Echocardiographic assessment of mital valve anatomy

Echocardiographic assessment of mital valve anatomy is crucial for successful BMV

1. Echocardiographic Assessment Before And After PTMC Dr Monika Bhandari Profesor (Jr) DM, FACC, FSCAI Dept of Cardiology, KGMU

2. The leading cause of mitral stenosis (MS) throughout the world is rheumatic carditis At least 15·6 million people have RHD, 0.3of about 0·5 million individuals who acquire ARF every year go on to develop RHD 233 000 deaths annually are directly attributable to ARF or RHD. Carapetis JR. The current evidence for the burden of group A streptococcal diseases. WHO/FCH/CAH/05·07

3. The symmetrical fusion of the commissures results in a small central oval orifice in diastole that on pathologic specimens is shaped like a fish mouth or buttonhole because the AML is not in the physiologic open position. The most useful descriptor of the severity of obstruction is the degree of valve opening in diastole, or the MVA. In normal adults, the cross-sectional area of the MV orifice is 4 to 6 cm2 In Severe MS, MVA< 1.5 cm2 Percutaneous mitral commissurotomy works on the principle of commissural splitting.

4. Stages of MS From Nishimura RA, Otto CM, Bonow RO, et al: 2014 AHA/ACCF guideline for the management of patients with valvular heart disease: A report of the ACC Foundation/AHA Task Force on Practice Guidelines. J Am Coll Cardiol 63:e57, 2014.

5. MITRAL VALVE ANATOMY

6. Echocardiographic assessment M-mode- D-E Excursion, E-F slope, Leaflet motion 2D- valve motion, leaflet thickening and motion, calcification, subvalvular apparatus, commissural fusion and leaflet separation and valve are by planimetry, chamber sizes, IAS, MVA (planimetry) Doppler: Gradient, Pressure half-time (severity and valve are), MR, PAH 3D echo: Valve morphology and MVA (planimetry) TEE: IAS, LA/LAA Thrombus

7. M-Mode

8. Dense echo at mitral valve Decreased D-E excursion (D-E amplitude < 18 mm- Pliable valve) Decreased E-F slope (E-F slope < 20 mm/sec- severe MS) Poor leaflet separation: Anterior motion of posterior leaflet

9. 2D-ECHO Restricted movement and diastolic motion of leaflets Thickened and calcified leaflets Thickened sub-valvular apparatus Commisural fusion

10. 2D-Colour Doppler Gradient assessment Pulmonary pressure assessment Any regurgitation across mitral and any other valve 3D-Echo 3D-Echo is superior in evaluating MVA D irect visualization of the valve orifice in multiple planes ensures that the planimetry takes place at the level of the mitral leaflet tips, where the valve orifice is narrowest. 3D planimetry has been reported as the most accurate method for mitral valve area evaluation

11. TEE For excluding LA thrombus For assessing severity of MR IAS thickness

12. Echocardiography Assessment Cont.. Severity of MS Degree of MR Pulmonary artery hypertension Valve suitability of PTMC- scoring LA/LAA thromnus Inter-atrial septum Other associated valvular disease

13. Severe MS Criteria Mitral Valve area: MVA < 1.5 cm2 Planimetry (more reliable): Done in PSAX view Measure maximum opening in mid-diastole lowest gain setting Plane should be perpendicular to orifice Measure in zoom mode Include open commisures Real time 3D or 3D guided biplane imaging is useful in optimizing positioning of measurement plane and improves reproducibility

14. MVA BY PHT

15. Mitral leaflet separation index The mitral leaflet separation (MLS) index, measures the distance between the tips of the mitral leaflets in parasternal long-axis and four- chamber views. These two readings are averaged to yield the mitral leaflet separation index MLSI< 8mm suggest severe MS

16. Diastolic Gradient Across Mitral valve Mean diastolic gradient across mitral valve> 10 mmHg Measured in apical 4 chamber view Colour doppler at the tips of MV leaflets Derived from transmitral flow curve Heart rate should be controlled Peak and mean gradient calculated

17. Mitral Valve Scores For PTMC Wilkins score Reid score (Br Heart J.1977:39;1088-92). Lung Cormeir (Antunes MJ, Acquired Heart Valve disease, 1955) RT3DE Score Padial Score Commissural calcium score

18. Wilkins Score: Most commonly employed

19. Wilkins Score A score of less than 8 gives better results and long term succes of the procedure than more than 8 There is no absolute contraindication to PMV in patients with higher echo scores

20. Chen et al is a modified Wilkins score parameter for subvalvular thickening according to the involved segment of chordal length (1) if less than 1/3, (2) if more than 1/3, (3) if more than 2/3, and (4) if involved the whole chordal length with no separation Upto 2/3 rd involvement: PTMC is feasible

21. Reid Score I ncludes leaflet motion, leaflet thickness, subvalvular disease, and commissural calcium Leaflet motion was expressed as a slope by dividing the height (H) by the length (L) of doming of anterior leaflet. Leaflet thickness was expressed as the ratio between the thickness of the tip of MV and thickness of posterior wall of aortic root. The score was assigned as 0 for mild affection, 1 for moderate, and 2 for severe affection

22. Limitations Of Scoring Systems(particularly Wilkins) Echocardiography limited in ability to differentiate nodular fibrosis from calcification Assessment of commissural involvement is not included or underestimated. Doesn’t account for uneven distribution of pathologic abnormalities. Doesn’t account for relative contribution of each variable (no weighting of variables). Frequent underestimation of subvalvular disease. Doesn’t use results from TEE or 3D echocardiography

23. Ideal Score Global & semental evaluation of each MV apparatus Includes all points predicting PTMC success Validated in large studies in different age groups Easily applicable & interpretable High reproducibility & reliability Unified for both TTE & TEE

24. Nobuyoshi score

25. Reid score includes leaflet motion, leaflet thickness, subvalvular disease, and commissural calcium Leaflet motion was expressed as a slope by dividing the height (H) by the length (L) of doming of anterior leaflet. Leaflet thickness was expressed as the ratio between the thickness of the tip of MV and thickness of posterior wall of aortic root. The score was assigned as 0 for mild affection, 1 for moderate, and 2 for severe affection

26. RT3DE Score Total score ranges from 0-31 Mild MS < 8 Moderate MS: 8-13 Severe MS > 14

27. PADIAL SCORE Predicts occurrence of significant post PTMC ( Cut off is 10) Uneven mitral valve thickening Severe subvalvular disease Commisural calcification

28. Significance of Commisural Calcification

29. Exclude LA/LAA thrombus A thrombus should be excluded in the cardiac chambers prior to PMV. Most of the sites in LA can be effectively seen by TTE. TEE is helpful when TTE is suboptimal. The sites which should be specifically looked for thrombus are (a) LAA (b) at the junction of LAA and LA, (c) IAS, (d) layered thrombus in LA wall and (e) LA spontaneous echo contrast.

30. Manjunath’s Classification of LA/LAA Clot

31. Role Of Echocardiography During PTMC During transseptal puncture- TTE/TEE can be used in difficult transseptal puncture, routinely used in some centres E specially in patients with large atrium or unusual morphology of the interatrial septum (thick septum,septal aneurysm, pregnancy, previous cardiac surgery etc) During valvotomy- Valvotomy after septal puncture usually done under fluoroscopy In difficult cases, TEE can help to optimize balloon position across the MV leaflets and avoid entrapment in the subvalvar apparatus

32. Echo Post PTMC Immediately following PTMC, the TTE or TEE can assess MVA, T he peak and mean gradients, U ni-commissural or bilateral commissural opening D efine presence, degree and site of MR (commissural, leaflet or otherwise) On follow-up PTMC is a palliative procedure and all patients should undergo an echocardiographic follow-up at 1 year or earlier( esp in cases with sub-optimal results) to see for Changes in valve haemodynamics , MR, Regression of PH and TR, Ventricular function and Progression of lesions in other valves

33. Predictors of PTMC Outcome by echo Heavy calcification of the valve and/or bi-commissural calcification are also associated with poorer acute and long term outcomes Bi- commisural symmetric fusion had a better success than assymetric A small LA size tells about less space available for manipulation of catheters, wires and balloons A very large RA size detected with TTE will be problematic during transeptal puncture

34. Aneurysm of IAS although rare should also be mentioned while doing TTE for a patient undergoing PTMC. Similarly a thick IAS can identify prior to transseptal puncture that might require some extra effort during procedure Presence of asymmetric comnmisural calcification is a high risk of MR, underdilation preferred and later refer to surgical treatment Can perform PTMC with upto IIa LA thrombus at high risk Can do PTMC upto grade 2 MR

35. THANK YOU