ΓΙΩΡΓΟΣ ΜΑΚΑΒΟΣ

ΚΑΡΔΙΟΛΟΓΟΣ

Β’ ΠΑΝ.ΚΑΡΔΙΟΛΟΓΙΚΗ ΚΛΙΝΙΚΗ “ATTIKON”

MITRAL VALVE ANATOMY

Anterior

leaflet

A1

A2A3

Posterior

leaflet

P1

P2 P3

Anterior lateral

commissure

Posterior

medial

commissure

Επιφάνεια : 4-6 cm 2

B. C.

Kολπική επιφάνεια MB – Μιτροειδικό χαμόγελο

• A.Gross Pathology ,C. Lancet 2009; 373: 1382–94, modified with permission

• Ho Heart 2002

Κοιλιακή επιφάνεια MB – Yποβαλβιδικός σχηματισμός

Mιτροειδική συσκευή

MITRAL STENOSIS

ETIOLOGY OF MITRAL STENOSIS

Most common

-Rheumatic fever (2/3 female)

Uncommon

-Degenerative calcification of mitral annulus

Rare

-Inflammatory diseases (e.g. systemic lupus)

-Infiltrative diseases (Hurler syndrome)

-Congenital (Lutembacher syndrome, cor triatriatum)

-Carcinoid

-Drug induced

-Atrial myxoma, thrombus

RHEUMATIC MS

25% of all patients with rheumatic heart disease have isolated MS

40% have combined MS and MR

40% multivalvular disease

Braunwald’s heart disease 9th edition

RHEUMATIC MS

Commissural fusion (fish mouth)

Chordal shortening and fusion

Leaflet thickening (tips of leaflets)

Calcification in later disease states with restriction of leaflet motion

D.D.

Degenerative

Annular calcification

Leaflet thickening and calcification (base of leaflets)

ROLE OF ECHOCARDIOGRAPHY

IN MS

Valve anatomy

Assessment of MS severity

Associated lesions

(LA enlargement, LA thrombus/spontaneous contrast)

Associated MR, AS,TR/TS

Pulmonary artery systolic pressure

RV function/Dilation of tricuspid annulus

Discrepancy between severity of MS and symptoms (Stress Echo)

Suitability for commissurotomy

Therapy guidance

Evaluation after treatment

ECHO MS

Thickened and calcified MV and subvalvular

apparatus

“Hockey stick”/”doming” appearance of

anterior MV Leaflet

“Fish mouth” MV orifice

LA enlargement

Level 1 recommendations

Pressure gradient

Pressure Half-time

Planimetry of valve area

ECHO ASSESSMENT OF MSSEVERITY

Baumgartner European Journal of Echocardiography (2009) 10, 1–25

-Transmitral velocity flow simplified

Bernoulli equation

ΔP = 4V²

-Correlates well with invasive

measurement using transeptal

catheterization

- CW Doppler preferred

-Apical windows allow for parallel

alignment of US beam

-Color Doppler aids in alignment of the

CW Doppler

-Obtain multiple measurements in the

presence of AF (5 cardiac cycles with the

least variation of R-R interval)

Nishimura J Am Coll Cardiol 1994;24:152–8.

Mean Pressure Gradient

Low cardiac output or bradycardia low mean

gradient in the presence of severe MS

Mean Pressure Gradient

Pressure half-time

Time interval between maximal mitral

gradient in early diastole and the

time point where the gradient is half

Decline of velocity is inversely

proportional to valve area

MVA = 220/PHT

AF average different cardiac cycles

Avoid flow from short diastoles

Bimodal deceleration slope

Use deceleration slope in mid diastole

Prolonged PHT does not always indicate MS

-Abnormal myocardial relaxation prolongs PHT

with a E velocity usually <1m/s

-Decreased LV compliance shortens PHT

underestimates mitral stenosis

Pressure half-time

MVA Planimetry

-Considered the reference measurement for MVA

-Best correlation with anatomic valve area as measured on explanted valves

-Measure contour of inner mitral orifice parasternal short axis zoom mode

-Lowest gain to visualize the whole mitral orifice

-Measure in mid diastole

-Obtain several measurement in the presence of AF

- Measurement plane must be

optimally positioned on the mitral

orifice

- It may not be feasible even by

experienced echocardiographers

when there is a poor acoustic window

or severe valve calcifications of the

leaflet tips.

MVA Planimetry

MS 3D ECHO

3D-guided biplane optimizing the

positioning of the measurement

plane

Improves the accuracy of planimetry

measurement when performed by less

experienced echocardiographers

MV stenosis 3D ECHO

“En face” MV area

Continuity equation

(Level 2 Recommendation).

-Mitral regurgitation may overestimate the severity

-Aortic regurgitation may underestimate the severity

-Increase in number of measurements may lead to errors

-Cannot be used in cases of AF

Proximal isovelocity surface area method

(Level 2 Recommendation).

Based on the hemispheric shape of the convergence of

diastolic flow on the atrial side of the valve

Divide mitral flow volume by the diastolic flow acquired

from the CWD

-Technically

demanding

Increase in number

of measurements may

lead to more errors

-Uncertainties in

measurements

-Convergent radius

-Opening angle

PULMONARY ARTERY SYSTOLIC

PRESSURE

Guidelines for the Echo Assessment of the Right Heart

J Am Soc Echocardiogr 2010;23:685-713

Bernuli equation: RVSP=4 x TRVmax² + RA pressure

MS SEVERITY CLASSIFICATION

Baumgartner European Journal of Echocardiography (2009) 10, 1–25

» «Εργαστήριο Ηχωκαρδιογραφίας»

Β’Καρδιολογική Κλινική Πανεπιστημίου Αθηνών

Πανεπιστημιακό Νοσοκομείο «ΑΤΤΙΚΟΝ»

2-D Echo, LAX : 46-27mm Right V. Systoic Pressure (RVSP):65mmHg

2-D , Διαμιτροειδική Ροή:mgr:18mmhg 2-D , Διαμιτροειδική Ροή, PHT: 233msec

ECHO MS

ASSOCIATED LESIONS

LA SIZE

2D

3D

MS TOE

LA SPONTANEOUS CONTRAST+THROMBUS

MITRAL STENOSIS

Mitral StenosisManagement Guidelines

Interventional and Surgical Options

Percutaneous mitral balloon valvotomy

(PMBV)

Closed commissurotomy (obsolete)

Open commissurotomy

Mitral valve replacement

J Am Coll Cardiol 2014

European Heart Journal 2012

SCORING OF MV ANATOMY IMPAIRMENT

WILKINS SCORE

A score >8 does not preclude PMBV,

but is associated with less optimal results.

COMMISSURAL CALCIFICATION

SCORE-Predictor of achieving an MVA

post-PMBV >1.5 cm2 without creating

significant MR.

-Influence not significant

in patients with a Wilkins score >8.

-Patients with a commissural

calcification grade 0/1 had larger valve

areas and a better improvement of

symptoms than patients

with grade 2/3.

-Commissural calcification is

a strong predictor of adverse

outcomes of PMBV and severe MR as

a major complication of PMBV

Wunderlich et al. J Am J Coll Cardiol Img 2013;6:1191–205

ECHOCARDIOGRAPHIC

GROUPING

Echo and fluoroscopic

(calcification) assessment of the

following characteristics:

-valve mobility,

-fusion of the subvalvular

apparatus

-amount of leaflet calcification

Wilkins score 7-9 correlated

with the echocardiographic

group 1

8 -12 correlated with the

echocardiographic

group 2

10 -15 with group 3Jung et al.Circulation 1996;94:2124–30.

Jung et al. J Am Coll Cardiol 1996;27:407–14.

ANWAR RT-TT3D ECHO SCORE

Evaluation of both mitral leaflets and the subvalvular apparatus.

Incidence and severity of post-procedural MR are associated with a high

RT-TT3DE calcification score

Anwar et al.J Am Soc Echocardiogr 2010;23:13–22

Inoue's percutaneous mitral commissurotomy

technique

After PMBV, the

MVA increases to an

average of 1.9 to 2.0 cm.

Good immediate results are

obtained in nearly 90%

of patients, with 60%

improving to New York Heart

Association functional class I

and 30% to functional

class II

ECHO ASSESSMENT DURING

PMBV-Transeptal puncture

-Balloon size choice

-Guide the balloon into the MV determine the

best position of the balloon between

the mitral leaflets

-Avoid chordal rupture, tearing of the valve

leaflet at a site other than the commissures

Wunderlich et al. J Am J Coll

Cardiol Img 2013;6:1191–205

ASSESSMENT AFTER PMBVMVA >1.5 cm2

and absence of complications

(including MR>grade 2/4

Opening of the commissures is shown

more clearly by real-time 3D echo Zamorano et al Eur Heart J

2004;25:2086–91

Post- PMBV

-MVA using mean Doppler gradients and

2D and 3D MV planimetry,

- reassess commissural opening

-evaluate MV leaflet mobility

- determine the severity and location of

MR

.Wunderlich et al. J Am J Coll Cardiol Img 2013;6:1191–205

Impact of Degree of Commissural Opening

After Percutaneous Mitral Commissurotomy on

Long-Term Outcome

Zeitub et al J Am Coll Cardiol Img 2009;2: 1–7

Complete CO is associated with larger

MVA, smaller gradients, and functional

improvement. The degree of CO provides

important prognostic information and thus

should be systematically evaluated during

and after PMC

PREDICTORS OF OUTCOME

AFTER PMBV

Wunderlich et al. J Am J Coll Cardiol Img 2013;6:1191–205

ECHO post PMBV

, «Εργαστήριο Ηχωκαρδιογραφίας»

Β’Καρδιολογική Κλινική Πανεπιστημίου Αθηνών

2 -D Continuous Wave and Colour Doppler

1. Mean gradient : 18mHg → 9mmHg

2. Mitral V Area : 0,9 cm2 → 1,3 cm2

3. RVS Pressure : 65mmHg → 37mmHg

ΕΥΧΑΡΙΣΤΩ