Mitral valve Stenosis *Read pages 1 – 9 in The Echocardiographer’s Pocket Reference; Read pages 259 – 262 and 277 – 286 in Otto; Read Pages 185 – 190 in Echo Review Guide *The mitral valve takes on a “hockey stick” appearance seen best in the PLAX and Apical 4 windows(important to know)!

Pictures of Mitral stenosis

*Definition: A narrowing of the mitral valve orifice, which impedes the diastolic flow into the LV from the LA Rheumatic fever is the most common cause at approximately 99% of all cases The principal, or most common, presenting symptom of mitral stenosis is Dyspnea upon exertion(approx. 80% include this symptom) Hemoptysis(coughing up of blood or blood in sputum) is the 2nd most common symptom(approx. 30% include this symptom) Chest pain is another symptom, but occurs at much lower rate of approx. 15% Other findings include: palpitations, orthopnea(difficulty breathing while lying Flat), Paroxsymal nocturnal dyspnea(attacks of severe shortness of breath and coughing that occurs at night), fatigue, syncope and right heart failure.

A closer look at the most common causes of mitral stenosis…………… Dyspnea upon exertion is caused by the blood not being able to leave the LA. This causes the blood to back up or not be able to enter the LA as easy. Which in turn, causes the lungs to work harder to get rid of the oxygenated blood. Ex. Trying to put more water in an already full water balloon Hemoptysis is a result of the blood not having anywhere to go, so the body will get rid of it the easiest way it can, which is through the lungs.

*Upon physical examination the patient will have: A low normal BP, caused by all the pressure backing up into the lungs Irregular pulse, caused by afib (a heart in afib doesn’t beat efficiently . Patient can experience palpitations, which are sensations of a racing Irregular HR. Patient can also experience weakness, lightheadedness, CP or confusion. Apical diastolic thrill, which is a vibration felt at the apical window.

*Complications that occur from mitral stenosis: Mitral Regurgitation that occurs with mitral stenosis, which is Simply caused by the MV not closing properly due to the Valve being calcified. Passive/reactive pulmonary hypertension (Passive PHTN is caused By post-pulmonary capillary elevation associated with PCWP or Pulmonary Capillary Wedge Pressures, this is measured by Introducing a catheter into the distal Pulmonary Artery and a Balloon is inflated. While the balloon is inflating, the pressure Is measured, which is very close to the pressure of the LA. Reactive PHTN is initially passive but the upstream vasculature responds to chronic passive congestion by developing an Active superimposed-on-passive component Left atrial thrombus, which is more of a direct result from afib. These are mostly found in the LAA or Left Atrial Appendage. Embolization occurs approx. 20% of the time in patients without afib and 80% of the time in patients with afib.

*Cardiac Auscultation: Opening snap is a very important physical sign Low pitched diastolic rumble, which is the murmur you would hear!

*Treatment for mitral stenosis: Prophylactic antibiotic therapy(until age 40) Anticoagulation and Diuretics Mitral valve replacement

Mmode findings: Normal MV mmode Mitral stenosis mmode Thickened MV leaflets Decreased E-F slope Anterior motion of the posterior MV leaflet

2D findings Thickened MV leaflets Hockey stick appearance(see arrow), which is diastolic “doming” of the anterior MV leaflet Commissural fusion, which means that the MV leafleats are fused together Left atrial dilatation Spontaneous echo contrast(you can see the blood flowing in the LA, which is also called “smoke”(seen in second picture)

PW and CW Doppler Turbulent flow Increased MV E velocity Decreased E-F slope of the MV inflow *The more severe the mitral stenosis, the less steep the E-F slope

Color flow doppler Narrow “flame –shaped” jet May form a PISA done on the atrial side of the MV

Mitral stenosis severity scale Pressure ½ time Normal 30 to 60 msec Abnormal 90 to 400 msec Gray Area 60 to 90 msec Mild 90 to 150 msec Moderate 150 to 219 msec Severe > 219 msec Mitral valve area( 220/ P ½ time) Normal 4 to 6 cm squared Mild 1.5 to 2.5 cm squared Moderate 1.0 to 1.5 cm squared Severe < 1.0 cm squared Mean pressure gradient Mild < 6 mmHg Moderate 6 to 12 mmHg Severe > 12 mmHg