Principles

Causes Causes
NOTE:
Prevalence
depends on
socioeconomic
status of the
country
Rheumatic (85,4%)
NOTE:
Prevalence
depends on
socioeconomic
status of the
country
Rheumatic fever (75% valvular
involvment)
NOTE:
Prevalence
depends on
socioeconomic
status of the
country
Stenotic annular calcication
(12,5%)
NOTE:
Prevalence
depends on
socioeconomic
status of the
country
Congenital (0,6%)
NOTE:
Prevalence
depends on
socioeconomic
status of the
country
Rheumatic fever Rheumatic fever
Group A streptococcal
(GAS) tonsillopharyngitis
Arthritis joints
Chorea minor Subcutaneous nodules
Pancarditis
Congenital Mitral Stenosis Congenital Mitral Stenosis
Rare (0,6% of CHD)
Combined with other cong. defects
Forms: Annulus hypoplasia, parachute, double
orice
NOTE: Shone complex is an association of congenital mitral stenosis and
other left-sided in and outow obstruction (coarctation, valvular/
subvalvular aortic stenosis)
NOTE: Shone complex is an association of congenital mitral stenosis and
other left-sided in and outow obstruction (coarctation, valvular/
subvalvular aortic stenosis)
011 // Mitral Stenosis
1
Pressure Tracing LV/LA Pressure Tracing LV/LA
LA-LV gradient Elevated pressure in LA
Elevated pressure pulm.
capillaries
Pulm. cong. / edema
PHT / reactive PHT Tricuspid regurgitation
Right heart failure Atrial brillation
Echocharacteristics of MS Echocharacteristics of MS
Doming (diastolic
buldging of the AMVL)
Reduced valve opening
Commisural fusion Leaet tip thickening
Secondary calcication
Subvalvular involvement
(thickend and fused
tendinae)
Associated problems Associated problems
Thickened aortic valve
Reduced LVF (rheumatic
myocarditis)
Enlarged LA Pulmonary hypertension
Other valve involvement Aortic regurgitation
Tricuspid stenosis Thrombus
Risk of Thrombus Risk of Thrombus
NOTE:
Most thrombi are
seen in the left
atrial appendage.
Thus you will miss
them with
transthoracic
Echo!!
Systemic embolism in 20% of
all MS patients
NOTE:
Most thrombi are
seen in the left
atrial appendage.
Thus you will miss
them with
transthoracic
Echo!!
80% of patients are in Ab
NOTE:
Most thrombi are
seen in the left
atrial appendage.
Thus you will miss
them with
transthoracic
Echo!!
45% have spontaneous left
atrial contrast
NOTE:
Most thrombi are
seen in the left
atrial appendage.
Thus you will miss
them with
transthoracic
Echo!!
011 // Mitral Stenosis
2
Quantication
MV Area Reference Values MV Area Reference Values
Normal (cm) 4 6 cm
Mild (cm) > 1,5 cm
Moderate (cm) 1 1,5 cm
Severe (cm) < 1 cm
Problems with MV Planimetry (PSAX) Problems with MV Planimetry (PSAX)
NOTE:
Nevertheless, if
feasible,
planimetry is the
most exact
method to
evaluate MV
area
Image quality Alignment
NOTE:
Nevertheless, if
feasible,
planimetry is the
most exact
method to
evaluate MV
area
Timing Calcication
NOTE:
Nevertheless, if
feasible,
planimetry is the
most exact
method to
evaluate MV
area
Atrial brillation Incompl. comm. fusion
NOTE:
Nevertheless, if
feasible,
planimetry is the
most exact
method to
evaluate MV
area
Operator experience
NOTE:
Nevertheless, if
feasible,
planimetry is the
most exact
method to
evaluate MV
area
Forms of Mitral Stenosis Forms of Mitral Stenosis
Classic form Funnular form
011 // Mitral Stenosis
3
MS Gradients Reference Values MS Gradients Reference Values
Mild (mmHg) < 5 < 8
Moderate (mmHg) 5 10 8 15
Severe (mmHg) > 10 > 15
NOTE: Gradients are higher in the setting of additional MR! NOTE: Gradients are higher in the setting of additional MR! NOTE: Gradients are higher in the setting of additional MR!
PHT Pitfalls PHT Pitfalls PHT Pitfalls
Diastolic dysfunction Aortic regurgitation
Following valvuloplasty
Concave shape of
tracing
Degenerative calcic MS
Color Doppler , PISA and Continuity Equation Color Doppler , PISA and Continuity Equation Color Doppler , PISA and Continuity Equation
Candle ame MR
PISA for quantication PISA for quantication
MVA = Mitral volume ow/ Peak velocity of
diastolic mitral ow
MVA = Mitral volume ow/ Peak velocity of
diastolic mitral ow
Continuity Equation ( doesnt work if AR and MR
present)
Continuity Equation ( doesnt work if AR and MR
present)
Quantication of Mitral Stenosis in Atrial Fibrillation Quantication of Mitral Stenosis in Atrial Fibrillation
Planimetry Several diferent measurements
Mean gradients
Average 5 cycles with small variation of R-R intervals
close to normal HR
PHT
Avoid mitral ow from short diastoles/ average
diferent cardiac cycles
011 // Mitral Stenosis
4
Valvuloplasty
Indication and Results Indication and Results
Indication
Clinically signicant MS (valve area < 1,5 cm or <
1,8 cm in unusually large patients)
Results
Good immediate results (valve area > 1,5 cm with
no regurgitation) can be obtained in over 80%
NOTE: PHT method is not reliable immediately after valvuloplasty! NOTE: PHT method is not reliable immediately after valvuloplasty!
Prevalvuloplastic Echoevaluation Prevalvuloplastic Echoevaluation
Mobility Subvalvular thickening
Valve thickening Calcication
Calcication of
commissures
Thrombus
Mitral regurgitation Tricuspid regurgitation
011 // Mitral Stenosis
5