Echocardiographic Evaluation of Mitral Stenosis

Enrique TueroOctubre 7, 2016 Albert Starr

Sociedad de Cardiologia Rosarioviernes 7 de octubre 2016

Ausencia de interes financieroni asociacion o afiliacion conorganización/es que se puedapercibir como conflicto de interes

Redefinicion de historia natural / riesgo quirurgico

Avances en el diagnostico no invasivo

Avances en las tecnicas percutaneas

Realizacion de trabajos multicentricos

Logros valvulopatias

Mitral Stenosis

Etiologies• Rheumatic - almost all adults cases (RHD> 15million worldwide)

-60% of pts don’t have a history of ARF-50% of pts who have ARF don’t develop VHD

Very Severe Mitral Annular Ca++- (uncommon- CRF- hyperparathyroid,elderly)Congenital – rare parachute , Shone complexCor triatiatum sinister, mixoma,vegetation,thrombusProsthetic valve disfunction – 2 to Mitra Clip / surgery

Valvulopatias alta prevalenciaFR etio principal

Ecocardiografia

3 %

0      5       10       15       20       25       30       35       40

1

2

3

4

Time

Survival

Natural theoretic evolution of a valvular lesion

Mitral stenosisNatural history

100

80

60

40

20

05        10      15      20

Years

Survival %

1

2

34

Carabello1990

Natural historyLonger evolution

Mitral stenosisGeneral considerations & treatment

Diagnostic & severityEcodopplerScorePulmonary hypertension

ExerciseNon invasive

Percutaneous valvuloplastyEarlier indicationETE

ATG - EI

SurgicalReparativeProsthesisMaze surgeryLAA exclusion

Percutaneous MV replacementExperimental valveNon aproved FDA valve

Mitral stenosisMechanical correction

PMV‐ CHS‐ OHS‐ Prosthesis

Mobility

Commisuralfussion

Calcification

Subvalvularinvolment

Less symt. More symt.

Acute Subacute Chronic

Onset of overload

Acute heart failureSevere & sudden onsetRisk of death from shockProbable survival w/ correction overloadPossible survival w.o/correction (operational adaptative mech.)

Response to overload

Chronic adaptationSlow & progressiveEventual descompensation w/ or w.o irreversible structural  and functional changes despite correction of hemodynamic overload

Prosthetic valve thrombosis 

Clinical examples

Valvular rupture

Valvular rupture (IE)

Valvular calcification, rapid

CHD

RHD

Mitral Stenosis

LA Pr increases as C.O. increases:

2x Flow = 4x Pr Gradient

d/t  impeded LA to LV flow*

Mitral Stenosis

Mitral Stenosis- generally asymptomatic if MVA > 1.5cm2

Often present – pregnancy, hyperthyroid, infection

***

Physical Exam of Mitral Stenosis• Loud S1• Opening Snap• Diastolic Apical Rumble (murmur)• May be associated with:

• MR or AS• Right Sided Murmurs- PI – Graham Steel Murmur , or TR

EM – Criterios modo M

Engrosamiento y Ca valvasValva posterior inmovil /movimiento anterior

Disminucion / perdida onda ADisminucion pendiente EF

EM – Criterios modo bidimensional

Engrosamiento y Ca valvasLimitacion movimiento valvular

Palo de hockeyFusion comisural

Boca pescadoCompromiso aparato subvalv.

EM – Criterios modo bidimensional

Engrosamiento y Ca valvasLimitacion movimiento valvular

Palo de hockeyFusion comisural

Boca pescadoCompromiso aparato subvalv.

MV – VIEW FROM LA (Aorta at 11 o’clock) MV- VIEW FROM LV (Aorta at 7 o’clock)

RHEUMATIC MITRAL  STENOSIS

EM – Criterios modo dopplerFlujo turbulento mitral

Aumento velocidadesAliasingPISA

Gradiente mitral holodiastolico

Echo-Doppler Assessment of MS Severity

• MV area by planimetry*- 2D or 3D• Diastolic MV Pressure ½ time*• Continuity equation• PISA• Mean Gradient*• PA pressure

*Most common

Most accurate method is Direct LA & LV pressure measurement but

Echo- Doppler BETTER than PCWP- LV pressure gradient d/t delay in PCWP

MVA by Planimetry- best correlation with MVA on explanted hearts

• 2D-Parasternal short axis -Measure at tip of leaflets when maximal leaflet excursion seen

• Trace inner edge in mid-diastole• Avoid high gain settings-may lead to underestimation of MVA

Consideraciones en planimetria

3D‐TEE multiplane method for MVA

Advantage: precise definition of orifice area during diastole

Disadvantage: lowertemporal resolution- lower frame rate-TTE 2D less invasive

MVA by 2D & 3D 2D Planimetry2D planimetry tends measure slightly larger areas than 3D

• Pressure half time (PHT, T1/2) is defined as the time needed for the peak transvalvular pressure gradient to fall to its half value, in milliseconds (ms) – use CW Doppler.

• According to the Bernoulli equation, when pressure is halved, velocity is equal to peak transvalvular velocity divided by the square root of 2.

• The faster the gradient falls, the easier the passage of blood through a valve, and vice versa.

• PHT is always proportionally related to deceleration time (DT): PHT = 0.29 x DT• PHT is simple way to assess MVA. Duration of decline of diastolic transmitral blood

flow velocity is inversely proportional to mitral valve area (MVA), and MVA is derived using an empirical formula

Limitations• A. Fib → trace long diastoles & multiple cardiac cycles • If pts have abnormal LA or LV compliance

Presence of: • Aortic regurgitation • ASD• POST MV valvuloplasty - MAC

DO NOT SOLEY RELY ON PHT

PHT in Mitral Stenosis

HOW  was the MVA calculated?a)‐ P1/2 ?b) How did get MVA of 1.17cm2

HOW  was the MVA calculated?

a)P1/2‐ Time for MV pressure gradient to fall to its half valueb)  MVA of 1.17cm2?‐

Pressure ½ Time

With a bimodal deceleration slope:

- Which slope do you use?

diferente PHT y area FA

diferentes THP pendiente

MS Severity- mean mitral gradient• CW Doppler has good correlation transeptal LA- LV gradient• Peak early gradient strongly influenced by LA compliance & LV

diastolic function

• MEAN MV GRADIENT IS MAJOR DETERMINANT OF MITRAL STENOSIS SEVERITY

• But highly flow and heart rate dependent• What are implications of this fact?

Doppler LA - LV gradient is superior to PCW – LV gradient for assessment of MS

Mitral valve mean gradient correlates wellWith invasive measures of LA-LV gradient

Valoracion severidad EM X PISA

PISA‐ flow convergence

What does PISA stand for ?

•PISA is technically demanding for MS•Can be accurate if correctly done•3D PISA methods in development -promising

MVA by continuity ecuation

Assume diastolic MV flow = aortic stroke volume = Pulm.SV

MVA = pi ( D2/4 ) ( VTI aorta cm ) / ( VTI mitral cm )D= LVOT diameter

Limited accuracy and reproducibility due to # of measurements

If > mild MR or AR not valid

AHA/ACC Echocardiographic Guideline for Severity of Mitral Stenosis

• Mean MV Pgr (mmHg) <5 5-10 >10

• PASP (mmHg) <30 30-50 >50

• MVA (cm2) >1.5 1.5-1.0 <1.0

Progresive Severe VSevere

3.7m/s = 55mmHgMVA<1.0 cm2Mean Pgr = 13mmHgM-modePASP= RVSP + RAP

Mitral stenosisMechanical correction

PMV‐ CHS‐ OHS‐ Prosthesis

Mobility

Commisuralfussion

Calcification

Subvalvularinvolment

Less symt. More symt.

ValvulopatiaEtiologiareumatica2 valvulas

lesion predominanteEMSeveridad

RepercusionDilatacion AI y ADDilatacion VDMov. Anormal septum IA/IVHTP

ComplicacionEI2 valvulasperforacion y fistula

Pronostico

Wilkins’ ScoreSimilar by TTE & TEE

Each of 4 factors*

Graded 0-4Maximum score =16

↑ Score =↓ likelihoodfor lasting result

*

*

*

*

Commisural Ca++ More predictive than complex scoring systems

Cannan JACC 1997

- Not only survival, also MVR, repeat PBMV

Ca anular CT gruesas retraidas

1

2

Cateterismo en estenosis mitral

Patron oro

Se utiliza

para realizar VMP

discordancia clinico ecocardiografica

Mujer 35 aAntc FRDisnea IIEM severa ecoScore valvular 8

Hombre 67 aAntc confusos de FRIRC HTADisnea IIIEco Calcificacion severamitral

PSAP 70 mmmHgPresion wedge 28 mmHg

Gradiente mitral 6 mmHg

Conducta

1- Administrar liquidos2- Ejercicio3- Modificar FC4- Repetir mediciones SG5- Cateterismo

Cateterismo

Cateter en AI y VI , medidas simultaneas AI-VI

PSAP 75 mmHGP Ai 30 mmHg

PDVI 25 mmHg

P Ao 220/140 mmHG

Con cateterismo se midenpresiones absolutas

≥3 scoring systems - Wilkins most commonFor PMBV – need commissural fusion

Other important factors:Leaflet mobility & thickeningInvolvement of sub-mitral apparatusSeverity of calcificationPre-procedure MRLA or LAA thrombus

MS- suitability for PMBV

TEE for PBMV- LA Thrombus

• LAA thrombus “contraindication” for PBMV (AHA/ACC) If + postpone procedure - Rx Warfarin→ INR 3.0 until resolved on TEEIf not resolved many recommend surgery

• Several cases of uneventful PBMV reported in patients with LAA thrombus

Park - JASE 2000, Nobuyoshi - Circ 1989, Thomas Br Heart J 1992, Ritoo – Am Heart J 1993

LA thrombus – Sens / Spec 81 / 99 %

LAA thrombus – Sens / Spec 98 / 98 % (surgery – gold STD)