ECHO 2013 / Mitral Stenosis Quantitation It’s Not All About the Gradient
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PISA for MVA in Mitral Stenosis
Technically challenging and not recommended for routine use
•PISA for MVA in mitral stenosis is valid in multiple clinical settings including the presence
of AR and MR
Bennis, A et al. Int J Cardiovasc Imaging 18: 443–451, 2002.
Additional Information:Vena
Contracta
•Vena contracta in the 4Ch view of < 1.0 cm
sensitivity of 88% and a specificity of 77% for severe MS (compared to planimetry, PHT, and CE).
Park T-H et al. Heart Vessels (2006) 21:273– Vena Contracta = 0.97 cm
Right Ventricular Systolic Pressure
•Tricuspid Regurgitation
RVSP = [(VelocityTR)2 x 4] + RA pressure
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TR Vel = 4.1m/s |
TR = 2.4 m/s |
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Gradient = 68 mmHg |
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On-Axis
Imaging is
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Parasternal Inflow vs Apical 4Ch Views |
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Measure PEAK, well-defined spectral border |
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TR = 3.1 m/s |
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SPAP should be reported in all patients
Normal TR Velocity ≤ 2.8-2.9 m/s
Rudski LG et al, J Am Soc Echocardiogr 2010;23:685-713
Pulmonary Artery Diastolic Pressure
•Pulmonic Regurgitation
PADP = [(VelocityPRend)2 x 4] + RAP
Mean PAP = [(VelocityPRpeak)2 x 4] + RAP
Masuyama T et al. Circulation 1986;74:484-492
Pulmonary Vascular Resistance
• Resistance Pressure/Flow
Mean PA Pressure – PCWP
PVR |
Cardiac Output |
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Tricuspid Regurgitant Velocity |
PVR |
RVOT VTI |
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PVR = 10 (TRV/RVOT VTI) + 0.16
Ratio > 0.175 is consistent with a PVR > 2 WU
Recommendation: The estimation of PVR is not adequately
• Sn 77%, Sp 81%
established to be recommended for routine use but may be
Ratio > 0.2 is consistent with a PVR > 2 WU
considered in subjects in whom pulmonary systolic pressure may
• Sn 70%, Sp 94%
be exaggerated by high stroke volume or misleadingly low (despite increased PVR) by reduced stroke volume.
Rudski LG et al, J Am Soc EchocardiogrAbbas AE2010;23:685et al JACC-7132003;41:1021-7
Case: Low Stroke Volume
•PA pressures
Peak systolic = 44 mmHg
Mean PAP = 30 mmHg
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Tricuspid Regurgitant Velocity |
PVR |
RVOT VTI |
PVR = 10 (TRVel/RVOTVTI) + 0.16
•PVR
TRVel:RVOTVTI = 0.24
Estimate = 2.6 WU
Mitral Valve Score
Echo Score Index for Mitral Stenosis
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Grade |
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Mobility |
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Subvalvular |
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Leaflet Thickening |
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Calcification |
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thickening |
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1 |
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Highly mobile |
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Minimal thickening |
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Leaflets near normal |
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A single area of |
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valve with only |
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just below the mitral |
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in thickness (4 – 5 |
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echo brightness |
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leaflet tips |
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leaflets |
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mm) |
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restricted |
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2 |
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Leaflet mid and |
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Thickening of |
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Mid-leaflets normal, |
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Scattered areas of |
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base portions have |
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chordal structures |
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considerable |
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brightness |
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normal mobility |
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extending up to 1/3 |
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thickening of margins |
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confined to leaflet |
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of the chordal length |
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(5 – 8 mm) |
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margins |
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3 |
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Valve continues to |
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Thickening |
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Thickening |
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Brightness |
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move forward in |
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extending to the |
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extending the entire |
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extending into the |
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diastole, mainly |
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distal 1/3 of the |
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length of the leaflet |
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midportion of the |
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from the base |
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chords |
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(5-8mm)t |
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leaflets |
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4 |
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No or minimal |
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Extensive thickening |
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Considerable |
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Extensive |
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forward movement |
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and shortening of all |
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thickening of al |
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brightness |
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of the leaflets in |
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chordal structures |
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leaflet tissue (> 8 – |
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throughout much |
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diastole |
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extending down the |
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10mm) |
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of the leaflet tissue |
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papillary muscles |
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Abascal VM et al, JACC 1988;12:606-615
Echocardiographic Score: Mitral Valve
Regurgitation
Grade |
Subvalvular thickening |
Leaflet Thickening (score |
Calcification |
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each leaflet separately) |
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1 |
Minimal thickening just |
Leaflets near normal in |
Fibrosis and/or calcium in |
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below the mitral leaflets |
thickness (4 – 5 mm) |
only one commissure |
2 |
Thickening of chordal |
Leaflet fibrotic and/or |
Both commissures mildly |
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structures extending up |
calcified evenly; no thin |
affected |
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to 1/3 of the chordal |
areas |
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length |
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3
Thickening extending to the distal 1/3 of the chords
Leaflets fibrotic and/or |
Calcium in both |
calcified with uneven |
commissures, one |
districution; thinner |
markedly affected |
segments are mildly |
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thickened (5-8 mm) |
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4 |
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Calcium in both |
Extensive thickening |
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commissures, both |
and shortening of all |
Leaflets fibrotic and/or |
markedly affected |
chordal structures |
calcified with uneven |
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extending down the |
distribution; thinner |
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papillary muscles |
segments are near normal |
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(4-5 mm) |
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Padia et al, JACC, 1996
What would you recommend?
A.Surgery (STS score ~8)
B.Balloon Mitral Valvuloplasty
C.Medical therapy since this is mild MS
D.Stress Echo to further assess severity of valvular disease