ECHO- Mitral Stenosis Flashcards
T/F: patient with MS often asymptomatic until they develop AFib
TRUE
T/F: patient with MS symptoms exacerbated during pregnancy
True
Natural progression of Mitral Stenosis
it will took 10-15 years from onset of RF to symptoms (Class I-II)
Physical examination for MS
notable is Mitral Facies-> Malar Flush
Cardiac PE for MS
Opening Snap better heard with diaphragm
Loud S1
holodiastolic rumble/murmur using the bell of steth
in MS, what is the relationship between S2 and Opening snap?
the shorter S2 to OS, the more severe the MS
Echo Criteria for severe MS
Valve hemodynamics:
MVA ≤1.5cm2
Diastolic PHT ≥150ms
Hemodynamic Consequences:
- severely Dilated LA ( >48ml/m2)
- PASP > 50mmHg
**C- asymptomatic
**D - symptomatic
in MS, why gradient is not included in the echo criteria/qualifier of severity?
gradient is highly dependent on HR.
in the report, include HR in the report.
***severe MS mean G of >10mmHg
ECHO findings in MS, PLAX view
Hockey-stick appearance
doming of the AML
considered as the reference in measuring MVA
MVA planimetry
**measure in mid-diastole
include open commissures
Formula for MVA via PHT
MVA= 220/PHT
***PHT= Deceleration time x 0.29
T/F: Doppler angle on incidence does not influence MVA by PHT
TRUE
but mean gradient will be affected.
see pic for example
see pic for the Q
A is the correct slope
PITFALLS in MVA by PHT method
due to possible errors with change in LV and LA compliance
Do not use PHT in calcific mitral stenosis (MAC), AR, marked tachycardia, very high LA pressure, etc
What is Mitral Annulus Calcification?
- chronic, degenerative process in the fibrous BASE of the mitral valve
formula for MVA by Continuity equation
MVA = SV/mitral VTI
in MAC, what is the prefered method to measure MVA?
- 2D or 3D planimetry
***do not use PHT
Echo view to assess MAC?
PSAX view
but for anterior and posterior Annulus, you have to change the angle.
what is the recommendation for exercise testing in MS?
Class I indication. if there is discrepancy between resting echo and clinical symptoms, exercise testing with doppler is recommended.
Indication for exercise testing for MS with >1.5cm2 MVA?
for progressive MS (MVA >1.5cm2) but with exertional symptoms. see pic
Indication for exercise testing for MS with ≤1.5cm2 MVA?
for asymptomatic MS with PASP of <50mmHg.
to evaluate the PASP
Acceptable Wilkins score for mitral valve balloon annuloplasty
<8
Components of Wilkins Score
- Mobility
- Subvalvular Thickening
- Thickening
- Calcification
aside from Wilkins score, what else should you check for a favorable outcome with PTMC?
Commissural calcification
Recommendation for Degenerative MS?
Class IIb only
- for symptomatic severe MS attributable to extensive mitral annular calcification, valve intervention may be considered only after discussion of the high procedural risk.
What are the contraindications for PMC in Rheumatic MS?
- MVA >1.5cm2
- LA thrombus
- more than mild MR
- Severe or bi-commisural calcification
- absence of commissural fusion
- severe concomitant AV disease or severe combined tricuspid stenosis and regurgitation requiring surgery
- Concomitant CAD requiring Surgery
Percutaneous Mitral Commissurotomy vs Surgery in severe MS? (ESC)
aHigh thromboembolic risk: history of systemic embolism, dense spontaneous contrast in the LA, new-onset AF. High-risk of haemodynamic decompensation: systolic pulmonary pressure >50 mmHg at rest, need for major NCS, desire for pregnancy.
bSurgical commissurotomy may be considered by experienced surgical teams in patients with contraindications to PMC.
cSee recommendations on indications for PMC and mitral valve surgery in clinically significant mitral stenosis in section 7.2.
dSurgery if symptoms occur for a low level ofexercise and operative risk is low.
Class IIa recommendations for PMC?
- PMC should be considered as initial treatment in symptomatic patients with suboptimal anatomy but no unfavorable clinical characteristics
- PMC should be considered in asymptomatic patients without unfavorable clinical characteristics and anatomical characteristics for PMC and
1. high thromboembolic risk - Hx of systemic embolism, dense spontaneous echo contrast in the LA, new-onset or paroxysmal Afib), and/or
2. High risk hemodynamic decompensation - PASP >50mmHg, need for major NCS, desire for pregnancy
**Unfavourable characteristics for PMC can be defined by the presence of several of the following characteristics.
Clinical characteristics:
- old age,
-history of commissurotomy,
-New York Heart Association class IV,
-permanent AF,
-severe pulmonary hypertension.
Anatomical characteristics:
- echocardiographic score >8,
- Cormier score 3 (calcification of mitral valve of any extent as assessed by fluoro- scopy),
- very small MVA,
- severe tricuspid regurgitation.
rheumatic vs MAC-related MS.
difference in terms of Anatomy, Epidemiology, Assessment and Treatment.
see pic
follow up echo for Severe asymptomatic MS and moderate MS
asymptomatic severe MS - yearly
moderate MS - every 2-3 years
