Mitral Stenosis Division of Cardiology, Department of Internal Medicine, College of Medicine, Kyung Hee University R4 Jong Shin Woo

승모판협착증 (mitral stenosis) Mitral Valve 승모판은 2개의 소엽으로 구성되어 있으며, 정상 판구면적은 4-6 cm2 입니다. 판구면적이 1 cm2 미만일 때 severe mitral stenosis라고 정의하고 있습니다. http://home.cc.umanitoba.ca/~soninr/Mitral.html

Etiology Rheumatic fever Congenital Carcinoid SLE Rheumatoid arthritis Lt. Atrial mass (tumor / thrombus) Extensive mitral annulus calcification

Pathophysiology Impaired blood flow through mitral valve Elevated LA pressure Passively elevated pulmonary venous pressure Pulmonary HTN Right ventricular hypertrophy & dilatation Tricuspid regurgitation (mostly functional) Right heart failure

This is a diagrammatic representation of the circulation in patients with normal hemodynamics (top), tight mitral stenosis (center), and tight mitral stenosis with pulmonary vascular disease, and the development of a second stenosis at the pulmonary arteriolar level (below). Reproduced with permission from Baim DS, Grossman W, eds. Grossman’s Cardiac Catheterization, Angiography, and Intervention. 6th ed. Lippincott Williams & Wilkins, 2000:761.

The cross-sectional area of the orifice of the normal open mitral valve varies between 3-5 cm2, depending on the size of the subject. As shown by simultaneous LV and LA pressures, as recorded by high fidelity catheter-tipped micromanometers, there is no significant gradient during diastolic flow across the normal mitral valve. Right Panel: Sutten G, Anderson RH, et al. Slide atlas of cardiology. London: Medi-Cine Ltd., c1978:Slide 2. Copyright© American College of Cardiology.

With chronic rheumatic mitral valve disease, there is progressive narrowing of the mitral orifice due to fibrosis, calcification, and scarring. As the orifice becomes less than 2.5 cm2, a pressure gradient develops between the LA and LV, with elevation of the LA pressure. In this patient with severe mitral stenosis and a mitral valve area of less than 1 cm2, the mean LA pressure is approximately 25 mm Hg. Right Panel: Sutten G, Anderson RH, et al. Slide atlas of cardiology. London: Medi-Cine Ltd., c1978:Slide 3. Copyright© American College of Cardiology.

2-D echo findings of MS 1) Thickened and calcified mitral leaflets 2) Restricted opening of mitral leaflets 3) Immobility of the posterior mitral leaflets 4) Thickening, shortening and fusion of chordae tendinae

2-D 소견 (Parasternal short axis view) 정상 MS 5) “Fish-mouth” orifice in short-axis view

승 모 판 협 착 증 의 중 증 도 협 착 정 상 경 도 (mild) 중등도 (moderate) 중 증 (severe) 협 착 정 상 경 도 (mild) 중등도 (moderate) 중 증 (severe) 판 구면적 4.0 - 6.0 cm2 1.6 - 2.5 cm2 1.0 - 1.5 cm2 1.0 cm2 이하 PHT (msec) 40-70 90-150 150-210  220 평균압력차 < 5 mmHg 6-12 mmHg > 12 mmHg

Planimetry Ao LV LA Parasternal long axis view Parasternal short axis view

PHT method LA LV RV RA Peak V Peak V의１/√ 2 PHT MVA(cm2) = 220 / PHT

) ( r SV = MV area = SV ÷ MIF TVI Continuity equation π × LVOT TVI 2 × SV = MIF TVI MV area =　SV ÷　MIF TVI Continuity equation MV area X MV flow = LVOT area X LVOT flow

Wilkin score 1 2 3 4 Mobility Highly Mobile Immobile valve Thickening Near normal Severe thickening Calcification No bright echoes Extensive brightness Subvalvular thickening Severe thickening & shortening Minimal

Cormier score Echocardiographic Group Mitral Valve Anatomy Group 1 Pliable noncalcified anterior mitral leaflet and mild subvalvular disease (ie, thin chordae ≥ 10 mm long) Group 2 Pliable noncalcified anterior mitral leaflet and severe subvalvular disease (ie, thickened chordae <10 mm long) Group 3 Calcification of mitral valve of any extent, as assessed by fluoroscopy, whatever the state of the subvalvular apparatus Circulation. 1996;94:2124-2130

LONG-TERM FOLLOW-UP AND PREDICTORS OF RESTENOSIS AND EVENT-FREE SURVIVAL Catheterization and Cardiovascular Interventions 69:313–321 (2007)

Assessment of Consequences 좌심방 확대 (LA dilatation) 좌심방 내 혈전 (LA thrombus) 폐고혈압소견 (pulmonary hypertension) 우심방, 우심실 확장 승모판 역류 평가 삼첨판 역류 평가

Percutaneous Mitral Balloon Valvuloplasty AHA Indication Moderate or severe mitral stenosis and favorable valve morphology Symptomatic NYHA function class II, III, IV Pulmonary hypertension New onset of atrial fibrillation

Mechanism of PMBV by Echo Commissural Fusion at Leaflet Edges Fused Commissures Split by BMV

PBMV - hemodynamic impact

Severe Complication of PMBV

Mechanism of Severe MR by PMV Commissural Fusion With Marked Thickening Severe MR Due to Anterior Leaflet Tear

Immediate Results of PMBV

Late Result of PMBV Circulation. 1999;99:3272-3278

Late Results after PMBV n Age (years) Follow-up (years) Event-free survival (%) Cohen et al 146 59 5 51 Dean et al 736 54 4 60 Orrange et al 132 44 7 65 Meneveau et al 532 7.5 52 Stefanadis et al 441 9 75 Hernandez et al 561 53 69 Iung et al 1024 49 10 56 Ben Farhat et al 654 34 72 Palacio et al 879 55 12 33 Fawzy et al 493 31 13 74

Event-free survival according to echocardiographic score Circulation. 2002;105:1465-1471

Circulation 1999;99:3272-3278

Decrease in MVA after PMBV Circulation. 1999;99:1580-1586

Contraindications to PMBV Persistent left atrial thrombosis (including in the left atrial appendage) More than mild mitral regurgitation Massive or bicommisurral calcification Severe concomitant aortic valve disease Severe organic tricuspid stenosis or severe functional regurgitation with enlarged annulus Severe concomitant coronary artery disease requiring bypass surgury

Summary Planimetry using 2D echo is the reference measurement for valve area The use of cardiac catheterization to evaluate mitral valve area should be limited to the situations in which noninvasive measurements are inconsistent or discordant with clinical findings Patient selection should not overstress the assessment of valve anatomy but take into account a number of clinical and echocardiographic variables, the predictive value of which has been validated in large series Severe MR is the most frequent complication of BMV. It remains difficult to predict in a given patient The most frequent cause of late functional deterioration after BMV is mitral restenosis, which occurrence follows an approximately linear pattern