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Echo Conference
April 6, 2011
Frances Canet, MD
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Causes andAnatomy
Assessment of
Mitral Stenosis How to Grade
Mitral Stenosis
Cases andApplication
Outline
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Rheumatic MSCommissural fusion
Degenerative MS
Annular calcificationAssociated with elderly, hypertension,atherosclerosis and aortic stenosis
Congenital MS
Abnormalities of subvalvular apparatus
Other: Systemic lupus, infiltrative disease, carcinoidheart disease, drug-induced valve disease
Causes and Anatomy
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Level 1 Recommendations:Pressure gradient
MVA Planimetry
Pressure half-time
Level 2 Recommendations:
Continuity equation
Proximal isovelocity surface area method (PISA)
Stress echocardiography
How to Assess Mitral Stenosis
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Continuous wave doppler is preferred
Gradient is measured in the apical window
Color doppler is used to identify eccentric diastolic mitral jets
Doppler beam is guided by the highest flow velocity zoneidentified by color doppler
Mean gradient is the relevant hemodynamic finding
Measure heart rate at which gradients are obtainedIf patient is in atrial fibrillation, the mean gradient should be anaverage of five cycles with the least variation of R-R intervals
Pressure Gradient
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Mitral Valve Area Planimetry
Direct tracing of the mitral orifice including opened commissures in theparasternal short-axis view at mid-diastole
Advantages:- Direct measure of MVA- Does not involve hypothesis regarding flow conditions, cardiac chamber
compliance or associated valvular lesions- Best correlation with anatomic valve area of explanted valves
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Obtaining and measuring the image:
-Scan apex to the base of the LV to ensure the cross-sectional area is measured at the leaflet tips.
-Plane should be perpendicular to the mitral orifice,elliptical shape.
-Gain, sufficient to see contour of the mitral orifice.
- If too excessive, may cause under estimation of the valve area.
-Perform several measurements if the patient has atrialfibrillation or incomplete commissural fusion
Mitral Valve Area Planimetry
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T1/2= time intervalin milliseconds
between the
maximum mitral
gradient in early
diastole and the
time point where
the gradient is
half the maximum
initial value
MVA = 220/ T1/2
Pressure half-time
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Measuring T1/2 with a bimodal, non-linear decreasing slope of the E-wave
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Based on assumption that the filling volume of diastolic mitral flow is equalto aortic SV.
MVA = pi (D2/4) (VTIAortic / VTIMitral)
D is the diameter of the LVOT in cm
VTI is in cm.
Accuracy and reproducibility is hampered by the number of measurements
increasing the impact of errors of measurements.Cannot be used in atrial fibrillation or associated significant MR or AR
Continuity equation Level 2
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MVA = pi (r2) (Valiasing) / Peak Vmitralx
alpha/1800
R is the radius of the convergencehemisphere in cm
Valiasing is the aliasing velocity in cm/s
Peak Vmitralis the peak CWD velocity of
mitral inflow in cm/salpha is the opening angle of mitralleaflets relative to flow direction
Proximal isovelocity surface areamethod Level 2
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Parasternal short-axis view
valve thickness (maximum and heterogeneity)
commissural fusion
extension and location of localized bright zones (fibrous nodules orcalcification)
Parasternal long-axis view
valve thickness
extension of calcification
valve pliabilitysubvalvular apparatus (chordal thickening, fusion, or shortening)
Apical two-chamber view
subvalvular apparatus (chordal thickening, fusion, or shortening)
Detail each component and summarize in a score
Valve Anatomy
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Enables measurement of mean
mitral gradient and systolic
pulmonary artery pressure during
effort.
Semi-supine exercise
echocardiography allows
monitoring of gradient.
Useful in patients with equivocal or
discordant with the severity of MS.
Stress Echocardiography Level 2
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How to Grade Mitral Stenosis
Normal MVA is 4.0-5.0 cm2
MVA >1.5 cm2 does not produce symptomsAs severity increases, cardiac output decreases and fails toincrease during exercise.
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Grades morphological changes in the MV during echo:
Leaflet mobility
Leaflet thickening
Valve calcification
Involvement of the subvalvular apparatus
Each characteristic is graded from 0-4, with a total of 16points total.
A score >8 is predictive of low success post percutaneousmitral valvuloplasty.
Wilkins (Valvotomy )Score
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72-year-old man with known moderate aortic stenosis,mitral regurgitation, hypertension, diabetes, COPD, TIAand severe pulmonary hypertension based on cardiaccatheterization results is referred for echocardiogram to
assess severity of mitral valve regurgitation.
How severe is his mitral regurgitation? Does he havemitral stenosis? What are his options for repair calculate
valvotomy score?
Case 1
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PSL MV
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PSL Zoom
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PSL MV Color
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4C AP
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4C AP Color
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MV Planimetry
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PSS MV Planimetry Still
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MV VTI for Pressure Gradient
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MV half time 3
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LVOT Diameter is 2.1
VTI aortic is 87
VTI mitral is 87.2
MVA = pi (D2/4) (VTIAortic / VTIMitral)
MVA = 3.89 cm2 (Not accurate compared to MVA of 1.15 cm 2calculatedfrom pressure gradient. Remember, it is not accurate in patient with severe
mitral regurgitation or atrial fibrillation.)
Less accurate calculation of MVA as it relies on several other measurementsto be accurate.
Continuity equation
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Valvotomy Score = 12Mobility valve
moves forward in
diastole, moves
mainly from base
3 points
Subvalvular
Thickening
thickening of chordal
structures extending
into 1/3rdof the
chordal length3 points
Thickening extends
through the entire
leaflet
3 points
Calcification
Brightness extending
into the mid-portion
of the leaflets
3 points
Total score = 12
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56-year-old woman with a history of rheumatic mitralvalve stenosis, respiratory failure, heart failure, atrialfibrillation, recent stroke, COPD, sarcoidosis,schizophrenia was transferred from an outside hospital
for a second opinion on mitral valve replacement. She haspoor functional and neurologic status at present.
Evaluate the grade of her mitral stenosis and calculate her
valvotomy score.
Case 2
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PSL MV
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PSL MV Zoom
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PSL MV Color
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4C AP MV
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PSS Planimetry Loop
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Planimetry Still
This is not acutally the area of
the MV orfiice. Look at the
small sliver of black area justbelow the tracing.
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Pressure gradient
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Pressure half-time
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Resting mean pressure gradient: 16mmHg(severe is >10mmHg)
Mitral valve area using half time: 0.77cm2(severe
is
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Valvotomy score:
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Mobility: 4
No or minimalforward movement of theleaflets.
Subvalvular Thickening: 2-3-
Thickening of chordal
structures up to one-third ofthe chordal length possibly todistal third of the chords.
Thickening: 4 Considerablethickening of all leaflet tissue
(>8-10mm).
Calcification: 4 Extensivebrightness throughout muchof the leaflet tissue.
Valvotomy score: 14 out of 16