1. Echo Conference April 6, 2011 Frances Canet, MD

2. Causes and Anatomy Assessment of Mitral Stenosis How to Grade Mitral Stenosis Cases and Application Outline

3. Rheumatic MS Commissural fusion Degenerative MS Annular calcification Associated with elderly, hypertension, atherosclerosis and aortic stenosis Congenital MS Abnormalities of subvalvular apparatus Other: Systemic lupus, infiltrative disease, carcinoid heart disease, drug-induced valve disease Causes and Anatomy

4. Level 1 Recommendations: Pressure gradient MVA Planimetry Pressure half-time Level 2 Recommendations: Continuity equation Proximal isovelocity surface area method (PISA) Stress echocardiography How to Assess Mitral Stenosis

5. Continuous wave doppler is preferred Gradient is measured in the apical window Color doppler is used to identify eccentric diastolic mitral jets Doppler beam is guided by the highest flow velocity zone identified by color doppler Mean gradient is the relevant hemodynamic finding Measure heart rate at which gradients are obtained If patient is in atrial fibrillation, the mean gradient should be an average of five cycles with the least variation of R-R intervals Pressure Gradient

7. Mitral Valve Area Planimetry Direct tracing of the mitral orifice including opened commissures in the parasternal short-axis view at mid-diastole Advantages: -Direct measure of MVA -Does not involve hypothesis regarding flow conditions, cardiac chamber compliance or associated valvular lesions -Best correlation with anatomic valve area of explanted valves

8. Obtaining and measuring the image: -Scan apex to the base of the LV to ensure the cross- sectional area is measured at the leaflet tips. -Plane should be perpendicular to the mitral orifice, elliptical shape. -Gain, sufficient to see contour of the mitral orifice. -If too excessive, may cause under estimation of the valve area. -Perform several measurements if the patient has atrial fibrillation or incomplete commissural fusion Mitral Valve Area Planimetry

9. T 1/2 = time interval in milliseconds between the maximum mitral gradient in early diastole and the time point where the gradient is half the maximum initial value MVA = 220/ T 1/2 Pressure half-time

10. Measuring T 1/2 with a bimodal, non- linear decreasing slope of the E-wave

11. Based on assumption that the filling volume of diastolic mitral flow is equal to aortic SV. MVA = pi (D 2 /4) (VTI Aortic / VTI Mitral ) D is the diameter of the LVOT in cm VTI is in cm. Accuracy and reproducibility is hampered by the number of measurements increasing the impact of errors of measurements. Cannot be used in atrial fibrillation or associated significant MR or AR Continuity equation – Level 2

12. MVA = pi (r 2 ) (V aliasing ) / Peak V mitral x alpha/180 0 R is the radius of the convergence hemisphere in cm V aliasing is the aliasing velocity in cm/s Peak V mitral is the peak CWD velocity of mitral inflow in cm/s alpha is the opening angle of mitral leaflets relative to flow direction Proximal isovelocity surface area method – Level 2

13. Parasternal short-axis view valve thickness (maximum and heterogeneity) commissural fusion extension and location of localized bright zones (fibrous nodules or calcification) Parasternal long-axis view valve thickness extension of calcification valve pliability subvalvular apparatus (chordal thickening, fusion, or shortening) Apical two-chamber view subvalvular apparatus (chordal thickening, fusion, or shortening) Detail each component and summarize in a score Valve Anatomy

14. Enables measurement of mean mitral gradient and systolic pulmonary artery pressure during effort. Semi-supine exercise echocardiography allows monitoring of gradient. Useful in patients with equivocal or discordant with the severity of MS. Stress Echocardiography – Level 2

15. How to Grade Mitral Stenosis Normal MVA is 4.0-5.0 cm 2 MVA >1.5 cm 2 does not produce symptoms As severity increases, cardiac output decreases and fails to increase during exercise.

16. Grades morphological changes in the MV during echo: Leaflet mobility Leaflet thickening Valve calcification Involvement of the subvalvular apparatus Each characteristic is graded from 0-4, with a total of 16 points total. A score >8 is predictive of low success post percutaneous mitral valvuloplasty. Wilkins (Valvotomy )Score

17. 72-year-old man with known moderate aortic stenosis, mitral regurgitation, hypertension, diabetes, COPD, TIA and severe pulmonary hypertension based on cardiac catheterization results is referred for echocardiogram to assess severity of mitral valve regurgitation. How severe is his mitral regurgitation? Does he have mitral stenosis? What are his options for repair – calculate valvotomy score? Case 1

18. PSL MV

19. PSL Zoom

20. PSL MV Color

21. 4C AP

22. 4C AP Color

23. MV Planimetry

24. PSS MV Planimetry Still

25. MV VTI for Pressure Gradient

26. MV half time 3

27. LVOT Diameter is 2.1 VTI aortic is 87 VTI mitral is 87.2 MVA = pi (D 2 /4) (VTI Aortic / VTI Mitral ) MVA = 3.89 cm 2 (Not accurate compared to MVA of 1.15 cm 2 calculated from pressure gradient. Remember, it is not accurate in patient with severe mitral regurgitation or atrial fibrillation.) Less accurate calculation of MVA as it relies on several other measurements to be accurate. Continuity equation

28. Valvotomy Score = 12 Mobility – valve moves forward in diastole, moves mainly from base 3 points Subvalvular Thickening – thickening of chordal structures extending into 1/3 rd of the chordal length 3 points Thickening – extends through the entire leaflet 3 points Calcification – Brightness extending into the mid-portion of the leaflets 3 points Total score = 12

29. 56-year-old woman with a history of rheumatic mitral valve stenosis, respiratory failure, heart failure, atrial fibrillation, recent stroke, COPD, sarcoidosis, schizophrenia was transferred from an outside hospital for a second opinion on mitral valve replacement. She has poor functional and neurologic status at present. Evaluate the grade of her mitral stenosis and calculate her valvotomy score. Case 2

30. PSL MV

31. PSL MV Zoom

32. PSL MV Color

33. 4C AP MV

34. PSS Planimetry Loop

35. Planimetry Still This is not acutally the area of the MV orfiice. Look at the small sliver of black area just below the tracing.

36. Pressure gradient

37. Pressure half-time

38. Resting mean pressure gradient: 16mmHg (severe is >10mmHg) Mitral valve area using half time: 0.77cm 2 (severe is <1.0 cm 2 ) PHT: 285 ms (severe is greater than 220ms) Grade of mitral stenosis: Severe

39. Valvotomy score:

40. Mobility: 4 – No or minimal forward movement of the leaflets. Subvalvular Thickening: 2-3- Thickening of chordal structures up to one-third of the chordal length possibly to distal third of the chords. Thickening: 4 – Considerable thickening of all leaflet tissue (>8-10mm). Calcification: 4 – Extensive brightness throughout much of the leaflet tissue. Valvotomy score: 14 out of 16