Mitral Stenosis

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Mitral Stenosis
Emerson Liu Echo conference Nov. 5, 2008
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Etiologies

• Rheumatic Fever
• Congenital MS
• Rare complication of
• carcinoid, SLE, RA,
• mucopolysaccharidoses,
• Whipple, amyloid deposit
• MAC may extend onto leaflet bases
• Obstructive physiology myxoma, IE, cor
  triatriatum
• Cafergot Toxicity

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MV Orifice Area

• Normal 4 - 6 cm2
• Mild stenosis 1.6 - 2.5 cm2
• Mod (usu Asx at rest) 1.1 - 1.5 cm2
• Severe 1.0 cm2

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S1 S2 OS
S1

• First heart sound (S1) is accentuated and
  snapping
• Opening snap (OS) after aortic valve closure
• Low pitch diastolic rumble at the apex
• Pre-systolic accentuation (esp. if in sinus
  rhythm)

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Pathophysiology
Right Heart Failure Hepatic Congestion JVD Tricuspid Regurgitation RA Enlargement ? Pulmonary HTN Pulmonary Congestion LA Enlargement Atrial Fib LA Thrombi ? LA Pressure
RV Pressure Overload RVH RV Failure LV Filling
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Clinical Presentation

• Dyspnea

• Hemoptysis
• Chest pain
• Palpitations and embolic events
• Ortner syndrome hoarseness due to
• compression of the left recurrent laryngeal
• by dilated LA, tracheobronchial LN, and PA

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Role of Echocardiography

• Diagnose Mitral Stenosis
• Assess valve morphology thickness, mobility,
  degree of calcification, extent of subvalvular
  involvement
• Assess hemodynamic severity mean gradient, MV
  area, PAP
• Assess RV size and function.
• Assess suitability for percutaneous valvuloplasty
• Diagnose / assess concomitant valvular lesions
• Reevaluate pts with known MS with changing
  symptoms or signs, and F/U of asx pts with
  mod-severe MS

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M-Mode

• 1. Thickened Mitral leaflets
• 2. Decreased E to F slope (increased EPSS)
• 3. Diastolic anterior motion
  of posterior leaflet
• 4. Abnormal septal motion
• 5. Left Atrial enlargement
• 6. Left Atrial thrombus
• 7. RV dilatation
• 8. Pulmonary hypertension
• 9. Small LV

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Thickened Leaflets in Mitral Stenosis
Mild Moderate
Severe
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Increased EPSS
Mild Moderate
Severe
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Continuity equation
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Diastolic Anterior Motion of Posterior Leaflet
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2-D Echo Findings in MS

• 1. Thickened (gt 3 mm) and calcified mitral
  leaflets and subvalvular apparatus.
• 2. Hockey-stick appearance of the anterior
  mitral leaflet in diastole
  (long-axis view).
• 3. Fish-mouth orifice in short-axis view.
• 4. Immobility of posterior leaflet.
• 5. Increased Left Atrial Size.
• 6. Small Left Ventricle.

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Rheumatic MS
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Rheumatic MS
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Pitfalls

• Pressure Gradient
• Intercept angle
• beat to beat variability in AF
• Dependence on transmitral volume flow rate
• (exercise, coexisting mitral regurgitation)

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Mitral valve Area
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2D planimetry
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Pitfalls

• 2D planimetry
• Image orientation
• Tomographic plane
• 2D gain settings
• Poor acoustic access
• Deformed valve anatomy post-valvuloplasty

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220 t½
MVA
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Pitfalls

• T½ Valve Area
• Definition of Vmax and early diastolic slope
• Nonlinear early diastolic velocity slope
• Sinus rhythm with a wave superimposed on early
  diastolic slope
• Afib Hemodynamics averaged over 5-10 cycles
• Influence of coexisting AR
• Changing LV and LA compliances (post
  commisurotomy)

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Continuity equation
MVA x VTI (ms jet) transmittal SV
LVOT CSA x VTI
in the absence of MR
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PISA Method
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Pitfalls

• Continuity equation
• Accurate measurement of transmitral SV
• parallel intercept angle
• without significant MR

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TEE

• Class IIa
• 1. Check for LA thrombus in patients
• considered for PBV or cardioversion.
• 2. Evaluate valve morphology and
  
• hemodynamics when transthoracic
  
• echo is suboptimal.
• Guide trans-septal
• puncture, or position
• of balloon, during PBV

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Natural History

• Progressive, lifelong disease
• Usually slow stable in the early years
• Progressive acceleration in the later years
• 20-40 year latency from rheumatic fever to
  symptom onset
• Additional 10 years before disabling symptoms

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Exercise Hemodynamics

• For patients who have exertional symptoms and
  in whom resting hemodynamics do not clearly
  indicate severe MS.
• With fixed valve area, ? CO and HR will ?
  transmitral gradient, LA pressure an PA pressure

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Percutaneous Mitral Balloon Valvotomy

• Class 1 Indications
• Symptoms (NYHA II, III, IV), MVA 1.5cm², and
  valve morphology favorable for percutaneous
  balloon valvotomy, in the absence of left atrial
  thrombus or moderate to severe MR.

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Wilkins Score
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Percutaneous Commissurotomy
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Mitral Valve Repair

1. Pts. with NYHA III-IV, MVA 1.5 cm², and valve
   morphology favorable for repair if PBV is not
   available.
2. Pts. with NYHA III-IV, MVA 1.5 cm², and valve
   morphology favorable for repair if a left atrial
   thrombus is present despite anticoagulation.
3. Pts. with NYHA III-IV, MVA 1.5 cm², and a
   nonpliable or calcified valve with decision to
   repair or replace valve made at time of surgery.

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Mitral Valve Replacement

• Pts. with NYHA III-IV, MVA 1.5 cm²,
• and are not candidates for PBV or MV repair.