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

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

3. Parachute Mitral Valve (single papillary muscle)

4. 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

5. 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

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

7. 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

8. 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

11. 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
Severe > 50

12. Mitral Stenosis 2D Severe doming

13. 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

14. 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

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