REVIEW

CURRENT
OPINION Imaging in mitral stenosis
Basil Al-Sabeq and Mohammed A. Chamsi-Pasha

Purpose of review
Mitral stenosis remains clinically relevant in developing countries where rheumatic heart disease is the
predominant culprit. In the western world, mitral annular and valvular calcification is an increasingly
recognized cause, particularly in an aging population. Echocardiography plays a primary role in imaging
mitral stenosis with a growing role for cardiac computed tomography and magnetic resonance imaging. In
this review, we aim to revisit mitral stenosis assessment and quantification using multimodality imaging.
Recent findings
There is an increasing role for advanced cardiac imaging especially in the era of transcatheter mitral valve
intervention. Also, when echocardiography is suboptimal or discordant with symptoms, computed
tomography can provide anatomical data, whereas magnetic resonance imaging can provide anatomical
along with hemodynamic data.
Downloaded from http://journals.lww.com/co-cardiology by BhDMf5ePHKbH4TTImqenVE5wmW8EcRnjwx8T+sIH6aLGD9XD8/faYVB72mRsxnnX on 08/15/2020

Summary
Diagnosis of mitral stenosis is crucial as it carries an increased morbidity and mortality risk.
Echocardiography is the cornerstone imaging modality with alternative, complementary advanced imaging
considered when images are suboptimal.
Keywords
3D mitral valve area, degenerative mitral stenosis, mitral annular calcification, rheumatic mitral stenosis

INTRODUCTION in the era of structural valvular interventions. Inva-

The mitral valve is a complex, dynamic structure
consisting of the mitral valve annulus, leaflets, chor-
dae tendineae, and papillary muscles. Mitral steno-
sis refers to a reduction in mitral valve area (<2 cm2)
and associated reduction in left ventricular inflow
[1]. It is a progressive, irreversible etiologies with a
long latency period until symptoms develop. The
etiologies of mitral stenosis are diverse and geo-
graphically biased, with rheumatic heart disease
being the prevailing cause in the developing world,
and degenerative calcification predominating in the
developed world, accounting for 12–26% of all
mitral stenosis cases [2]. Congenital, drug-induced,
and radiation-induced causes also exist [3]. Mitral
stenosis tends to affect females more than males
(both degenerative and rheumatic) [4 ].
&
The recognition of mitral stenosis, identifica-
tion of its cause and mechanism, and accurate grad-
ing of its severity and hemodynamic impact is
essential because of its association with significant
morbidity and mortality [5]. This is most commonly
achieved with echocardiography, but a growing role
has emerged for anatomical imaging [mainly cardiac
computed tomography angiography (CCTA), and to
a lesser extent cardiac magnetic resonance (CMR)]
in challenging, nondiagnostic cases, and especially
sive hemodynamic assessment of mitral stenosis still
has a role (though not as commonly performed) in
suboptimal imaging windows or when patient’s
symptoms are not explained by severity of mitral
stenosis obtained by echocardiography [6]. More-
over, the management of this valvular lesion varies
significantly according to its cause, further empha-
sizing an appreciation of valve anatomy and ‘the
company it keeps’ rather than an isolated emphasis
on stenosis severity.
ROLE OF ECHOCARDIOGRAPHY
Echocardiography remains the cornerstone imaging
modality to evaluate mitral stenosis because of its
ubiquitous availability, portability, overall safety,
Department of Cardiology, Cardiovascular Imaging Institute, Methodist
DeBakey Heart and Vascular Center, Houston, Texas, USA
Correspondence to Mohammed A. Chamsi-Pasha, MD, FACC, FASE,
Department of Cardiology, Weill Cornell Medical College, Houston
Methodist DeBakey Heart and Vascular Center, 6550 Fannin Street,
Smith 18, Houston, TX 77030, USA. Tel: +1 346 238 5280;
e-mail: machamsi-pasha@houstonmethodist.org
Curr Opin Cardiol 2020, 35:445–453
DOI:10.1097/HCO.0000000000000760

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Imaging and mitral regurgitation
KEY POINTS
 Mitral stenosis is a progressive disease which is
primarily rheumatic in origin, but with aging
populations, degenerative calcification is becoming
more evident.
 Echocardiography plays a pivotal role for assessment
of mitral valve structure and hemodynamic significance
using multiple parameters (effective valve area, mean
transmitral gradient). Echo-derived scores (e.g.,
Wilkins) are widely used to determine candidacy for
percutaneous mitral balloon valvuloplasty.
 There is an increasing role for the use of advanced
cardiac imaging (cardiac CT and CMR) when
echocardiographic examination is limited,
nondiagnostic, or discrepancy exists between symptoms
and imaging findings.
 With advances in transcatheter mitral valve therapies,
preprocedural imaging of mitral stenosis with CT is
routinely performed for mitral annular assessment and
to avoid complications (e.g. left ventricular outflow tract
obstruction).
and ability to noninvasively provide accurate
hemodynamic information.
Transthoracic echocardiography
This is usually the initial test that identifies mitral
stenosis, with two-dimensional, color Doppler, and
spectral Doppler techniques playing unique roles in
the comprehensive assessment of the lesion. This
not only includes evaluation of the lesion itself, but
also associated findings such as the degree of left
atrial enlargement and collateral damage from
increased left-sided filling pressures translating to
pulmonary hypertension. The latter includes elevated
pulmonary arterial pressure estimates, right ventricu-
lar dilation, and subsequent dysfunction [7]. Trans-
thoracic echocardiography (TTE) is essential to define
mitral valve anatomy, including leaflet mobility and
calcification, annulus, and subvalvular apparatus, as
well as to determine cause (e.g., rheumatic versus
calcific) (Fig. 1). Common echocardiographic features
of rheumatic mitral stenosis include commissural
fusion, thickening at the leaflet tips, chordal shorten-
ing, and restricted mobility of the posterior mitral
valve leaflet [1]. The widely used Wilkins score should
be reported to determine feasibility of percutaneous
mitral balloon valvuloplasty (PMBV), which takes into
account four features of the mitral valve (leaflet mobil-
ity, valve thickening, calcification, and subvalvular
involvement). A calculated score of 8 or less is associ-
ated with more favorable procedural and postproce-
dural outcomes [8].
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Color Doppler helps identify flow acceleration
across the mitral valve and concomitant mitral
regurgitation, the severity of which may contrain-
dicate PMBV in the case of rheumatic mitral steno-
sis. Although the hemodynamic consequences of
mitral stenosis are determined by incorporating
mean Doppler transvalvular diastolic pressure gra-
dient and pulmonary pressures, its severity is
defined by mitral valve area (MVA). The cutoff for
‘severe’ mitral stenosis has alternated between less
than 1.0 cm2 and less than 1.5 cm2 by various guide-
lines in the past [9–11]; however, there is consensus
that an area of less than 1.5 cm2 is small enough to
cause symptoms and warrant consideration for
intervention. The European guidelines give a class
IIa recommendation for intervening on MVA less
than 1.5 cm2 with a resting systolic pulmonary
artery pressure more than 50 mmHg [12].
Mitral valve area assessment
The four common methods for estimating MVA are
pressure half time (PHT), continuity equation, direct
planimetry (2D or 3D), and the proximal isovelocity
surface area (PISA) method. It is worth mentioning
that each method has inherent limitations, and no
single method should be solely relied on:
(1) PHT technique, initially validated by Hatle et al.
[13] is so named because it is the time required
in milliseconds for the transmitral diastolic
pressure gradient to reach half its peak value.
Using 220 as a constant, an empiric MVA for-
mula of dividing 220 by PHT was validated.
Invasively derived MVA of 1.0 cm2 using the
modified Gorlin equation correlated well with
a continuous wave Doppler-derived PHT of
220 ms. PHT can be affected by tachycardia or
atrial fibrillation, rendering it less reliable. PHT
is directly proportional to atrioventricular com-
pliance. Increased ventricular stiffness and pres-
ence of aortic regurgitation can cause
shortening of PHT and overestimation of
MVA [9]. The mean diastolic transmitral gradi-
ent, a commonly used measure of mitral steno-
sis severity and well validated against invasive
measurements [1], is derived from spectral con-
tinuous wave Doppler, using the simplified Ber-
noulli equation, by averaging instantaneous
gradients. Assuming a normal mean left ventric-
ular diastolic pressure of 5 mmHg, a mean mitral
valve gradient of about 15 mmHg will cause a
mean left atrial pressure of 20 mmHg, sufficient
enough to cause pulmonary venous congestion
[6]. The gradient is highly dependent on heart
rate, cardiac output, and transmitral flow
Volume 35  Number 5  September 2020
 Imaging in mitral stenosis Al-Sabeq and Chamsi-Pasha

FIGURE 1. Typical appearance of rheumatic mitral valve on TTE in a 23-year-old-female (panels a–d). Panel a, parasternal
long-axis view showing thickened and doming anterior leaflet (hockey-sticking) and restricted mobility of the posterior mitral
valve leaflet. Panel b, apical four-chamber view showing severe left atrial enlargement. Panel c, spectral continuous wave
Doppler profile across the mitral valve shows peak velocity of 2.4 m/s, pressure half time of 176 ms, mean gradient of
7 mmHg at a heart rate of 57 bpm, and an effective mitral valve area of 1.2 cm2, consistent with moderate mitral stenosis.
Panel d, real-time three-dimensional transesophageal echocardiogram of the mitral valve (surgeon’s view) with typical fish-
mouth appearance in diastole and favorable Wilkins score (6 in this case). Panels (e–g) show a case of degenerative severe
valve calcification on TTE in a 70-year-old female patient. Panel (e, f) parasternal and apical four, long-axis views with diffuse
calcification involving anterior and posterior leaflets. Panel g, continuous wave Doppler across the mitral valve shows an
elevated peak velocity and mean gradient (2.5 m/s, 9 mmHg) at a heart rate of 57 bpm, with mitral valve area derived by
continuity equation of 0.9 cm2 consistent with severe stenosis. Notice area-gradient mismatch in the setting of bradycardia.
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Imaging and mitral regurgitation
conditions. A mean gradient at least 5 mmHg at
heart rates between 60–80 in sinus rhythm is
consistent with at least moderate mitral stenosis
[9]. Low-flow low-gradient mitral stenosis is an
emerging entity (defined as gradient <10 mmHg
and low transvalvular flow rate of 35 ml/m2)
commonly associated with decreased left ven-
tricular compliance and higher afterload, with
recent data suggesting less symptomatic benefit
from valvuloplasty [14 ].
&
(2) The continuity equation, based on the law of
conservation of mass, is another method used
to define mitral stenosis severity via a calculated
effective MVA. Blood volume flowing across the
mitral orifice during diastole should equal blood
flow across the left ventricular outflow tract
(LVOT) during systole, provided concomitant
mitral regurgitation or aortic regurgitation are
no more than mild. In other words, the LVOT
stroke volume (product of the calculated LVOT
area and LVOT velocity time integral) equals
mitral valve stroke volume (product of mitral
valve velocity time integral and MVA). Thus,
MVA can be calculated using the remaining
three readily obtained variables. This method
is recommended in patients with degenerative
valvular or annular calcification as other param-
eters (like PHT) will not be valid in the setting of
noncompliant left atrium or left ventricle [9,15].
(3) Planimetry-derived anatomic MVA is another use-
ful tool that may be performed using either 2D or
3D imaging. This technique affords the advan-
tage of direct measurement of the mitral valve
orifice without the hemodynamic influences of
Doppler-derived MVA. In practice, planimetry
has been shown to have the best correlation with
anatomic valve area assessed on explanted valves
[16]. However, the method relies on optimal
imaging of the valve at the level of both leaflet
tips (i.e., its narrowest point) to be accurate. With
TTE, this is achieved with a parasternal short axis
window and presents its own challenges as the
echo beam may transect one but not both leaflet
tips. It has been previously shown that both
larger left atrial dimensions and larger angles
between the line of the true mitral valve tip
and the line of the echo beam to the tip are
associated with overestimations of MVA when
3D transesophageal echocardiography (TEE)
derived MVA using multiplanar reconstruction
was used as the reference standard [17].
(4) The PISA method is based on the principle of flow
convergence, whereby acceleration of blood
toward a narrowed orifice results in concentric
hemispheres of increasing velocities and
decreasing radii. As flow rate is the product of
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area and velocity, flow rate at a given hemi-
spheric shell (area (2pr2)  aliasing veloc-
ity  a/1808) equals the peak flow rate across
the orifice (MVA  peak mitral stenosis veloc-
ity), satisfying the law of mass conservation. A
leaflet angle correction factor (a/1808) is used as
only a portion of hemispheric blood flow crosses
the funnel-shaped mitral inflow [1].
Transesophageal echocardiography
TEE offers several advantages over TTE because of
the mitral valve’s posterior location and proximity
to the transesophageal probe. This allows superior
definition of valve anatomy and subvalvular appa-
ratus. Real-time, 3D-TEE provides a unique orienta-
tion of the mitral valve leaflets and commissures at
any angle or plane. Using multiplanar reconstruc-
tion, a cross-sectional plane oriented at the leaflet
tips in a double orthogonal view is created to trace
&
anatomical orifice area [1,18 ] (Fig. 2), which is
typically slightly higher than the Doppler-derived
effective MVA at the vena contracta level. 3D-TEE
derived mitral valve area has been shown to be
superior and more accurate over TTE [17]. Similar
to the Wilkins score, a 3D-TEE scoring system was
validated providing a simple number for each leaflet
scallop and subvalvular apparatus separately and
shown to be highly reproducible [19]. TEE is an
especially important prerequisite when PMBV is
planned. In that regard, contraindications to bal-
loon valvuloplasty such as left atrial or atrial
appendage thrombi, mitral regurgitation that is
moderate or greater in severity, or unfavorable valve
anatomy (high Wilkins score) can simultaneously
be ruled out using TEE. Intraprocedural TEE guid-
ance for PMBV is standard of care to guide trans-
septal puncture, direct the Inoue balloon into the
left ventricle, and assess immediate postprocedural
success via MVA planimetry, mitral regurgitation
severity, and exclusion of left atrial thrombi or
&
pericardial effusions [18 ].
The role of stress echocardiography
This remains an important tool in the assessment of
mitral stenosis when plausible exertional symptoms
are not explained by resting valvular hemodynamics
and measured valve area. In addition, it can be used
to reveal symptoms in asymptomatic, severe mitral
stenosis cases. This is a class I recommendation by
the American College of Cardiology 2014 valvular
disease guidelines [20]. Exercise may be performed
using a treadmill or supine bicycle, with the latter
offering the potential ergonomic advantage of a
consistent apical window throughout the test.
Dobutamine stress testing can also be performed.
Volume 35  Number 5  September 2020
 Imaging in mitral stenosis Al-Sabeq and Chamsi-Pasha

FIGURE 2. Rheumatic appearing mitral valve on TEE with favorable Wilkins score (6). Panel a, mid-esophageal four-chamber
view showing thickened mitral valve leaflets and restricted opening. Panel b, continuous wave Doppler showing peak velocity
of 1.6 m/s, mean gradient of 6 mmHg at a heart rate of 52 bpm. Panel c, 3D-TEE with commissural fusion and diffuse leaflet
thickening. Panel d, reconstructed short axis view of the mitral valve at leaflet tips showing an anatomical valve area of 1 cm2,
consistent with severe stenosis.

Mitral stenosis is diagnosed as severe if the mean
gradient is more than 15 mmHg on exertion, or
more than 18 mmHg with dobutamine [21]. The
American guidelines give a class IIb recommenda-
tion for PMBV in nonsevere mitral stenosis
(MVA > 1.5 cm2) but with exercise-induced mean
gradient more than 15 mmHg [12,20]. Given that
exertional systolic pulmonary artery pressure at least
60 mmHg is a marker of hemodynamically signifi-
cant mitral stenosis, peak tricuspid regurgitation jet
velocity in addition to mitral valve continuous wave
Doppler for mean gradient measurement should be
obtained at minimum [12,21].
MITRAL ANNULAR CALCIFICATION
Degenerative, calcific mitral stenosis due to signifi-
cant mitral annular calcification (MAC) deserves
special mention because of its prevalence (10%)
in an aging patient population with multiple comor-
bidities (diabetes, obesity and chronic kidney
disease) [22]. Almost half of the patients with aortic
stenosis have concomitant MAC. Heavy calcifica-
tion typically starts from the annulus and extends
toward the base of the leaflets (Fig. 3, panels c,d)
hence the relative low prevalence of mitral inflow
obstruction (unlike rheumatic involvement which
progresses from the commissures and tips to body
and base). Recent studies suggested that an esti-
mated prevalence of 12–26% of all mitral stenosis
cases are due to degenerative changes [2,22]. The
natural history of MAC is not well defined. In a
recent study evaluating 2927 patients, the preva-
lence of severe MAC (defined as involving more
than two-thirds of the annulus and/or invading
adjacent myocardium) was seen in 30%. Sixteen
percent have developed severe mitral stenosis
undergoing valve replacement (over 15 years fol-
low-up) with noticeable faster progression (mean
&
gradient progression was 0.112 mmHg/year) [23 ].
Echocardiography plays an adjunct role to
CCTA in calcific mitral stenosis preprocedural

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Imaging and mitral regurgitation

FIGURE 3. Cardiac CTA in axial (Panel a) and modified sagittal views (Panel b) showing severely thickened mitral valve
leaflets (asterisk) with mild calcification, and commissural fusion consistent with rheumatic mitral stenosis. There is biatrial
enlargement present. Panel c shows severe MAC on TTE on both parasternal long and apical four-chamber views (asterisk).
Cardiac CTA in a sagittal orientation (Panel d) shows caseating mitral annular calcification with hyperdense mass peripherally
and central different tissue densities.

transcatheter planning via assessment of basal septal
hypertrophy, anterior mitral leaflet length, and evi-
dence of LVOT obstruction at baseline [17]. A rare
form of MAC (caseating necrosis) can be mistaken
on TTE as a pseudotumor and anatomical imaging
typically with CCTA shows a well-defined peripher-
ally calcified mass with a central region of variable
attenuation [24].
EMERGING USE OF ADVANCED CARDIAC
IMAGING
Cross-sectional cardiac imaging (CCTA and CMR)
has emerged over the years in the valvular disease
arena as high spatial resolution imaging techniques
with multiplanar reconstruction capabilities. The
need for advanced imaging is reserved to where
TTE or TEE images are of poor quality or where there
is discrepancy between symptoms and echocardiog-
raphy findings.
CMR: CMR is an attractive, nonionizing radia-
tion imaging technique that provides comprehen-
sive anatomical and quantitative evaluation of
mitral valve disease. The commonly used balanced
steady-state free precession sequence has been the
power horse for cine imaging and valve anatomy,
with high signal-to-noise ratio and bright blood
imaging without the need for gadolinium contrast
administration. Creating multiple sagittal thin slices
perpendicular to the mitral valve at two orthogonal
views and tracing direct planimetry of minimal
diastolic area at the leaflet tips is feasible in mitral
stenosis cases [25,26] (Fig. 4). Small studies have
shown good correlation between CMR and TTE-
derived valve area and gradients [16,26], as well as
3D-TEE derived valve area [27]. Hemodynamic
assessment of mitral stenosis severity utilizing trans-
valvular flow and velocities can be obtained utiliz-
ing phase contrast imaging, measured on a short-
axis view in a plane perpendicular to the direction of
flow (Fig. 4, panel f). Studies have consistently
shown mitral velocities obtained via CMR to be
significantly lower than TTE because of lower tem-
poral resolution [26]. More importantly, atrial fibril-
lation with elevated heart rates creates gating
artifacts which significantly degrades imaging qual-
ity and makes flow or mitral valve area assessment
invalid. CMR with contrast can provide unique
tissue characteristics in the setting of MAC, which
appears hypointense on T1 and T2-weighted

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 Imaging in mitral stenosis Al-Sabeq and Chamsi-Pasha

FIGURE 4. CMR role in mitral stenosis assessment. Panels (a–c) show a rheumatic appearing mitral valve with evidence of
thickening/calcification of anterior leaflet in both 3-chamber long (panel a) and four-chamber view (Panel b). Panel c shows
anatomical MVA assessment using a modified sagittal orientation perpendicular to the leaflet tips on two orthogonal
projections cross-referenced. The area is 1 cm2. Panels (d–f) shows a case of severe MAC extending to the myocardium
(asterisks). Classic tissue characteristics are hypointense mass on T1 and T2-weighed imaging. The MVA here is 0.9 cm2.
Panel f shows phase contrast imaging where it directly measures blood flow through an enface image of the mitral orifice with
a through plane peak velocity of 2.1 m/s.

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Imaging and mitral regurgitation
imaging, with an outer rim of delayed hyperen-
hancement [24] (Fig. 4, panels d,e). Finally, CMR
has been the gold standard for chambers volumes
and functional assessment, and consequences of
severe mitral stenosis (like atrial enlargement, right
ventricular enlargement, and dysfunction) can be
accurately assessed.
CCTA is a 3D-anatomical, contrast-enhanced
imaging technique with high spatial resolution
(0.5 mm) allowing clear depiction of mitral valve
leaflet thickening, calcification (because of high X-
ray attenuation) (Fig. 3, panels a,b), evaluation of
the extent of MAC (Fig. 3, panel d), and accurate
annular sizing. In addition, planimetry of the valve
on short axis at the leaflet tips can be calculated. Its
role has increased to guide transcatheter mitral valve
interventions [15,22]. CCTA can help assess for
coronary artery disease (with a high negative pre-
dictive value) prior to surgical intervention and
accurately rule out left atrial appendage thrombus,
which is more prevalent in mitral stenosis [28].
NEW APPLICATIONS
Growing interest in personalized medicines is
noted, and technological advances in 3D printing
have allowed complex mitral valve diseases detected
on volumetric clinical imaging [usually computed
tomography (CT)] to be transformed into patient-
specific 3D models, with clear depictions of valve
and annular geometry. These can be helpful in
transcatheter or surgical planning but also to simu-
late in-vitro flow conditions [29].
CONCLUSION
In conclusion, cardiac imaging remains crucial in
diagnosing and risk stratifying the hemodynamic
severity of mitral stenosis patients and has largely
obviated the need for invasive hemodynamic assess-
ment. Echocardiography remains to date the pri-
mary imaging modality (2D and 3D TTE and TEE).
CCTA is complementary for assessing morphologi-
cal characteristics of the stenotic valve, annular
calcification, and to guide transcatheter therapies.
CMR is an alternative to echocardiography as it
provides both anatomical and hemodynamic data,
though it is still not widely utilized for mitral steno-
sis in particular.
Acknowledgements
None.
Financial support and sponsorship
None.
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Conflicts of interest
There are no conflicts of interest.
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