I.

Assessment of MVA and severity of MS

 Assessment of MVA by planimetry :

In short axis plane of the mid papillary muscle level, going up towards the base of
the mitral annulus, in a parallel plane to the MV opening plane. Measurement by zoom
mode, lower gain to avoid underestimation, in mid-diastole tracing is made at the black–
white interface and at least three cardiac cycles in sinus rhythm m measure at least five
cardiac cycles in atrial fibrillation(20) (fig.1).

Fig1. Image acquisition and measurement of the MVA by planimetry with 2D TTE

 Assessment of trans-mitral diastolic pressure gradient:

At apical 4chamber (AP4CH) view Use color wave to identify highest flow

velocity zone then in eccentric jets Trace CW profile to obtain mean gradient. Maximum

pressure gradient (PPG) across the valve is related to the high velocity jet in the stenosis

through the simplified Bernoulli equation: PPG = 4 × V2. Mean pressure gradient (MPG)

is calculated by averaging the instantaneous gradients over the flow period Pressure

gradient depends on MVA, LV–LA compliance, heart rate and transvalvular flow. Re-

evaluation is mandatory after adequate heart rate control(20) (adjustment of beta blocker

treatment, optimal HR < 80 bpm) (Fig 2).

Fig. 2 Colour Doppler-guided detection. To avoid underestimation of PG (A) and
Measurement (B).

 Pressure half-time (PHT):

Its obtain in AP4CH Continuous wave Doppler of the mitral inflow pattern, with

the measurement of pressure half-time indicated by the line of the mitral E-wave

deceleration slope (fig3). Is the time interval (in milliseconds) between the maximal

trans-mitral PG and the time point at which this gradient attains the half of its maximal
 value. MVA to PHT is MVA

(cm2) = 220/PHT (ms)

PHT gives the functional

MV area ≠ MVA by

planimetry and it is validated

for native MV stenosis

only.

Fig.3: MVA assessment by PHT

II. Assesment of Systolic pulmonary artery pressure (SPAP):

In the AP4CH view the CW Doppler on Tricuspid valve and Measure max

velocity of TR jet, RVSP can be reliably determined from peak TR jet velocityusing the

simplified Bernoulli equation and combining this value with an estimate of the RA

pressure: RVSP = 4(V)2 + RA pressure, where V is the peak velocity (in meters per
second) of the tricuspid valve regurgitant jet and RA pressure is estimated from IVC

diameter and respiratory changes [29] (figure 4).

IVC diameter ≤2.1 cm that collapses >50% with a sniff suggests a normal RA

pressure of 3 mm Hg (range, 0-5 mm Hg), whereas an IVC diameter > 2.1 cm that

collapses <50% with a sniff suggests a high RA pressure of 15 mm Hg (range, 10-20 mm

Hg). In indeterminate cases in which the IVC diameter and collapse do not fit this

paradigm, an intermediate value of 8 mm Hg (range, 5-10 mm Hg) may be used (21)

(table.1).