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Mitral stenosis: Quantification and treatment
Παρασκευή Κουτρολού-Σωτηροπούλου MD, FACC
Καρδιολόγος, 3η Καρδιολογική Κλινική, Νοσοκομείο Υγεία
•No disclosures
Etiology of Mitral Stenosis
✓Rheumatic heart disease (RHD)
✓Mitral annular calcification
✓Radiation heart disease
✓Congenital heart disease
✓Other rare conditions: Fabry disease, carcinoid valve disease, endomyocardial fibrosis, Systemic inflammatory disease (e.g., systemic lupus erythematosus & rheumatoid arthritis),drug-induced
✓RHD is the result of an exaggerated immune response to specific bacterial epitopes in a susceptible host
Inflammatory process initiated by cross-reactivity between streptococcal antigen & valve tissue; no active infection of valve leaflets
Mitral Stenosis
Rheumatic mitral stenosis
✓Leaflet thickening starts at the tip
✓Commissural fusion
✓Short posterior leaflet
✓Calcification starts late
✓Chordae: thick/ retracted
Mitral Stenosis
Degenerative mitral stenosis
✓Leaflet thickening starts at the base
✓Calcification
✓Associated with HTN and AS
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary Nishimura, Circulation 2014
Baumgartner et al. Eur J Echocardiography 2009
Mitral Stenosis
✓Anatomy first…..
✓And then… Quantification
2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Mitral Valve Area
✓Planimetry
✓Continuity equation
✓Pressure half-time
✓PISA
25 year old Female with rheumatic mitral
stenosis
MVA
Continuity Equation for MVA
x
0.7cm²
Problems with
Continuity:
✓ Additional
source of errors
(LVOT)
✓ Unreliable
✓ MR / AR
✓ Atrial fibrillation
PHT method in patients with rheumatic mitral
stenosis
PHT= The time required for the velocity to drop to ½ the peak pressure
✓ PHT only applies to
rheumatic mitral
stenosis
✓ Diastolic pressure half-time ≥150 msec>>> severe MS
✓ Diastolic pressure half-time ≥220 msec>>>very severe MS
Pressure Half Time Method
Affected by:
✓AR (short PHT)
✓Sudden changes in LV-LA compliance (immediately after BMVP)
✓Diastolic dysfunction (increased LV filling pressure) : avoid in degenerative MS
Mitral Stenosis in calcific MS
✓ MVA planimetry if
possible
✓ Assess gradient
but dot rely on it
✓ Stress test
Severe Mitral Annular Calcification. Multimodality Imaging for Therapeutic Strategies and InterventionsMackram F. Eleid, Thomas A. Foley, Sameh M. Said, Sorin V. Pislaru and Charanjit S. Rihal. JACC 2016
✓Exercise hemodynamic bike
Increase in mean gradient of >15mmHg or PASP>60mmHg
Lancellotti et al. JASE 2017
Increased filling pressures
✓ In patients presenting with dyspnea, with both significant MS and hypertension, increased left ventricular (LV) filling pressure due to hypertension could influence assessment of the severity of MS.
✓Severity of MS could be underestimated because the increased diastolic pressure reduces the mitral valve gradient, and the increased LV stiffness shortens pressure half-time (PHT)
✓ Cardiac catheterization can be useful to determine whether pulmonary hypertension is secondary to the mitral stenosis or left ventricular diastolic dysfunction
Hemodynamics in the Cardiac Catheterization Laboratory of the 21st Century Rick A. Nishimura, MD; Blase A. Carabello, MD. Circulation 2012
Management of Mitral Stenosis✓ Anticoagulation (warfarin preferred)
Atrial fibrillation
Prior embolic event
Left atrial thrombus
LA enlargement & spontaneous echo contrast predictors of thromboembolism
Risks and benefits of anticoagulation in patients in sinus rhythm with these findings uncertain
✓ Diuretic therapy (usually a loop diuretic)
✓ Dietary salt restriction
✓ Beta blockers
✓ Digoxin in selected patients
Commissural calcification
✓ Absence of MR
AND
✓ LA thrombus
Feasibility of percutaneous mitral commissurotomy
Valve Guidelines 2017
2014 AHA/ACC Valvular Heart Disease Guideline: Executive Summary
62 year old Female with history of rheumatic MS
PHT: 202
MVA by PHT:1
Mean gradient:
10mmHg 72bpm
PASP: 83mmHg
Wilkins score: >8
Echo guidance during PMBV
Before valvuloplasty
After Valvuloplasty
Surgery for MS
✓In patients with suboptimal valve anatomy for PMBV
✓LA thrombus that persists despite anticoagulation
✓If significant mitral regurgitation is present
✓In patients with significant tricuspid regurgitation who have better outcomes with surgery that includes a tricuspid valve repair
Calcific Mitral StenosisMitral Annular Calcification (MAC)
✓Reduced normal annular dilatation during diastole
✓Impaired anterior mitral leaflet mobility
✓ Calcium extension more than half-way onto 1 or both leaflets
✓Posterior mitral leaflet usually involved
✓Reduced maximal leaflet opening angle in both the anterior and posterior segments
✓Older age, female sex, diabetes mellitus, presence of coronary artery calcification, hypertension, smoking, and high CRP, chronic kidney disease and increased body mass index have been shown to be independent predictors of MAC
Degenerative Mitral Stenosis Unmet Need for Percutaneous Interventions Circulation 2016
✓Debridement of the calcified tissue is risky because it may result in separation of the atrium and ventricle or damage the circumflex coronary artery✓Usually high risk patients
Current and evolving strategies in the management of severe mitral annular calcification. J Thorac Cardiovasc Surg 2019
An alternate approach to valve replacement in patients with mitral stenosis and severely calcified
annulus. Sameh M. Said, MD, and Hartzell V. Schaff, MD, Rochester, Minnesota
Russell, Guerrero et al JACC 2018
Guerrero et al JACC 2016
✓ 94% had MS
✓ 8% female
✓ 53% CKD
✓ Technical success 77%
✓ 14.7% needed a second THV
✓ 11.2% (13 patients) LVOT obstruction
after
✓ 30 day all cause mortality 25%
✓ 1 year all cause mortality 53,7%
✓ LVOT obstruction was the most
important and independent predictor
of 30 day and 1 year mortality
✓ Need of patient selection
Three-dimensional prototyping for procedural simulation of transcatheter mitral valve replacement in patients with mitral annular
calcification. Sabbagh et al. Catheter Cardiovasc Interv. 2018
Τhank you!