MITRAL STENOSIS

Nick Tehrani, MD
Epidemiology of MS

Hx of Rheumatic fever is elicited in only 50% of
path proven cases

Other causes
Severe MAC
Congenital MS

Clinical Diagnosis of Rheumatic Fever

Diagnosis of acute rheumatic fever
Two major Jones criteria, OR
One major criterion, and two minor criteria

Major Minor
Carditis Fever
Erythema marginatum PR prolongation
Chorea ESR elevation
Subcutaneous nodules Hx of Rheumatic fever


Clinical Diagnosis of Acute Rheumatic
Fever

Additionally, serologic evidence of recent
streptococcal infection is needed:

Positive bacteriologic culture
Increase in ASO titers
Increase in anti-DNAse B titers
Histopathology
The acute valvular pathology caused by Rheumatic fever is:

Mitral Regurgitation

Over the next several decades stenosis accrues by:
Thickening of the leaflets
Fusion of the commisures
Fusion or shortening of the chordae


Definitions of severity of Mitral
Stenosis
Valve Area:
<1.0 cm2 Severe
1.0-1.5 cm2 Moderate
>1.5-2.5 cm2 Mild

Mean gradient:
>10 mmHg Severe
5-10 mmHg Moderate
<5 mmHg Mild


Flow Across a Normal Mitral Valve in
Diastole

Flow Across the Stenotic Valve
Persistent LA-LV gradient
in diastole sustained
flow throughout diastole

The slope of the envelope
is proportional to the
severity of stenosis
Flow Across the Stenotic Valve
Note the A in patient
who is in sinus
Diastolic Transmitral Pressure
Gradient due to Limited LV Filling
Pathophysiology
Limited flow into the LV has 3 major sequale:
Elevation of Lt. Atrial pressure
Secondary RV pressure overload
Reduced LV ejection performance
Due to diminished preload
Tachycardic response to compensate to
decreased SV worsens the transmitral
gradient
Determinants of Transmitral Pressure
Gradient
Increased
Flow, OR
Decreased
orifice size

Incr. Gradient.

Elevated LA
pressure
HR=72
HR=100
Variability
The three inter-related parameters are:

HR

CO

Trans-mitral gradient

Mitral valve area


Heart rate variability
CO measurement and reproducibility
Problems are
Introduced by:
Different ways of Measuring Mitral
Valve Area
Echocardiographic:
PISA
2-D
Pressure half-time
Cath:
Gorlins Equation
Pressure half time
The Gorlin Equation
Torricellis Law:



( )( ) gh 2 Cv V=
( )
( ) Cc x V
Flow
Area =
Cc =Coefficient of
Orifice contraction


Cv=Coefficient of
Velocity
The Second Equation:


The Gorlin Equation
Substituting for V, in Torricellis Eq.





h x 980 x 2 x Cc x Cv
Flow
Area =
h 44.3 x C
Flow
Area =
Simplification of the above:

C 44.3
?
The Numerator of the Equation
Flow Across any Valve:



For Mitral (and Tricuspid) valve:

(HR) DFP) or (SEP
CO
Flow =
HR x DFP
CO
Flow =
h 44.3 x C
Flow
Area =
The Gorlin Equation
Substituting for Flow and h in the first Eq.:
h C x 44.3
Flow
Area =
HR x DFP
CO
Flow =
P h A =
Gorlins Formula for Mitral Area
The Gorlin Formula for Mitral Valve area:
(
(
(
(

A
=
P C x 44.3
HR x DFP
CO
Area Valve
Gorlins Formula for Mitral Area
CO Cardiac output
DFP Diastolic Filling Period
HR Heart Rate
44.3 Derived Constant
C Correction factor for valve type
C=1.0 for all valves except Mitral
C=0.85 for Mitral valve
P Mean pressure gradient
How Do you use this Eqn.?
Step 1: Figure out the Numerator First:



Dimensional analysis:
HR x DFP
CO
Flow =
) (beats/min x (sec/beat)
cc/min
cc/sec =
(
(
(
(

A
=
P C x 44.3
HR x DFP
CO
Area Valve
Figure out the DFP
DFP in Sec/beat
Measure the Distance in mm from MV opening to MV
closing in one beat
Convert distance to time




100 speed= 100 mm/sec, makes life easy
50 speed= 50 mm/sec, tough life

( )
|
.
|

\
|
mm/Sec in speed Paper
1
beat / mm in DFP
(
(
(
(

A
=
P C x 44.3
HR x DFP
CO
Area Valve
Figure out the Heart Rate
Assuming Patient is in Sinus
Measure the RR interval
in mm
Convert to Beats/min
by





In 100 speed just divide
6,000 by the RR in mm

( )( )
Beats/min in HR
mm/beat RR
mm/Sec in Speed Paper Sec/min 60
=
(
(
(
(

A
=
P C x 44.3
HR x DFP
CO
Area Valve
Lets Figure out the Denominator
(
(
(
(

A
=
P C x 44.3
HR x DFP
CO
Area Valve
No Mitral Stenosis
Diastolic Transmitral Pressure
Gradient due to Limited LV Filling
Left Atrial
Tracing
Need to Left Shift the PCWP Tracing
V
A
C
DFP
Planimeter
Shifted Over
Instrumentation

The trickiest part is to set up the instrument
correctly:


The reading must be adjusted to
0.0000
From Planimetered Area to Mean
Pressure Gradient
Area as provided by the instrument is in (in)x(in)
Must convert to (cm)x(cm)
Multiply by 6.45 cm2/In2
To obtain mean Area under the curve
Divide the Area by the DFP in cm
To convert cm of pressure to mm of Hg
Multiply the above # in cm, by the scale factor
Get Scale factor from the tracing: mm Hg/cm

How many tracings to Planimeter

If patient is in sinus => 5 tracings

If patient is in A-Fib.=> 10 tracings
Putting things in Perspective
(
(
(
(

A
=
P C x 44.3
HR x DFP
CO
Area Valve
CC/Sec
mm Hg
cm2
CC/sec.cm2.(mm Hg)P0.5
Potential Pitfalls
Wedge vs. LA Pressure
Stiff End-hole catheter: Cournand
Verify true wedge by checking O2 Sat
Mean Wedge should be less than Mean PA
Cardiac Output
True Fick vs. Thermodilution vs. Green dye
Concurrent MR with MS:
Gradient across the valve reflects forward and
regurgitant flow
CO reflects the net forward flow only
Likely underestimation of the true valve area

Mitral Stenosis and the LA
Even in sinus rhythm, the low velocity flow
predisposes to formation of atrial thrombi.
Low flow pattern is seen as spontaneous contrast on
echocardiography
17% of patients undergoing surgery for MS have
LA thrombus
In one third of cases thrombus restricted to the
LAA
Pulmonary Hypertension
Normal pressure drop across pulmonary bed:
10-15 mm Hg

Expected mean PA in Mitral Stenosis:
Mean LA (elevated of course) + (10-15 mm Hg)

In MS, Mean PA pressure often exceed the
expected.

Pulmonary Hypertension
This pulmonary hypertension has two components:

Reactive pulmonary arterial vasoconstriction,

Potentially Fixed resistance, secondary to
morphologic changes in the pulmonary
vasculature

How Do you use this Eqn.?
Step 1: Figure out the Numerator First:



Dimensional analysis:
HR x DFP
CO
Flow =
) (beats/min x (sec/beat)
cc/min
cc/sec =
(
(
(
(

A
=
P C x 44.3
HR x DFP
CO
Area Valve
Figure out the DFP
DFP in Sec/beat
Measure the Distance in mm from MV opening to MV
closing in one beat
Convert distance to time




100 speed= 100 mm/sec, makes life easy
50 speed= 50 mm/sec, tough life

( )
|
.
|

\
|
mm/Sec in speed Paper
1
beat / mm in DFP
(
(
(
(

A
=
P C x 44.3
HR x DFP
CO
Area Valve
Figure out the Heart Rate
Assuming Patient is in Sinus
Measure the RR interval
in mm
Convert to Beats/min
by





In 100 speed just divide
60,000 by the RR in mm

( )( )
Beats/min in HR
mm/beat RR
mm/Sec in Speed Paper Sec/min 60
=
(
(
(
(

A
=
P C x 44.3
HR x DFP
CO
Area Valve
V
A
C
DFP
Planimeter
From Planimetered Area to Mean
Pressure Gradient
Area as provided by the instrument is in (in)x(in)
Must convert to (cm)x(cm)
Multiply by 6.45 cm2/In2
To obtain mean Area under the curve
Divide the Area by the DFP in cm
To convert cm of pressure to mm of Hg
Multiply the above # in cm, by the scale factor
Get Scale factor from the tracing: mm Hg/cm