15 year old boy Rahul came with symptoms

dyspnea ,migratory joint pains, fever. His

echocardiogram showed the following features,
What is your probable diagnosis ?
Echocardiographic evaluation of
mitral stenosis
Dr.Sruthi Meenaxshi MBBS,MD ,PDF
• Mitral stenosis (MS) is a mechanical
obstruction in blood flow from the left atrium
to the left ventricle.
• The normal area of the mitral valve orifice is
about 4–6 cm2 
• Impediment to the flow of blood into left
ventricle creating pressure gradient occurs
when the mitral valve area goes below 2 cm2
 Etiology
• Mitral stenosis consists of 12% of all valvular heart disease in Euro
Heart Survey.

• Rheumatic heart disease (90 %)

• Infective endocarditis, ball valve thrombosis , atrial myoxma
• Mitral annular calcification
• Congenital malformation ( parachute mitral valve)
• Systemic lupus erythematosis
• Carcinoid heart disease
• Endomyocardial fibrosis
• Radiation-associated valve disease, including MS, is increasingly
recognized as late manifestation in survivors of Hodgkin’s lymphoma 
• M-mode echocardiogram — The M-mode
examination is performed from the precordium
and guided from the 2D long and short axis views.
• Normally, the anterior mitral leaflet exhibits a
motion pattern that reflects the phasic nature of
ventricular filling and produces a familiar M-
shaped pattern
• The posterior leaflet moves in a nearly mirror
image "W" pattern with a smaller excursion
M mode mitral valve
 2D of mitral stenosis
• The following parameters need to be assessed
about the valve morphology:
• Thickening
• Mobility
• Subvalvular fusion
• Commissural fusion
• Calcification.
 Valvular thickening

• Normal mitral valve thickness is 2-4 mm

• Mitral leaflet thickness can be compared to
posterior aortic wall thickness, and the ratio gives
an objective assessment.
• Normally, the ratio of valve thickness/posterior
aortic wall thickness is < 1.4.
• 1.4 to2.0 mild Thickening
• 2 to 5 moderate thickening
• >5 severe thicknening
 Mobility of valve
• (PLAX) and apical four‑chamber views
• Assessed by reid index by a line drawn from
posterior aortic root wall to the anterior mitral
leaflet tip
• H/L ratio (ab/xy ratio)
• <0.25 mild
• 0.25-0.44 moderate
• >0.45 severe
Reid index
 Subvalvular apparatus
• Measuring chordal shortening
• Mild stenosis is if chordal length > 10 mm
• Severe disease chordal length < 10 mm
 Calcification
• Bright echogenicity of the leaflets –
calcification
• Commisural calcification is absolute
contraindication for BMV
• Two-dimensional echocardiogram — The 2D
appearance of the normal mitral valve on TTE
depends somewhat upon the imaging plane
from which it is viewed.
• In the parasternal short axis plane, the valve
presents itself as an ovoid (fish mouth) orifice
• parasternal long axis and apical views, it
resembles clapping hands

• anterior hand longer and more mobile than

the posterior
• mitral valve leaflets are thin and translucent;
the rough attachment points of its chordae to
their free margins are thicker than their
smooth bellies. The chordae from each leaflet
connect to both papillary muscles.
• the valve appears homogeneous and thin, <4
mm in thickness. 
 What happens in mitral stenosis ?
• Anatomically, the commissural separation
between the anterior and posterior or mural
leaflets is
• subvalvular apparatus is altered by chordal
foreshortening
• Immobility of the posterior leaflet is a
common early finding with a "hockey
stick/knee bend" appearance to the anterior
mitral leaflet due to leaflet tethering.

• Doming of the anterior leaflet corresponds

temporally to the opening snap on
auscultation.
 M Mode diagnosis for mitral stenosis
• early diastolic closure slope, the E-F slope,
produces an easily recognized pattern
•  severity of obstruction, a slope of less than 10
mm/sec (normal is >60 mm/sec) during suspended
respiration means severe mitral stenosis
• Reversal of diastolic motion from the normal
pattern makes the M-mode of the posterior leaflet
one of the most valuable means of identifying
mitral stenosis
 2 D evaluation of mitral stenosis
• dome or bulge into the ventricle throughout
diastole
• "knee bend" appearance on the precordial
long axis view 
Doming of AML
 2D Planimetry
• In the parasternal short axis plane, the opening
of the valve can be imaged just above the tips
of the papillary muscles.
• From this orientation, its maximum diastolic
opening area can be measured by direct
planimetry of the 2D image.
• A mitral valve area (MVA) of less than 1.5 cm2 is
considered severe, regardless of the method
used to calculate its size.
 Doppler methods
• Doppler methods can measure the velocity of mitral inflow.
• In mitral stenosis, this velocity increases at rest from a normal value of less
than 1 m/sec to greater than 1.5 m/sec.

• The algorithm to convert Doppler velocity into pressure gradient is the

modified Bernoulli equation.

 Peak gradient, in mmHg  =  4  x  peak velocity

• Thus, a peak velocity of 1 m/sec indicates a peak gradient of 4 mmHg; a

peak velocity of 2 m/sec indicates a peak gradient of 16 mmHg; 3 m/sec
indicates a peak gradient of 36 mmHg.[
• The mean transmitral gradient can be
measured by tracing the area-under-the-curve
of the mitral E and A waves obtained by
continuous wave Doppler.
• With severe mitral stenosis, the mean
transmitral gradient is >10 mmHg in sinus
rhythm at heart rates between 60 and 80 bpm
continous wave doppler in mitral valve tips ( apical 4 chamber view )
Calculate the pressure gradient
value > 10 is severe mitral stenosis
 Calculation of mitral valve area
• Pressure half time method
• convert Doppler velocity into a pressure
gradient, the initial flow velocity is divided by
1.41 (square root of 2), because velocity bears
a second order relationship to pressure.
Empirically, a pressure half-time of 220 msec is
equivalent to a valve area of 1.0 cm2; therefore:
•  MVA  =  220  ÷  pressure half-time
Severity grading of mitral stenosis
Indirect methods to identify severity of mitral
stenosis
• degree of foreshortening of the chordae
tendineae
• leaflet calcification
• left atrial enlargement
• right ventricular and atrial dilatation
• measuring degree of tricuspid regurgitation
and pulmonary hypertension, as determined
by Doppler of tricuspid regurgitant jet.
• 2014 AHA/ACC guideline for valvular heart
disease defined severe mitral stenosis as
• MVA ≤1.5 cm2 (MVA ≤1.0 cm2 with very severe
MS) and diastolic pressure half-time ≥150 ms
• diastolic pressure half-time ≥220 ms with very
severe MS, along with severe left atrial
enlargement and pulmonary artery systolic
pressure >30 mmHg 
Wilkins score
 Mitral stenosis
• Assess valve doming / restriction / calcification
• 2D planimetry – Mitral valve area
• Assess Pressure gradient and TR jet velocity
associated Pulmonary artery hypertension
• Coexisting MR /LA thrombus
• Left ventricular and Right ventricular function
Assessment of mitral stenosis
THANKYOU