6Clinical Presentation DyspneaHemoptysisChest painPalpitations and embolic eventsOrtner syndrome – hoarseness due tocompression of the left recurrent laryngealby dilated LA, tracheobronchial LN, and PA
7Role of Echocardiography Diagnose Mitral StenosisAssess valve morphology – thickness, mobility, degree of calcification, extent of subvalvular involvementAssess hemodynamic severity: mean gradient, MV area, PAPAssess RV size and function.Assess suitability for percutaneous valvuloplastyDiagnose / assess concomitant valvular lesionsReevaluate pts with known MS with changing symptoms or signs, and F/U of asx pts with mod-severe MS
8M-Mode 1. Thickened Mitral leaflets 2. Decreased E to F slope (increased EPSS)3. Diastolic anterior motion of posterior leaflet4. Abnormal septal motion5. Left Atrial enlargement6. Left Atrial thrombus7. RV dilatation8. Pulmonary hypertension9. Small LV
9Thickened Leaflets in Mitral Stenosis Mild Moderate Severe
142-D Echo Findings in MS1. Thickened (> 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.
15Rheumatic MS31yo female w/ RF age 7, w/ palpitations. Mildly thickened mitral valve leaflets. Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. LA upper limit of normal. MVA>2cm2. mild/mod MR
16Rheumatic MS36yo M w/ RMS. moderately thickened mitral valve leaflets. Characteristic rheumatic deformity of the mitral valve leaflets with fused commissures and tethering of leaflet motion. No MVP. Moderate thickening of mitral valve chordae.. Mild to moderate (1-2+) MR. PLAX LA 4.7cm
18Pitfalls Pressure Gradient Intercept angle beat to beat variability in AFDependence on transmitral volume flow rate(exercise, coexisting mitral regurgitation)
19Mitral valve Areathe planar elliptical orifice is relatively constant in position in mid diastole, so that 2D short axis imaging of the diastolic orifice allows direct planimetry of the valve areaThe shape of the mitral valve inflow is similar to a funnel, with the narrowest CSA at the leaflet tips, and so it is important to move the image plan from apex to mitral valve to identify the smallest orifice.The approach is well validated compared with measurement of valve area by cardiac catheterization and at surgeryThis patient has relatively thin, flexible leaflets with little subvalvular involvement.
25Pitfalls T½ Valve Area Definition of Vmax and early diastolic slope Nonlinear early diastolic velocity slopeSinus rhythm with a wave superimposed on early diastolic slopeAfib: Hemodynamics averaged over 5-10 cyclesInfluence of coexisting ARChanging LV and LA compliances (post commisurotomy)
26Continuity equation MVA x VTI (ms jet) = transmittal SV = LVOT CSA x VTI** in the absence of MR
28Pitfalls Continuity equation Accurate measurement of transmitral SV parallel intercept anglewithout significant MR
29TEE Class IIa: 1. Check for LA thrombus in patients considered for PBV or cardioversion.2. Evaluate valve morphology andhemodynamics when transthoracicecho is suboptimal.Guide trans-septalpuncture, or positionof balloon, during PBV
30Natural History Progressive, lifelong disease Usually slow & stable in the early yearsProgressive acceleration in the later years20-40 year latency from rheumatic fever to symptom onsetAdditional 10 years before disabling symptomsTwenty percent of patients in whom the diagnosis of symptomatic mitral stenosis is made die within 1 year, and 50% die within 10 years after diagnosis, without surgical intervention.
32Exercise 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 pressureDobutamine stress Doppler echocardiography is most useful where we used catheterization with exercise in the past: in those patients with symptoms not explainable by the calculated valve area, where a rise in mean mitral valve gradient to 18 mm Hg or above is consistent with a patient whose symptoms are due to obstruction to flow and who would benefit from mitral valve intervention.
33Percutaneous 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.Because MS is a mechanical obstruction to forward flow, the only definitive therapy is mechanical relief of this obstruction. Three procedures are effective in providing such therapy. These are BMV, open commissurotomy, and mitralvalve replacement. Because clinical trials have found BMV to be superior to closed surgical commissurotomy, the latter procedure has been largely abandoned.
34Wilkins ScorePatient selection for predicted hemodynamic results and risk of procedural complications.Suitability for BVM is determined by valve morphology and the amount of mitral regurgitation present. The Wilkins score gives a rough guide to the suitability of the mitral valve’s morphology for BMV. This scoring system assigns a point value from 1 to 4 for each of (1) valve calcification, (2) leaflet mobility, (3) leaflet thickening, and (4) disease of the subvalvular apparatus. In general, patients with a score of 9 and less than moderate mitral regurgitation have the best outcomes, although many patients have benefited from BMV despite higher valve scores.
36Mitral Valve RepairPts. with NYHA III-IV, MVA ≤ 1.5 cm², and valve morphology favorable for repair if PBV is not available.Pts. with NYHA III-IV, MVA ≤ 1.5 cm², and valve morphology favorable for repair if a left atrial thrombus is present despite anticoagulation.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.
37Mitral Valve Replacement Pts. with NYHA III-IV, MVA ≤ 1.5 cm²,and are not candidates for PBV or MV repair.