MITRAL STENOSIS
Division of Cardiology, Department of Internal Medicine
Tae Kyung Yu
Mitral Stenosis

Resulting from thickening and immobility of the MV leaflets
causes an obstruction in blood flow from the LA to LV
 The etiology is almost always rheumatic
 Cardiac hemodynamics
↑ LA pressure -> ↑pulmonary venous, capillary, and
arterial pressures and resistance
 ↓LV filling and end-diastolic volume
-> ↓stroke volume and cardiac output

 A.fib and PTH is common
Echocardiography
 Gold standard of diagnosis
 Assessment of severity
 Assessment of concomitant valvular lesions
 Assessment of MV morphology to determine suitability for
percutaneous mitral balloon valvotomy
 Known MS with changing signs and symptoms
 Assessment of the hemodynamic response of the mean
gradient and PA pressure by exercise Doppler echo.
(discrepancy between the resting Doppler echocardiographic and
clinical findings)
2D and M-Mode Echocardiography (1)

Thickened and calcified MV leaflets and subvalvular apparatus

↓ E-F slope(M-mode)

Hockey-stick appearance of anterior mitral leaflet in diastole
(long-axis view) -> diagnostic

Immobility of the posterior mitral leaflet

Fish-mouth orifice (short axis view)

↑ LA size -> potential for thrombus formation
2D and M-Mode Echocardiography (2)
 2-D planimetry of mitral orifice
 MVA from parasteral short axis view
 Maybe difficult in pts who have heavy calcification or who
previously had commissurotomy
 Echocardiographic score used to predict outcome of mitral
balloon valvuloplasty
 Mitral leaflet mobility, vavular thickening, subvalvular thickening
and calcification
 ≤ 8 -> favorable outcomes
 > 8 or Commissural calcification or fusion -> poor outcomes
Grade
Mobility
Supravalvular
Thickening
Thickening
Calcification
1
Highly mobile
valve with only
leaflets tips
restricted
Minimal thickening
just below the
mitral leaflets
Leaflets near
normal in
thickness
(4-5mm)
A single area of
increased echo
brightness
2
Leaflet mid and
base portions
have normal
mobility
Thickening of
chordal structures
extending up to
1/3 of the chordal
length
Midleaflets
normal,
considerable
thickening of
margin (5-8mm)
Scattered areas
of brightness
confined to
leaflets margins
3
Valve continues
to move forward
in diastole,
mainly from
base
Thickening
extending to the
distal third of the
chords
Thickening
Brightness
extending
extending into
through the entire the midportion of
leaflets
the leaflets
(5-8mm)
4
No or minimal
forward
movement of the
leaflets in
diastole
Extensive
thickening and
shortening of all
chordal structures
extending down to
the papillary
muscles
•Considerable
thickening of all
leaflet tissue(>810 mm)
Extensive
brightness
throught much of
the leaflet tissue
Total score 0 to 16
Doppler and Color Flow Imaging (1)

Candle-flame apperance
Doppler and Color Flow Imaging (2)

Measurement of MVA
: Most reliable way to determine the severity of MS
1. Plainmetric measurement(2D)
2. Continuity equation
AreaLVOT x TVILVOT = MVA x TVIMV
MVA = LVOT D2 x 0.785 x TVILVOT/TVIMV
LVOT
TVI
D
TVI
MV
Doppler and Color Flow Imaging (2)

Measurement of MVA
3. PISA(proximal isovelocity surface area) method
Apical 4 chamber view color doppler
MVA x Peak MS velocity = 6.28 x r2 x α° / 180° x Aliasing velocity
MVA = 6.28 x r2 x Aliasing velocity / Peak MS velocity x α° / 180°
4. PTH (pressure half –time) method
MVA = 220/PTH
Peak V
r
α
PHT
Severity of MS
Mean gradient Valve area
(mmHg)
(cm2)
PHT
Normal
0
4.0-6.0
40-70
<30
Mild
<5
>1.5
90-150
<30
Moderate
5-10
1.0-1.5
150-210
30-50
Severe
>10
<1.0
 220
>50
(msec)
PA systolic pressure
(mmHg)
Transesophageal Echocardiography
 To assess the presence of absence of LA thrombus
 To guide transseptal punture or positioning of the balloon
during mitral balloon valvuloplasty
 To assess MV morphology and hemodynamics if TTE
provides suboptimal data
Treatment