ECHO- Mitral Stenosis

Question 1

T/F: patient with MS often asymptomatic until they develop AFib

Answer 1

TRUE

Question 2

T/F: patient with MS symptoms exacerbated during pregnancy

Answer 2

True

Question 3

Natural progression of Mitral Stenosis

Answer 3

it will took 10-15 years from onset of RF to symptoms (Class I-II)

Question 4

Physical examination for MS

Answer 4

notable is Mitral Facies-> Malar Flush

Question 5

Cardiac PE for MS

Answer 5

Opening Snap better heard with diaphragm
Loud S1
holodiastolic rumble/murmur using the bell of steth

Question 6

in MS, what is the relationship between S2 and Opening snap?

Answer 6

the shorter S2 to OS, the more severe the MS

Question 7

Echo Criteria for severe MS

Answer 7

Valve hemodynamics:
MVA ≤1.5cm2
Diastolic PHT ≥150ms

Hemodynamic Consequences:
- severely Dilated LA ( >48ml/m2)
- PASP > 50mmHg

**C- asymptomatic
**D - symptomatic

Question 8

in MS, why gradient is not included in the echo criteria/qualifier of severity?

Answer 8

gradient is highly dependent on HR.

in the report, include HR in the report.

***severe MS mean G of >10mmHg

Question 9

ECHO findings in MS, PLAX view

Answer 9

Hockey-stick appearance
doming of the AML

Question 10

considered as the reference in measuring MVA

Answer 10

MVA planimetry

**measure in mid-diastole
include open commissures

Question 11

Formula for MVA via PHT

Answer 11

MVA= 220/PHT

***PHT= Deceleration time x 0.29

Question 12

T/F: Doppler angle on incidence does not influence MVA by PHT

Answer 12

TRUE

but mean gradient will be affected.

see pic for example

Question 13

see pic for the Q

Answer 13

A is the correct slope

Question 14

PITFALLS in MVA by PHT method

Answer 14

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

Question 15

What is Mitral Annulus Calcification?

Answer 15

• chronic, degenerative process in the fibrous BASE of the mitral valve

Question 15

formula for MVA by Continuity equation

Answer 15

MVA = SV/mitral VTI

Question 16

in MAC, what is the prefered method to measure MVA?

Answer 16

• 2D or 3D planimetry

***do not use PHT

Question 17

Echo view to assess MAC?

Answer 17

PSAX view

but for anterior and posterior Annulus, you have to change the angle.

Question 17

what is the recommendation for exercise testing in MS?

Answer 17

Class I indication. if there is discrepancy between resting echo and clinical symptoms, exercise testing with doppler is recommended.

Question 18

Indication for exercise testing for MS with >1.5cm2 MVA?

Answer 18

for progressive MS (MVA >1.5cm2) but with exertional symptoms. see pic

Question 18

Indication for exercise testing for MS with ≤1.5cm2 MVA?

Answer 18

for asymptomatic MS with PASP of <50mmHg.

to evaluate the PASP

Question 19

Acceptable Wilkins score for mitral valve balloon annuloplasty

Answer 19

<8

Question 19

Components of Wilkins Score

Answer 19

• Mobility
• Subvalvular Thickening
• Thickening
• Calcification

Question 20

aside from Wilkins score, what else should you check for a favorable outcome with PTMC?

Answer 20

Commissural calcification

Question 21

Recommendation for Degenerative MS?

Answer 21

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.

Question 21

What are the contraindications for PMC in Rheumatic MS?

Answer 21

- 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

Question 21

Percutaneous Mitral Commissurotomy vs Surgery in severe MS? (ESC)

Answer 21

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.

Question 22

Class IIa recommendations for PMC?

Answer 22

- 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.

Question 23

rheumatic vs MAC-related MS. difference in terms of Anatomy, Epidemiology, Assessment and Treatment.

Answer 23

see pic

Question 24

follow up echo for Severe asymptomatic MS and moderate MS

Answer 24

asymptomatic severe MS - yearly moderate MS - every 2-3 years