MITRAL STENOSIS

Clinical Manifestation &

Echocardiography Assessment

dr. Muhammad Insani Ilman

DR. dr. Yudi Her Octaviono, SpJP (K)

CONGENITAL CLUB
OUTLINE
• ETIOLOGY
• PATHOPHYSIOLOGY
• CLINICAL MANIFESTATION
• ECHOCARDIOGRAPHY ASSESSMENT
– M-MODE
– 2D STUDY
– 2D COLOR DOPPLER
– SEVERITY GRADING
– MS ANATOMY SCORING
 ETIOLOGY
• Rheumatic Fever → Rheumatic Heart Disease

• Mitral Annular Calcification

• Congenital: parachute mitral valve, supravalvar mitral ring)

• LA Outflow Obstruction (LAOTO) : LA myxoma, ball-valve thrombus, SBE + Veg

PATHOLOGY
PATHOLOGY
PATHOLOGY
 PATHO- Obstruction to blood flow

PHISIOLO Impedance of
across the MV
Impaired

GY LA emptying LV filling

LA pressure ↑ Relative stagnation

of blood flow in LA
Retrograde transmission Chronic LA
of Hydrostatic Press. Press. Thrombus
Overload formation
Pulmonary venous & Pulmonary arterial press. ↑
capillary press. ↑ (Pulmonary HT) LA dilatation Risk of thrombo-
Disruption of emboly ↑
Transudation Pulmonary- Passive Reactive
Bronchial conducting
of plasma system Peripheral artery
into lung vein collateral RV pressure ↑ embolic occlusion
interstitial & channels
AF (e.g embolic stroke)
alveoli opening Chronic RV Press. Overload
Bronchial vein
RV hypertrophy & dilatation
rupture shortened diastole
Congestive SV ↓ → CO ↓
RV Heart Failure (shorten LV filling time)
Heart Failure hemoptysis
CLINICAL MANIFESTATION
1. SYMPTOMS
• Clinical presentation of MS ≈ reduction of the valve Area
(The more severe the stenosis, the greater the symptoms)
• Earliest manifestations: dyspnea and reduced exercise capacity.
• Condition/activities with ↑ heart rate and ↑ cardiac blood flow → symptoms of MS ↑ : fever,
anemia, hyperthyroidism, pregnancy, rapid arrhythmias (e.g. AF), emotional stress, and sexual
intercourse.
• Advanced MS and pulmonary hypertension → signs of right-sided heart failure: including
jugular venous distention, hepatomegaly, ascites, and peripheral edema
• Symptoms related to MS complications: AF, thromboembolism, infective endocarditis,
hemoptysis
• Symptoms related to LA enlargement: Ortner syndrome, Dysphagia megalantriensis
CLINICAL MANIFESTATION (Physical
Exam.)
Inspection
• Short of breath
• Jugular vein dilatation
• Mitral facies
Palpation
• Irregular pulse
• right ventricular “tap” on chest palpation
Auscultation
• Loud S1 (early stages)
• Opening snap (OS) : The interval between S2 and the OS relates inversely to the severity o MS
• Murmur: mid diastolic, low- frequency, decrescendo (diastolic rumble) →
‾ The duration, but NOT the intensity, of the murmur relates to the severity of MS
‾ presystolic accentuation (sinus rhythm)
‾ other valve lesions are often found concurrently in patients with MS
CLINICAL MANIFESTATION
3. ECG
• LAE (if sinus rhythm)
• RVH (in severe cases)
• AF
CLINICAL MANIFESTATION
• Left atrial enlargement (mitral configuration):
– Convenxity or straightening of LAA
– Double density sign
– Elevation of left main brochus & splaying of carina
– Lateral view: walking man sign
• Pulmonary congestion
– Upper lobe pulmonary venous diversion = cephalization (Stag’s Antler Sign)
– Intertitial edema: Peribronchial cuffing (doughnut sign, tram tracts sign), Septal (Kerley) lines
– Alveolar edema: air space oppasification (batwing distribution), air bronchogram
– Pleural effusion
• Right Ventricular hypertrophy
 Pulmonary Edema grading system
based on CXR

Grading CXR appearances Estimated PCWP

Grade 0 Normal CXR 8-12 mmHg
Grade 1 Evidence of upper lobe diversion 13- 18 mmHg
Grade 2 Interstitial Edema 19-25 mmHg
Grade 3 Alveolar Edema >25 mmHg

– Brant WE, Helms CA. Fundamentals diagnostic radiology. Lippincott Williams& Wilkins (200&)
– Weissleder R. Wittenberg J, Harisinghani MG, et al. Primer of diagnostic imaging. Mosby Inc (2007)
Lateral CXR
RVH
ECHOCARDIOGRAPHY
ASSESSMENT
The Purpose of an Echocardiography Examination:

1. To identify the disease and the etiology

2. To assess the disease severity
3. To provide information in deciding the
therapeutic options
 M-MODE
• AML and PML move together anteriorly
(rather than opposite from each other)
• Decreased EF Slope (ski slope)
• Increased LA size
• Thickened MV
TWO DIMENSIONAL STUDY
• Thickened Mitral Valve:
• Increased LA size
• Possible LA Thrombus
• Increase in RA and RV size
Rheumatic origin MS
• Diastolic doming of AML
• Fixed PML
• thickening at tips and chordal level
(hockey stick appearance)
• commissural fusion,
fish mouth appearance
MAC
• Mitral Annular Calcification → typical
calcification at the annulus
• Relatively mobile leaflets’ tips
• May developed into Caseous MAC
(CMAC) → liquefication necrosis. May
be mistaken for intracardiac tumor
Congenital MS
2D COLOR DOPPLER
• Acceleration through the valve

• Candle flame appearance

Methods of Grading Severity
Valve Area:
• Planimetry
• Presure Half Time (routine usage)
• Continuity Equation
• PISA

Supporting Evidence:
• Mean gradient (routine usage)
• RVSP or PAPs
Mitral Stenosis Planimetry
Quantitave Assessment
• measure slope
• Mitral valve area by Pressure
Half Time

MVA = 220
P½t
 Quantitave Assessment
• measure VTI → Preasure Gradient
• MVA can be measured by continuity
equation
VTI 1 . A 1 = VTA 2 . A 2
→ VTI (MV). MVA = VTI (LVOT) . ½ π 2 LVOT Diam
→ MVA = (VTI (LVOT) . ½ π 2 LVOT Diam)/ VTI (MV)
RVSP Estimation

TR Max PG + RAP = RVSP

Mild MS <30 mmHg

Moderate MS 30-50 mmHg
Severe MS >50 mmHg
 SEVERITY
Mild Moderate Severe
Specific finding
Valve Area (cm2) >1.5 1.0-1.5 <1.0
Supportive finding
Mean Gradient (mmHg) <5 5-10 >10
PASP/RVSP (mmHg) <30 30-50 >50

*At heart rates between 60 and 80 bpm and in sinus rhythm.

Baumgartner, et al. Echocardiographic Assessment Of Valve Stenosis,.

European Journal of Echocardiography, 2009
Mitral Valve Anatomy Assessment

Baumgartner, et al. Echocardiographic Assessment Of Valve Stenosis,.

European Journal of Echocardiography, 2009
Mitral Valve Anatomy Assessment

Baumgartner H, Falk V, Jeroen J. Bax et al . 2017 ESC/EACTS Guidelines for

the
Mitral Valve Anatomy Assessment

Baumgartner H, Falk V, Jeroen J. Bax et al . 2017 ESC/EACTS Guidelines for

the
Clinical Staging