of inflow

bull renukaRENUKA TEE20150110132342727avi

bull renukaRENUKA TEE20150110132342727avi

Effect of Concurrent conditions

bull 1Tachycardia

bull 2Mitral Regurgitation

bull 3Aortic regurgitation decreases PHT

bull 4LV dysfunction

bull 5ASD

bull 6Tricuspid stenosis

bull 7organic TR

bull 8pulmonic stenosis

bull 9CCP

Increased gradients

Left atrium in MS

bull Dilated

bull Giant LA gt 65 cm

bull LAA

bull SEC

bull Thrombus

bull LA clot formation in SR 24-135

bull Incidence is as high as 33 in patients with AF

Manjunath et al

Incidence and predictors of LA thrombus in patients with rheumatic MS and SR

Echocardiography 201128(4)257-60

Conclusion

bull Echocardiography is the primary modality for evlaution of mitral

valve disease

bull M mode2D echo color doppler all to be correlated in estimating the

severity of mitral stenosis

bull Concurrent conditions should be kept in mind when the values donrsquot

correlate with the clinical findings

bull 3d echo adds additional information

Left atrium in MS

bull Dilated

bull Giant LA gt 65 cm

bull LAA

bull SEC

bull Thrombus

bull LA clot formation in SR 24-135

bull Incidence is as high as 33 in patients with AF

Manjunath et al

Incidence and predictors of LA thrombus in patients with rheumatic MS and SR

Echocardiography 201128(4)257-60

Conclusion

bull Echocardiography is the primary modality for evlaution of mitral

valve disease

bull M mode2D echo color doppler all to be correlated in estimating the

severity of mitral stenosis

bull Concurrent conditions should be kept in mind when the values donrsquot

correlate with the clinical findings

bull 3d echo adds additional information

Conclusion

bull Echocardiography is the primary modality for evlaution of mitral

valve disease

bull M mode2D echo color doppler all to be correlated in estimating the

severity of mitral stenosis

bull Concurrent conditions should be kept in mind when the values donrsquot

correlate with the clinical findings

bull 3d echo adds additional information