ADULT ECHOCARDIOGRAPHY Lesson Seven The Mitral Valve Harry H. Holdorf PhD, MPA, RDMS, RVT, LRT, N.P.

Mitral Stenosis Etiology Rheumatic (commissarial fusion – most common) Congenital (rare-Parachute) Acquired (mitral annular calcification (MAC) Prosthetic valve dysfunction

Parachute Mitral Valve (single papillary muscle)

The insertion of mitral chordae tendineae into a single papillary muscle is: Parachute mitral valve Pathophysiology Diffuse leaflet thickening, scarring, contraction, commissural fusion and chordae shortening and fusion Associated mitral regurgitation may be present Increased left atrial pressure causes LA dilatation

Long-standing obstruction leads to pulmonary hypertension (RV & RA enlargement) Decrease in cardiac output Acute rheumatic fever: beta-hemolytic strep, Polyarthritis, fever, subcutaneous nodules, carditis, and a rash (45% develop MS) Increased risk for endocarditis

Physical Signs (MS) Diastolic murmur (rumble with opening snap Atrial fibrillation is common CHF symptoms (dyspnea, fatigue, orthopnea, peripheral edema Hemoptysis (bloody sputum)

ECHO Thickened MV leaflets with decreased mobility Tethered MV leaflet tips (“hockey-stick” presentation) Left atrial enlargement Signs of pulmonary hypertension in advanced cases Planimeter valve area in parasternal SAX view RV and RA enlargement

NOTES: Longstanding MS does NOT lead to: Left ventricular dilatation MS murmur = low frequency “Diastolic rumble” with an opening SNAP!! Know “hockey-stick” presentation (goes with rheumatic MS) Patients with mitral stenosis often develop atrial fibrillation Which cardiac valve is the second most common to be affected by rheumatic heart disease? Aortic

MS patients become very symptomatic with A-fib. Might lose 50% of diastolic filling since they are very dependent on atrial contraction. AHA/ACC Guidelines for Mitral Stenosis severity: MVA (cm sq.) Mild >1.5 Moderate1.0 – 1.5 Severe <1.0 Supportive findings Pulm. Artery pressure (mmHg) Mild < 30 Moderate 30 - 50 Severe > 50

Mitral Stenosis 2D Severe doming

Doppler Increased velocity and turbulence across the mitral valve Use pressure half-time for valve area Mitral regurgitation may be present Measure mean trans-valvular gradient Mitral valve area Normal 4-5 cm sq. Mild >1.5 cm sq. Mod 1.5 – I cm sq. Sev <1 cm sq. NOTE: with atrial fibrillation, mitral stenosis velocity calculations are best performed: averaged over 5-10 beats

Mitral pressure half-time Mitral valve area: To calculate mitral valve area: MVA (cm sq.) = 220/pressure half time 220 is the empirical number Given a mitral pressure half-time of 400 msec, what would the area be? 220/400 = .5

Next: The Tricuspid Valve End of Lesson Seven Next: The Tricuspid Valve