Upload
amberly-riley
View
226
Download
5
Embed Size (px)
Citation preview
DR RAJESH K F
ECHOCARDIOGRAPHY IN MITRAL STENOSIS
CAUSES AND ANATOMIC PRESENTATION
Rheumatic Commissural fusionLeaflet thickening Chordal shortening and fusion Superimposed calcificationDegenerative MS Annular calcificationRarely leaflet thickening and calcification at
base
Congenital MS Subvalvular apparatus abnormalitiesInflammatory-SLEInfiltrative Carcinoid heart disease Drug induced valve diseaseLeaflet thickening and restriction Rarely commissural fusion
2D ECHO
Commissural fusion PSAX echo scanning of valve Important in distinguishing degenerative from rheumatic valve Complete fusion indicate severe MS Narrow diastolic opening of valve leaflets
Restricted mobility -PLAX
Early diastolic doming motion of the AML- restriction of tip motion
Leaflet thickening -PLAX
Chordal thickening, shortening and fusion –PLAX and A4C
Superimposed calcification
Dilated LALA and LA appendage
thrombusParadoxical septal
motionDilated RV and RA
Wilkins score -Mitral valve score <8 are excellent candidates for BMV
Limitations of wilkin score
Assessment of commissural involvement is not included
Limited in ability to differentiate nodular fibrosis from calcification.
Doesn’t account for uneven distribution of pathologic abnormalities.
Frequent underestimation of subvalvular disease.
Doesn’t use results from TEE or 3D echo
Cormier’s method
3D ECHO
TEE and TTEHigher accuracy than 2D echoDetailed information of commissural fusion
and subvalvular involvementMVA measurement in calcified and irregular
valveMVA measurement after BMVRestenosis after commissurotomy commissural refusion valve rigidity with persistent commissural opening
From LA From LV
RT3DE score of MS severity
Total RT3DE score ranging from 0 to 31 points
Total score of mild MV involvement was defined as <8 points
Moderate MV involvement 8–13Severe MV involvement >14
M MODE ECHO
Decreased E-F Slope>80 mm/s MVA=4-6cm² <15mm/s⇒ MVA <1.3cm²Thickened Mitral LeafletsAnterior Motion or
Immobility of Posterior Mitral Leaflet-tethering at tips
Diastolic Posterior Motion of Ventricular Septum (severity of stenosis)
TEE
For diagnosis and quantification little yield
Spontaneous echo contrast
LA and LA appendage thrombus
Use of transgastric plane 90 -1200 for evaluation of chordal structures
Assessment of commissural calcification and fusion to predict procedural outcome after BMV
Commissure score
NON CALCIFIED FUSION
ANTEROLATERAL COMMISSURE
POSTEROMEDIAL COMMISSURE
ABSENT 0 0
PARTIAL 1 1
EXTENSIVE 2 2
TOTAL SCORE O TO 4
Scores for anterolateral and posteromedial commissures were combined such that each valve had an overall commissure score ranging from 0–4
A high score indicated extensively fused, non‐calcified commissures that were therefore more likely to split
A low score indicated either minimal fusion or the presence of resistant commissural calcification
ASSESSMENT OF MS SEVERITY
2D OR 3D ECHOMVA BY PLANIMETRYDOPPLERPRESSURE GRADIENTSMVA BY PHTCONTINUITY EQATIONPISAMITRAL VALVE RESISTANCEPASP
MVA BY PLANIMETRY
2D EchoBest correlation with anatomical areaScanning method to avoid overestimationmeasured at leaflet tips in a plane
perpendicular to mitral orifice Elliptical in shapeDirect measure of mitral orifice including
opened commissures in PSAX
Excessive gain setting may underestimate valve area
Zoom mode is better for delineationHarmonic imaging can improve planimetry
measurementOptimal time is mid diastole obtained by cine
loop mode on a frozen imageMultiple measurements in AF or incomplete
commissural fusiondifficult in calcified valve,chest deformity and
previous commissurotomy
Real time 3D echocardiography
identify true smallest orifice independent of its orientation
most accurate ultrasound technique for measuring MVA, with a superior pre- and postprocedural agreement with the Gorlin’s derived MVA
Less experience dependent and more reproducible
Mitral leaflet separation (MLS) index
Distance between the tips of the mitral leaflets in parasternal long-axis and four-chamber views
it can be used as a semiquantitative method for the assessment of MS severity
A value of 1.2 cm or more provided a good specificity and PPV for the diagnosis of non severe MS
less than 0.8 cm -severe MS.It is not accurate in patients with heavy mitral
valvular calcification and post BMV
PRESSURE GRADIENT
Apical windowCWD /PWD at or after tip of mitral valveMaximal and mean gradient Bernoulli equation( P =4V2)Derived from transmitral velocity flow curve Heart rate to be mentionedCD to identify eccentric mitral jet
Maximal gradient influenced by LA compliance and LV diastolic function
In AF average of 5 cycles with least variation of R-R interval and as close possible to normal HR
MVG dependent on HR,COP and associated MR
Tachycardia, increased COP and associated MR overestimates gradient
Maximal gradient is markedly affected
PRESSURE HALF TIME
T1/2 is time interval in msecs between max mitral gradient in early diastole and time point where gradient is half max gradient
Or it is the time when velocity falls to 1/1.414 peak
PHT related to decceleration timePHT =.29x DT
MVA=220/PHT
The empirically determined constant of 220 is proportional to the product of net compliance of left atrium and LV, and the square root of maximum transmitral gradient in a model that does not take into account active relaxation of LV
Obtained by tracing deceleration slope of E wave on Doppler spectral display
Concave not feasibleIf slope is bimodal deceleration slope in mid
diastole rather than early diastole is traced
AF avoid short cycles and average different cardiac cycles
Less dependent on COP or coexistent MRUseful when mean transmitral gradient is
misleading MR -transmitral gradient overesimatedLow COP –mean transmitral gradient -
underestimated
MS MS+MR MR
Factors that may affect PHT by influencing LA pressure decline
More rapid LA pressure decline shorten PHTLA draining to second chamber –ASDLA pressure drop rapidlyPHT shortenedStiff LA –low LA complianceLA pressure drop rapidlyPHT shortened
Factors affect PHT by influencing LV pressure rise
More rapid LV pressure rise shorten PHTIf LV fills from a second source PHT –ARLV pressure rise more rapidlyPHT will be shortenedIf LV is stiff-low ventricular complianceLV pressure may rise more rapidlyPHT will be shortened
All factors affect PHT (ASD, AR, low LA or LV compliance )
shorten PHT Leads to overestimation of MVATherefore PHT never under estimate MVATherefore if PHT >220 MS is severeIf PHT is < 220 consider other methods to
assess severity
Prosthetic MVANot been validatedAffected mainly by DDMore accurate method is continuity equation
Not reliable
After BMVNormally LA and LV compliance counteract
each other when gradient and compliance are subject to
important and abrupt changes alter relation between PHT and MVA
Upto 48 hrs post BMV
CONTINUITY EQATION
LVOT AREA
MVA X VTI mitral= LVOT area X VTI aortic
MVA = LVOT area X VTI aortic VTI mitral
MVA= p D2 X VTI aortic 4 VTI mitralD is diameter of LVOT in CM and VTI in CMSV can be estimated from PAMethod not useful in AF,AR or MRUseful in degenerative calcific MS
PISA
Based on hemispherical shape of convergence of diastolic mitral flow on atrial side of mitral valve and flow acceleration blood towards mitral valve
MVA x MV = PISA x AV
MVA = PISA x AV
MV
PISA = 2pr2 x a 180MVA = 2pr2 x AV x a MV
180
Zoom on the flow convergenceUpshift the baseline velocity and use an
aliasing velocity of 20–30 cm/sMeasure the radius of the flow convergence
region and the transmitral velocity at the same time in early diastole
Measure the α angle formed by the mitral leaflets
Use of a fixed angle value of 100° can provide an accurate MVA estimation in patients with MS.
Can be used in presence of significant MR, AR, differing heart rhythms
Not affected by LA,LV complianceMultiple measurements requiredM mode improves accuracy
Colour M-mode PISA
Instantaneous measurement of MVA throughout diastole
Under guidance of magnified 2D colour imaging, colour M-mode tracings were recorded by placing the M-mode cursor line through the centre of the flow convergence.
Diastole was divided into four phases of equal duration: early, mid, mid-late, and late diastole.
Peak radius of flow convergence was measured during each phase to calculate mitral flow rate
Each radius was measured from the red–blue aliasing level to the tip of the leaflet at the orifice
Colour M-mode analysis was then paired with continuous wave Doppler
Three to five measurements of each variable (on matched cycle for colour M-mode and Doppler methods) were averaged, depending on the patient's rhythm.
MVA was then calculated separately for each phase of diastole
MITRAL VALVE RESISTANCE
MVR=Mean mitral gradient/ transmitral diastolic flow rate
Transmitral diastolic flow rate= SV/DFP
It correlate well with pulmonary artery pressure
PASP
CWDEstimation of the systolic gradient between
RV and RAMultiple acoustic windows to optimize
intercept angleEstimation of RAP according to IVC diameter
STRESS ECHOCARDIOGRAPHY
Useful to unmask symptoms in patients with MVA<1.5cm2 and no or doubtful complaints
Discrepancy between resting doppler and clinical findings
Semi-supine echocardiography exercise (30 to 60 secs of leg lifts) is now preferred to post exercise echocardiography
Allows monitoring gradient and pulmonary pressure in each step of increasing workload
Mean mitral gradient and PASP to be assessed during exercise
Mean gradient >15 mmhg with exercise is considered severe MS
A PASP > 60 mmHg on exercise has been proposed as an indication for BMV
Dobutamine stress echo mean gradient >18 mmhg with exercise is considered severe MS
Associated lesions
Quantitation of LAEAssociated MR and its mechanismSeverity AS (underestimated)AR- t1/2 method to assess MS is not validTR ,tricuspid annulusSecondary pulmonary HTN-TR
GRADING OF SEVERITY OF MS
MILD MODERATE SEVERE
SPECIFIC
VALVE AREA(cm2)
>1.5 1-1.5 <1
NONSPECIFIC
MEAN GRADIENT (mmHg)
<5 5-10 >10
PASP (mmHg)
<30 30-50 >50
THANK U
1 Pressure half time in MS affected by all exceptA ASDB MR C ARD HOCM
2 In case of a pure MS transmitral mean gradient is 14 mmhg and mitral area by planimetry is 1.1cm2 it is graded asA severeB moderateC mild D indeterminate
3 Commissural fusion is not a feature of MS inA RHDB Calcific MSC SLED Carcinoid disease
4 Not included in Wilkins score is A commissural fusionB restricted mobility C leafllet thickeningD subvalvular fusion
5 harmonic imaging useful inA 2D MVAB PHTC PISAD M mode
6 mitral leaflet separation index less than ----cms indicate severe MSA 0.4B 0.6C 0.8D 0.2
7 continuity equation useful in MVA calculation in A AFB ARC MRD Calcific MS
8 Mean gradient greater than ---- mmhg with exercise echocardiography is considered severe MSA 10B 12 C 15D 18
9 In a case of severe AR with MS mitralPHT obtained is 280 severity of MS isA mild B moderate C severe D none of the above
10 Method to assess severity of MS in diastolic dysfunction isA PHTB PISAC continuity equationD mitral valve resistance
1 Pressure half time in MS affected by all exceptA ASDB MR C ARD HOCM
2 In case of a pure MS transmitral mean gradient is 14 mmhg and mitral area by planimetry is 1.1cm2 it is graded asA severeB moderateC mild D indeterminate
3 Commissural fusion is not a feature of MS inA RHDB Calcific MSC SLED Carcinoid disease
4 Not included in Wilkins score is A commissural fusionB restricted mobility C leafllet thickeningD subvalvular fusion
5 harmonic imaging useful inA 2D MVAB PHTC PISAD M mode
6 mitral leaflet separation index less than ----cms indicate severe MSA 0.4B 0.6C 0.8D 0.2
7 continuity equation useful in MVA calculation in A AFB ARC MRD Calcific MS
8 Mean gradient greater than ---- mmhg with exercise echocardiography is considered severe MSA 10B 12 C 15D 18
9 In a case of severe AR with MS mitralPHT obtained is 280 severity of MS isA mild B moderate C severe D none of the above
10 Method to assess severity of MS in diastolic dysfunction isA PHTB PISAC continuity equationD mitral valve resistance
3D echo planimetry
Mitral valve area measurement using anyplane echocardiography.
allows on-line assessment of the mitral valve area.
Images are displayed as two simultaneous intersecting orthogonal long-axis scans (B-mode scans) and two perpendicular short-axis scans (C-mode scans)
These C-mode scans allow the display of short-axis views of the mitral valve from an apical transducer position
9 Usual mitral valve angle in PISA method to assess severity of MS is ----degreeA 80B 100 C 150D 180