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Bogdan A. Popescu University of Medicine and Pharmacy Bucharest, Romania EAE Course, Bucharest, April 2010 European
Bogdan A. Popescu
Bogdan A. Popescu
University of Medicine and Pharmacy Bucharest, Romania
University of Medicine and Pharmacy
Bucharest, Romania
EAE Course, Bucharest, April 2010
EAE Course, Bucharest, April 2010
Bogdan A. Popescu University of Medicine and Pharmacy Bucharest, Romania EAE Course, Bucharest, April 2010 European
Bogdan A. Popescu University of Medicine and Pharmacy Bucharest, Romania EAE Course, Bucharest, April 2010 European

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Bogdan A. Popescu University of Medicine and Pharmacy Bucharest, Romania EAE Course, Bucharest, April 2010 European
This is how it started… European Society of Cardiology copyright -All right reserved

This is how it started…

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Mitral stenosis at a glance
Mitral stenosis at a glance
Mitral stenosis at a glance European Society of Cardiology copyright -All right reserved

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2D echo
2D echo
2D echo • narrow diastolic opening of MV leaflets • valve doming (‘hockey - stick”) •

narrow diastolic opening of MV leaflets
valve doming (‘hockey-stick”)
thickened leaflets ± calcifications
chordal thickening and fusion dilated LA
± dilated RV, paradoxical septal motion

2D echo • narrow diastolic opening of MV leaflets • valve doming (‘hockey - stick”) •
2D echo • narrow diastolic opening of MV leaflets • valve doming (‘hockey - stick”) •
2D echo • narrow diastolic opening of MV leaflets • valve doming (‘hockey - stick”) •
2D echo • narrow diastolic opening of MV leaflets • valve doming (‘hockey - stick”) •
2D echo • narrow diastolic opening of MV leaflets • valve doming (‘hockey - stick”) •

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Etiology
Etiology
Etiology European Society of Cardiology copyright -All right reserved

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Echocardiography in MS
Echocardiography in MS
The main method to assess:
The main method to assess:
• Extent of anatomic lesions • Severity • Consequences
• Extent of anatomic lesions
• Severity
• Consequences
Echocardiography in MS The main method to assess: • Extent of anatomic lesions • Severity •

ESC Guidelines on the management of valvular heart disease. EHJ 2007;28:230-68

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Extent of anatomic lesions
Extent of anatomic lesions
• Assessment by 2D echo: • leaflet mobility • calcification • commissural fusion • subvalvular involvement
• Assessment by 2D echo:
• leaflet mobility
• calcification
• commissural fusion
• subvalvular involvement
• Scores to assess the feasibility for PMC: (percutaneous mitral commissurotomy) • Wilkins (Boston) • Cormier
• Scores to assess the feasibility for PMC:
(percutaneous mitral commissurotomy)
• Wilkins (Boston)
• Cormier

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Severity of MS (quantitation)
Severity of MS (quantitation)
• 2D (3D) echo: • MV area (planimetry)
• 2D (3D) echo:
• MV area (planimetry)
• Doppler:
• Doppler:
Severity of MS (quantitation) • 2D (3D) echo: • MV area (planimetry) • Doppler: • pressure

pressure gradients MV area (pressure half-time) PISA continuity equation

Severity of MS (quantitation) • 2D (3D) echo: • MV area (planimetry) • Doppler: • pressure
Severity of MS (quantitation) • 2D (3D) echo: • MV area (planimetry) • Doppler: • pressure
Severity of MS (quantitation) • 2D (3D) echo: • MV area (planimetry) • Doppler: • pressure
Severity of MS (quantitation) • 2D (3D) echo: • MV area (planimetry) • Doppler: • pressure

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Grading severity of MS
Grading severity of MS
MILD
MILD
MODERATE SEVERE
MODERATE
SEVERE

SPECIFIC Valve area (cm 2 )

Grading severity of MS MILD MODERATE SEVERE SPECIFIC Valve area (cm ) > 1.5 1 -
> 1.5
> 1.5
Grading severity of MS MILD MODERATE SEVERE SPECIFIC Valve area (cm ) > 1.5 1 -
Grading severity of MS MILD MODERATE SEVERE SPECIFIC Valve area (cm ) > 1.5 1 -
1 - 1.5 < 1

1 - 1.5

< 1

1 - 1.5 < 1

NON-SIGNIFICANT

SIGNIFICANT

< 5

5 - 10

> 10

< 30

30 - 50

> 50

Grading severity of MS MILD MODERATE SEVERE SPECIFIC Valve area (cm ) > 1.5 1 -
Grading severity of MS MILD MODERATE SEVERE SPECIFIC Valve area (cm ) > 1.5 1 -
Grading severity of MS MILD MODERATE SEVERE SPECIFIC Valve area (cm ) > 1.5 1 -

SUPPORTIVE Mean grad (mmHg) SPAP (mmHg)

Grading severity of MS MILD MODERATE SEVERE SPECIFIC Valve area (cm ) > 1.5 1 -

Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for

clinical practice. Eur J Echocardiogr European Society of 2009 Cardiology May;10(3):47 copyright -All right reserved

Planimetry
Planimetry
Yields anatomical area
Yields anatomical area
Planimetry Yields anatomical area Aim for cut no. 1! European Society of Cardiology copyright -All right

Aim for cut no. 1!

Planimetry Yields anatomical area Aim for cut no. 1! European Society of Cardiology copyright -All right
Planimetry
Planimetry
Limitations:
Limitations:
• Funnel-shaped structure of the stenotic MV  overestimation of MVA if inadequate scanning
• Funnel-shaped structure of the stenotic MV
overestimation of MVA if inadequate scanning
• Instrumentation settings:  gain  underestimation of MVA (’blooming’)
• Instrumentation settings:
gain  underestimation of MVA (’blooming’)
• Commissurotomy - irregular oriffice, difficult to planimeter
• Commissurotomy
- irregular oriffice, difficult to planimeter
• Technical requirements: - adequate 2D image quality, zoom, freeze
• Technical requirements:
- adequate 2D image quality, zoom, freeze

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3D echo
3D echo
Strengths:
Strengths:
• Higher accuracy in MVA planimetry than 2DE (true smallest orifice, independently of its orientation)
• Higher accuracy in MVA planimetry than 2DE
(true smallest orifice, independently of its orientation)
3D echo Strengths: • Higher accuracy in MVA planimetry than 2DE (true smallest orifice, independently of
3D echo Strengths: • Higher accuracy in MVA planimetry than 2DE (true smallest orifice, independently of

Less experience-dependent and more reproducible

• Detailed information on commissural and subvalvular apparatus involvement (indication and results of PMC)
• Detailed information on commissural and subvalvular
apparatus involvement (indication and results of PMC)
• Applicable also when PSAX view has inadequate image quality
• Applicable also when PSAX view has inadequate image
quality

Zamorano J et al. J Am Coll Cardiol. 2004; 43: 2091-6 Xie Mx et al. Am J Cardiol. 2005 ; 95: 1496-9 Messika-Zeitoun D et al. Eur Heart J 2007; 28:72-9

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Pressure Half-Time

• Time the pressure gradient needs to drop to half its initial value
• Time the pressure gradient needs to drop
to half its initial value
• Because PG v 2 , i. e. VPG v: Time velocity needs to drop to
• Because PG v 2 , i. e. VPG v:
Time velocity needs to drop to 1/ V 2 of its
initial value:
V
max
V
max /2
t 1/2
MVA [cm ] = 220/t
2
[ms]
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1/2
European Society of Cardiology copyright -All right reserved Circulation 1979;60:1096-104.
European Society of Cardiology copyright -All right reserved Circulation 1979;60:1096-104.

European Society of Cardiology copyright -All right reserved

European Society of Cardiology copyright -All right reserved Circulation 1979;60:1096-104.

Circulation 1979;60:1096-104.

Doppler-derived PHT: relation to mitral valve area
Doppler-derived PHT: relation to mitral valve area
Doppler-derived PHT: relation to mitral valve area European Society of Cardiology copyright -All right reserved Hatle
Doppler-derived PHT: relation to mitral valve area European Society of Cardiology copyright -All right reserved Hatle

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Hatle L, et al. Circulation 1979;60:1096-104.

Pressure Half-Time (PHT) method
Pressure Half-Time (PHT) method
Yields functional area
Yields functional area
Pressure Half-Time (PHT) method Yields functional area Pro : it also works in the presence of
Pressure Half-Time (PHT) method Yields functional area Pro : it also works in the presence of
Pressure Half-Time (PHT) method Yields functional area Pro : it also works in the presence of
Pressure Half-Time (PHT) method Yields functional area Pro : it also works in the presence of

Pro: it also works in the presence of significant MR

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Factors that may affect Pressure Half Time by influencing LA pressure decline

Factors that may affect Pressure Half Time by influencing LA pressure decline LA More rapid LA
LA
LA

More rapid LA pressure decline will lead to a

shortened PHT
shortened PHT

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Factors that may affect Pressure Half Time by influencing LA pressure decline
Factors that may affect Pressure Half Time
by influencing LA pressure decline
Factors that may affect Pressure Half Time by influencing LA pressure decline 1. If the LA

1. If the LA empties into a second chamber (eg ASD):

LA pressure will drop more rapidly
LA pressure will drop more rapidly
PHT will be shortened
PHT will be shortened
2. If the LA is stiff (low atrial compliance)
2. If the LA is stiff (low atrial compliance)
LA pressure may drop rapidly
LA pressure may drop rapidly
PHT will be shortened
PHT will be shortened

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Factors that may affect Pressure Half Time by influencing LV pressure rise
Factors that may affect Pressure Half Time
by influencing LV pressure rise
LA
LA
Factors that may affect Pressure Half Time by influencing LV pressure rise LA More rapid rise

More rapid rise in LV pressure will lead to

a shortened PHT
a shortened PHT

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Factors that may affect Pressure Half Time by influencing LV pressure rise
Factors that may affect Pressure Half Time
by influencing LV pressure rise
1. If the LV fills from a second source (eg AR):
1. If the LV fills from a second source (eg AR):
LV pressure will rise more rapidly
LV pressure will rise more rapidly
PHT will be shortened
PHT will be shortened
2. If the LV is stiff (low ventricular compliance)
2. If the LV is stiff (low ventricular compliance)
LV pressure may rise rapidly
LV pressure may rise rapidly
PHT will be shortened
PHT will be shortened

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As a rule t 1/2
As a rule
t 1/2
• Therefore, PHT never underestimates MVA • Therefore, if PHT is > 220 ms, MS is
• Therefore, PHT never underestimates MVA
• Therefore, if PHT is > 220 ms, MS is severe
• However, if PHT is < 220 ms, consider:
• mean transmitral gradient
• MVA by planimetry
• pulmonary artery pressure
• exercise echocardiography
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All factors affecting PHT (AR, ASD, reduced LA- or LV compliance) lead to overestimation of MVA

PHT method limitations
PHT method limitations
Technique-related:
Technique-related:
• Non-paralel alignment to the transmitral flow • Non-linear slope (leading to difficult/incorrect meas.) • PW
• Non-paralel alignment to the transmitral flow
• Non-linear slope (leading to difficult/incorrect meas.)
• PW Doppler recordings
Principle-related:
• Factors affecting PHT (others than MS severity)
• Immediately after PMC (ASD)
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Pitfalls in PHT measurement
Pitfalls in PHT measurement

Correct: modal velocity

Incorrect: peak velocity

Pitfalls in PHT measurement Correct: modal velocity Incorrect: peak velocity European Society of Cardiology copyright -All
Pitfalls in PHT measurement Correct: modal velocity Incorrect: peak velocity European Society of Cardiology copyright -All

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Pressure gradients
Pressure gradients
• Derived by Bernoulli’s law from measured velocity • Highly rate- and flow-dependent
• Derived by Bernoulli’s law from measured velocity
• Highly rate- and flow-dependent
Pressure gradients • Derived by Bernoulli’s law from measured velocity • Highly rate- and flow-dependent Mean
Mean gradient
Mean gradient

Problems: tachycardia, significant coexistent MR

(when gradients overestimate MS severity)

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17 pts with MS underwent transseptal cardiac catheterization Simultaneous measurements of transmitral gradient were performed by:
17 pts with MS underwent transseptal cardiac catheterization Simultaneous measurements of transmitral gradient were performed by:

17 pts with MS underwent transseptal cardiac catheterization Simultaneous measurements of transmitral gradient

17 pts with MS underwent transseptal cardiac catheterization Simultaneous measurements of transmitral gradient were performed by:
were performed by:
were performed by:
17 pts with MS underwent transseptal cardiac catheterization Simultaneous measurements of transmitral gradient were performed by:
1. direct LA and LV pressures 2. PCW and LV pressures 3. Doppler echocardiography
1. direct LA and LV pressures
2. PCW and LV pressures
3. Doppler echocardiography
Nishimura RA, et al. J Am Coll Cardiol 1994;24:152-8.
Nishimura RA, et al. J Am Coll Cardiol 1994;24:152-8.

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Consequences of MS
Consequences of MS
HEMODYNAMIC THROMBOEMBOLIC INFECTION  LAP LA dilation Endocarditis Acute pulmonary  PVP Atrial Fib edema 
HEMODYNAMIC
THROMBOEMBOLIC
INFECTION
 LAP
LA dilation
Endocarditis
Acute
pulmonary
 PVP
Atrial Fib
edema
 PAP
LA thrombus
Recurrent
episodes of
rheumatic
fever
Systemic embolisation
RV dysfx
Systemic congestion

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Thromboembolic

risk

Reduced LAA emptying velocities
Reduced LAA
emptying velocities

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LA thrombus (TTE and TEE)
LA thrombus (TTE and TEE)

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Pulmonary HT and RV dysfx
Pulmonary HT and RV dysfx

Pulmonary HT and RV dysfx

sPAP
sPAP
mPAP
mPAP
Pulmonary HT and RV dysfx sPAP mPAP TAPSE European Society of Cardiology copyright -All right reserved
TAPSE
TAPSE

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Treatment selection in MS

Echocardiography plays a key role in decision

making regarding the optimal treatment

Anticoagulant therapy even in SR when:

LA thrombus (class I C) dense SEC (class IIa C) enlarged LA > 50 mm (class IIa C)

Guidance of cardioversion to sinus rhythm

Treatment selection in MS Echocardiography plays a key role in decision making regarding the optimal treatment

ESC Guidelines on the management of valvular heart disease. EHJ 2007;28:230-68

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Percutaneous Mitral Comissurotomy
Percutaneous Mitral Comissurotomy

When considering percutaneous treatment of MS echocardiography is essential to:

assess MV morphology rule-out LA thrombi and significant MR

monitor procedure (eg septal puncture)

assess result

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Leaflet mobility and calcification, coexisting MR
Leaflet
mobility and
calcification,
coexisting MR

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PMC indicated? Assess MV morphology
PMC
indicated?
Assess MV
morphology

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Indications for PMC in MS with valve area < 1.5 cm 2

Indications for PMC in MS with valve area < 1.5 cm  Symptomatic pts with favourable

Symptomatic pts with favourable characteristics for PMC (Class IB):
Symptomatic pts with favourable characteristics for PMC (Class IB):
 
ABSENCE of several of the following:
ABSENCE of several of the following:
ABSENCE of several of the following:
 

Clinical characteristics

Anatomic characteristics

Old age History of commissurotomy NYHA class IV Atrial fibrillation Severe pulmonary hypertension

Wilkins score > 8 Cormier score 3 Very small MVA Severe TR

Symptomatic pts with contraindication or high risk for surgery (Class IC

Rule out

LA/LAA

thrombus

Interatrial

septum

morphology

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Exercise echocardiography

Exercise echocardiography • To unmask symptoms in pts with MVA <1.5 cm and no or doubtful

To unmask symptoms in pts with MVA <1.5 cm 2 and no or doubtful complaints When there is a discrepancy between resting Doppler echocardiographic findings and clinical findings

Exercise echocardiography • To unmask symptoms in pts with MVA <1.5 cm and no or doubtful
Exercise echocardiography • To unmask symptoms in pts with MVA <1.5 cm and no or doubtful
Exercise echocardiography • To unmask symptoms in pts with MVA <1.5 cm and no or doubtful

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Remember

Always measure: • Mean pressure gradient • MVA by ≥ 2 methods (planimetry, PHT) • SPAP
Always measure:
• Mean pressure gradient
• MVA by ≥ 2 methods (planimetry, PHT)
• SPAP using peak TR jet velocity
• LA size
Carefully look at the other valves (Tricuspid!) When severity in doubt: exercise echo TEE in selected
Carefully look at the other valves (Tricuspid!)
When severity in doubt: exercise echo
TEE in selected cases (inconclusive TTE,
to rule out thrombi, to decide for PMC)
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