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    5a. Echo Evaluation of Mitral Stenosis, DR Azri

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    Jalu Panjongko
    Echo is important for evaluating mitral stenosis (MS). It determines diagnosis and stenosis severity. Severity is assessed through measurements of mitral valve area (MVA) using planimetry, pressure half-time, and pressure gradient. MVA planimetry directly measures the opening area and is the reference standard, while pressure half-time and gradient are alternatives that depend on flow and cardiac function. Secondary findings like left atrial enlargement are also evaluated.

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    5a. Echo Evaluation of Mitral Stenosis, DR Azri

    Uploaded by

    Jalu Panjongko
    26 views37 pages
    Echo is important for evaluating mitral stenosis (MS). It determines diagnosis and stenosis severity. Severity is assessed through measurements of mitral valve area (MVA) using planimetry, pressure half-time, and pressure gradient. MVA planimetry directly measures the opening area and is the reference standard, while pressure half-time and gradient are alternatives that depend on flow and cardiac function. Secondary findings like left atrial enlargement are also evaluated.

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    5a. Echo evaluation of mitral stenosis, dr Azri

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    Echo is important for evaluating mitral stenosis (MS). It determines diagnosis and stenosis severity. Severity is assessed through measurements of mitral valve area (MVA) using planimetry, pressure half-time, and pressure gradient. MVA planimetry directly measures the opening area and is the reference standard, while pressure half-time and gradient are alternatives that depend on flow and cardiac function. Secondary findings like left atrial enlargement are also evaluated.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    26 views37 pages

    5a. Echo Evaluation of Mitral Stenosis, DR Azri

    Uploaded by

    Jalu Panjongko
    Echo is important for evaluating mitral stenosis (MS). It determines diagnosis and stenosis severity. Severity is assessed through measurements of mitral valve area (MVA) using planimetry, pressure half-time, and pressure gradient. MVA planimetry directly measures the opening area and is the reference standard, while pressure half-time and gradient are alternatives that depend on flow and cardiac function. Secondary findings like left atrial enlargement are also evaluated.

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    ECHOCARDIOGRAPHIC EVALUATION

    OF MITRAL STENOSIS

    1
    • Echo memaikan peranan penting dalam
    evaluasi MS
    • Berperan dalam menentukan diagnosis dan
    derajat stenosis
    Etiologi Mitral Stenosis

     Rheumatic

     Degenerative

     Congenital MS

     Other: Systemic lupus , Infiltrative disease,


    Carcinoid heart disease , Drug-induced.
    4
    Gambaran Anatomis
     Rheumatic
    Commissural fusion
    Leaflet thickening
    Chordal shortening and fusion
    Superimposed calcification.

     Degenerative
    Annular calcification.
    Rarely leaflet thickening & calcification at base.

     Congenital
    Subvalvular apparatus abnormalities.

     Systemic lupus , Carcinoid & Drug induced

    Leaflet thickening & restriction are common here.


    Commissures are rarely fused.
    2D ECHO
    • Normal: AML & PML membuka
    dengan maximal excursion pada
    leaflet tips.

    • Pada rheumatic MS: doming


    motion of AML with restriction of
    motion at tips – Hockey Stick
    appearance.

    • Merubah mitral apparatus dari


    tubular channel menjadi corong
    (funnel-shaped orifice).
    2D ECHO
     Commissural fusion
    Assessed in PSAX view
    Rheumatic etiology
    Complete fusion - severe MS.

     Leaflet thickening
    Asssessed in PLAX

     Chordal thickening & fusion in


    PLAX , Apical 4 Chamber views
    M mode of mitral leaflets
    M Mode ECHO

    • Peningkatan echogenitas leaflets.

    • Decreased excursion & reduced


    separation of AML dan PML.

    • Reduced diastolic E-F slope of mitral


    closure
    Normal EF slope is > 60mm/sec
    If < 10 mm/sec indicate severe MS
    Assessment of Mitral Stenosis Severity
    Level 1 Recommendations: (metode yang direkomendasikan pada
    semua pasien stenosis)
    Pressure gradient.
    MVA Planimetry.
    Pressure half-time.

    Level 2 Recommendations: (metode yang dipakai apabila dibutuhkan


    informasi tambahan)
    Continuity equation.
    Proximal isovelocity surface area (PISA).
    Stress echocardiography.

    EAE/ASE RECOMMENDATIONS
    Pressure gradient
    • Diastolic pressure gradient dihitung berdasarkan persamaan
    Bernoulli : ∆P = 4V2

    • Berkorelasi baik dengan pengukuran invasif (transseptal


    catheterization)

    • Gradient diukur pada apical window.

    • Continuous wave doppler lebih disukai

    • Color doppler digunakan untuk mengidentifikasi eccentric mitral


    jets.
    Pressure gradient

    • Dihitung maximal & mean gradient.

    • Mean gradient is relevant hemodynamic finding.

    • Maximal gradient didapat dari peak mitral velocity, yang


    dipengaruhi oleh left atrial compliance & fungsi diastolik LV.

    • In AF: diambil rata-rata dari 5 pengukuran.

    • Dicatat HR saat pengambilan gradients.


    PRESSURE GRADIENT

    18
    MVA by Planimetry
    • Reference measurement of MVA.
    • Dilakukan dengan cara tracing langsung orificium mitral dengan
    memasukkan commisura yang terbuka pada PSAX view saat mid-
    diastole
    • Cross section area (CSA) diukur pada leaflet tips.
    MVA by Planimetry

    • Gain setting diatur sehingga cukup jelas terlihat kontur dari


    orifisium mitral
    • Excessive gain setting dapat menyebabkan underestimation area
    katup.

    • 3D echo imaging dapat meningkatan akurasi planimetri


    Both commissures are fused Unicommissural opening

    Bicommissural opening
    Advantages of planimetry

     Merupakan pengukuran langsung MVA.


     Tidak tergantung pada kondisi flow maupun compliance dari ruang
    jantung.

    Disadvantage

     Tidak akurat pada poor


    acoustic window dan
    kalsifikasi katup yang berat
    Pressure half-time (PHT) or T1/2
    • PHT adalah interval waktu (msec) antara saat gradient mitral
    maksimum pada early diastole dengan saat dimana gradient tinggal
    setengahnya.
    • MVA didapatkan dengan rumus: MVA = 220/PHT
    • PHT didapatkan dengan melakukan tracing pada deceleration slope
    E-wave pada spectral

    display doppler transmitral

    flow.
    Measuring T1/2 with a bimodal slope of E-
    wave

    Deceleration slope in mid-diastole rather than early to be traced


    MS with AF pts

    Tracing should avoid mitral flow from short diastoles and


    average of different cardiac cycles to be taken
    27
    Continuity equation
    • Continuity equation is based on the conservation of mass.
    • Filling volume of diastolic mitral flow is equal to aortic SV.

    • MVA = π D2 X VTI aortic


    4 VTI mitral
    D - diameter of the LVOT (cm)
    VTI – Velocity Time Integral (cm)

    • SV can also be estimated from


    the pulmonary artery.
    Disadvantages

     Memerlukan multiple measurements dan and meningkatkan


    kemungkinan untuk terjadinya error.

     Tidak bisa dipakai pada AF atau significant MR or AR.


    Mitral leaflet separation (MLS) index

    • Distance b/w tips of mitral leaflets in PLAX & four-chamber view in


    diastole.
    • Value < 0.8 cm predict severe mitral stenosis.
    • Value > 1.1 to 1.2 cm indicate mild MS.
    MITRAL STENOSIS SEVERITY

    31
    32
    Assessment of mitral valve anatomy by
    Wilkins score
    • Important for choice of intervention.

    • Parameters assessed are valve mobility , thickening , calcification ,


    subvalvular pathology.

    • Each parameter given score 1 to 4.

    • Total score is sum of four individual scores.

    • Score ≤ 8 are excellent candidates for BMV.

    • Score ≥ 12 are less likely to have satisfactory result.


    Wilkins score

    Wilkins et al. Br Heart J 1988;60:299-308


    Secondary features of MS

    • Menyebabkan peningkatan LA pressure.

    • LA and LA appendage akan mengalami dilatasi.

    • Meningkatkan risiko pembentukan trombus thrombus akibat stasi


    darah.

    • Dilated RA ,RV and paradoxical septal motion dapat terjadi akibat


    pulmonary hypertension.
    LA clot & spontaneous echo contrast
    THANK YOU

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