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

2. 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.

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

4. 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

5. 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.

6. 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.

7. 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.

8. 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

9. 2-D 소견 (Parasternal short axis view)정상 MS
5) “Fish-mouth” orifice in short-axis view

10. 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
cm2
cm2
cm2
1.0 cm2 이하
PHT (msec)
40-70
90-150
 220
평균압력차
< 5 mmHg
6-12 mmHg
> 12 mmHg

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

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

13. ) ( r SV = MV area = SV ÷ MIF TVI Continuity equation π × LVOT TVI2 ×
SV =
MIF TVI
MV area =　SV ÷　MIF TVI
Continuity equation
MV area X MV flow = LVOT area X LVOT flow

15. 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

16. 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:

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

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

19. 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

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

21. PBMV - hemodynamic impact

22. Severe Complication of PMBV

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

24. Immediate Results of PMBV

25. Late Result of PMBV
Circulation. 1999;99:

26. Late Results after PMBVn
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

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

28. Circulation 1999;99:

29. Decrease in MVA after PMBV
Circulation. 1999;99:

30. 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

31. 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