Echocardiography in mitral stenosis

MS (MITRAL STENOSIS) echocardiography

1. ECHOCARDIOGRAPHY IN MITRAL STENOSIS

2. MITRAL VALVE/STENOSIS Normal MV orifice area - 4 to 6 cm 2 Symptoms do not usually occur until orifice area less than 1.5cm 2

3. Pathology Rheumatic Commissural fusion Leaflet thickening Chordal shortening and fusion Superimposed calcification Annular calcification Degenerative MS Rarely leaflet thickening and calcification at base

4. PATHOLOGY(UNCOMMON) Congenital MS Subvalvular apparatus abnormalities Inflammatory-SLE Infiltrative Carcinoid heart disease Drug induced valve disease Leaflet thickening and restriction Rarely commissural fusion

5. 2D ECHO/PLAX/RHEUMATIC Valve domes in diastole due to commissural fusion Leaflet thickening beginning at the edges of the leaflets Produces significant narrowing of orifice

6. 2D ECHO/PLAX/RHEUMATIC Fibrosis, thickening and shortening of chordae common Calcification may also progressively involve chordae

7. 2DECHO/PSAX

8. 2D ECHO APICAL 4CH

9. 2D ECHO APICAL 2CH

10. COLOR DOPPLER/FOR MR

11. OTHER 2D FEATURES Dilated LA(20-60ml normal) LA and LA appendage thrombus Paradoxical septal motion Dilated RV and RA

12. ASSESSMENT OF MS SEVERITY M mode 2D ECHO MVA BY PLANIMETRY DOPPLER PRESSURE GRADIENTS MVA BY PHT CONTINUITY EQUATION PISA MITRAL VALVE RESISTANCE

13. Mitral Stenosis M-mode Anterior motion of posterior leaflet in diastole Decreased rate of diastolic closing of AML (decrease E-F slope) Loss of A wave Maintenance of fixed relation of two leaflets throughout diastole Thickening and Calcification of mitral valve Enlargement of left atrium Mitral Stenosis

14. Mitral stenosis M-mode Mitral Stenosis

15. Anterior motion of posterior leaflet in diastole Diagnostic Absent in 18% (body of posterior valve is pliable and doming) Decrease E-F slope E-F slope is affected by mitral orifice size, severity of fibrosis, calcification of leaflet , compliance of LV , rate and volume of filling through MV, heart rate , diastolic motion of mitral annulus not diagnostic doesn’t correlate severity of stenosis Absence of “a” wave With or with out AF With out AF = correlates with severity of MS (<1.2) Mitral Stenosis Mitral stenosis M-mode

16. M MODE NORMAL MITRAL STENOSIS

17. M MODE ECHO Decreased E-F Slope >80 mm/s MVA=4-6cm² < 15mm/s ⇒ MVA < 1.3cm² Thickened Mitral Leaflets Anterior Motion or Immobility of Posterior Mitral Leaflet-tethering at tips Diastolic Posterior Motion of Ventricular Septum (severity of stenosis)

18. PLANIMETRY PLANIMETRY Best correlation with anatomical area Scanning method to avoid overestimation measured at leaflet tips in a plane perpendicular to mitral orifice Elliptical in shape Direct measure of mitral orifice including opened commissures in PSAX METHOD

19. PLANIMETRY Exessive gain setting = underestimate Zoom mode Harmonic imaging Optimal time is mid diastole Multiple measurements in AF or incomplete commissural fusion difficult in calcified valve and chest deformity

20. GRADIENTS Pressure gradient = 4 v 2

21. GRADIENTS Apical window CWD at or after tip of mitral valve Maximal and mean gradient Derived from transmitral velocity flow curve Heart rate to be mentioned CD to identify mitral jet

22. POINTS Maximal gradient influenced by LA compliance and LV diastolic function AF = average of 5 cycles with least variation of R-R interval and as close possible to normal HR MVG = HR,COP and associated MR Tachycardia, increased COP and associated MR -overestimates gradient

23. Mitral Valve Area by Pressure Half-Time (PHT) Time for pressure to fall to half it’s original peak value (in msec) calculated from deceleration slope

24. MVA BY PHT MVA = 220/ pressure half-time ( ) PHT = 0.29 x Deceleration time MVA = 750 / Deceleration time 220 is proportional to the product of net compliance of left atrium and LV, and the square root of maximum transmitral gradient

25. MVA BY PHT tracing deceleration slope of E wave on Doppler spectral display

26. AF avoid short cycles and Average different cardiac cycles

27. deceleration slope is sometimes bimodal , the decline of mitral flow velocity being more rapid in early diastole than during the following part of the E-wave .= deceleration slope in mid-diastole rather than the early deceleration slope be traced. rare patients with a concave shape of the tracing- T1/2 measurement may not be feasible.

28. Factors that may affect PHT by influencing LA pressure More rapid LA pressure decline shorten PHT LA draining to second chamber –ASD LA pressure drop rapidly PHT shortened Stiff LA –low LA compliance LA pressure drop rapidly PHT shortened

29. Factors affect PHT by influencing LV pressure More rapid LV pressure rise shorten PHT If LV fills from a second source PHT –AR LV pressure rise more rapidly PHT will be shortened If LV is stiff-low ventricular compliance LV pressure may rise more rapidly PHT will be shortened

30. PRACTICAL POINTS All factors affect PHT (ASD, AR, low LA or LV compliance ) =Shorten PHT = overestimation PHT never under estimate if PHT >220 MS is severe If PHT is < 220 consider other methods to assess severity Unreliable immediately post BMV, causes under estimation of MVA.

31. When gradient and compliance are subject to important and abrupt changes . Immediately after balloon mitral commissurotomy =discrepancies between the decrease in mitral gradient and the increase in net compliance.

32. CONTINUITY EQATION

33. CONTINUITY EQUATION MVA X VTI mitral= LVOT area X VTI aortic MVA = LVOT area X VTI aortic VTI mitral MVA= p D 2 X VTI aortic 4 VTI mitral D is diameter of LVOT in cm and VTI in cm Method not useful in AF,AR or MR

34. PISA hemispherical shape of convergence of diastolic mitral flow on atrial side of mitral valve and flow acceleration blood towards mitral valve

35. MVA x MV = PISA x AV MVA = PISA x AV MV PISA = 2 p r 2 x a 180 MVA = 2 p r 2 x AV x a MV 180

36. METHOD Zoom on the flow convergence Upshift the baseline velocity and use an aliasing velocity of 20–30 cm/s Measure the radius of the flow convergence region and the transmitral velocity at the same time in early diastole Measure the α angle formed by the mitral leaflets fixed angle value of 100° =accurate MVA estimation in MS .

37. METHOD used in presence of significant MR, AR, differing heart rhythms Not affected by LA,LV compliance Multiple measurements required

38. Colour M-mode PISA Instantaneous measurement of MVA throughout diastole magnified 2D colour imaging, colour M-mode tracings are recorded by placing the M-mode cursor line through the centre of the flow convergence . Diastole - early, mid, mid-late, and late diastole . Peak radius of flow convergence is measured during each phase to calculate mitral flow rate

39. M itral leaflet separation (MLS) index Distance between the tips of the mitral leaflets semiquantitative value of 1.2 cm or more = non severe MS <0.8 cm -severe MS. not accurate in heavy mitral valvular calcification and post BMV

40. Mitral valve resistance ratio of mean mitral gradient to transmitral diastolic flow rate dividing SV by diastolic filling period. less dependent on flow conditions .

41. MVR = Mean MVG____ Trans Mitral D.F.R

42. PAH

43. STRESS ECHOCARDIOGRAPHY unmask symptoms in MVA<1.5cm2 and no or doubtful complaints Discrepancy between resting doppler and clinical findings Semi-supine echocardiography exercise (30 to 60 secs of leg lifts) is now preferred to post exercise echocardiography A llows monitoring gradient and pulmonary pressure in each step of increasing workload

44. Mean mitral gradient and PASP to be assessed during exercise Mean gradient >15 mmhg with exercise is considered severe MS A PASP > 60 mmHg on exercise has been proposed as an indication for BMV Dobutamine stress echo mean gradient >18 mmhg with Stress is considered severe MS but is less physiological.

45. Associated lesions Quantitation of LAE Associated MR and its mechanism Severity AS (underestimated) AR- t1/2 method to assess MS is not valid TR ,tricuspid annulus Secondary pulmonary HTN-TR

46. 3D ECHO Higher accuracy than 2D echo Detailed information of commissural fusion and subvalvular involvement MVA measurement in calcified and irregular valve MVA measurement after BMV

47. MANAGEMENT OF MS-Mitral Balloon Valvuloplasty May delay or avoid surgery 80% patients have long term relief of symptoms 7% restenosis rate at 7 years ECHO to determine ‘ pliability’,MR Wilkins score, cormier’s method

48. Wilkin’s score -Mitral valve score <8 are excellent candidates for BMV

49. Limitations of wilkin’s score commissural involvement is not included Limited in ability to differentiate nodular fibrosis from calcification. Doesn’t account for uneven distribution of pathologic abnormalities. Frequent underestimation of subvalvular disease .

50. Cormier’s method ( subvalvular disease)

51. Guiding the Procedure and Detecting Acute Complication guide the transeptal puncture. Atrial or ventricular perforation with tamponade Acute mitral regurgitation Valvular disruption.

52. Evaluating the short- and long-term results of the intervention. Assessment of valve area Planimetry ideal , half time shoudnt be used Long term results Assessment can be done by all methods with predictors of restenosis being echo score and valve area following procedure

53. GRADING OF SEVERITY OF MS/SUMMARY MILD MODERATE SEVERE SPECIFIC VALVE AREA(cm2) >1.5 1-1.5 <1 NONSPECIFIC MEAN GRADIENT (mmHg) <5 5-10 >10 PASP (mmHg) <30 30-50 >50

54. pressure half time Expected normal half time is longer than native valve and varies with type and size bioprosthetic valve, and for mechanical valves -220/t 1/2 provides reasonable approximation Continuity equation Pressure gradient can also be used with gradients varying with type and size of valve In Prosthetic Mitral Valve Stenosis Mitral Stenosis