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

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Presentation on theme: "Mitral Stenosis Emerson Liu Echo conference Nov. 5, 2008."— Presentation transcript:

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

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

4 Normal4 - 6 cm 2 Mild stenosis cm 2 Mod (usu Asx at rest) cm 2 Severe≤ 1.0 cm 2 MV Orifice Area

5   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) S1 S2 OS S1

6 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

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

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

9 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

10 Mild Moderate Severe Thickened Leaflets in Mitral Stenosis

11 Increased EPSS Mild Moderate Severe

12 Continuity equation

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14 Diastolic Anterior Motion of Posterior Leaflet

15 2-D Echo Findings in MS 1. 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.

16 Rheumatic MS

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

20 Mitral valve Area

21 2D planimetry

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

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24 220 t½ t½ MVA =

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

27 Continuity equation MVA x VTI (ms jet) = transmittal SV = LVOT CSA x VTI* = LVOT CSA x VTI* * in the absence of MR

28 PISA Method

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

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

31 Natural History Progressive, lifelong disease Progressive, lifelong disease Usually slow & stable in the early years Usually slow & stable in the early years Progressive acceleration in the later years Progressive acceleration in the later years year latency from rheumatic fever to symptom onset year latency from rheumatic fever to symptom onset Additional 10 years before disabling symptom s Additional 10 years before disabling symptom s

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

34 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.

35 Wilkins Score

36 Percutaneous Commissurotomy

37 Mitral Valve Repair  Pts. 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.

38 Pts. with NYHA III-IV, MVA ≤ 1.5 cm², and are not candidates for PBV or MV repair. Mitral Valve Replacement


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