Assessment of Primary Mitral Valve Disease: Clinical Presentation, Diagnosis, Medical and Surgical Therapy

Grade

Definition

Valve anatomy

Valve hemodynamics^a

Hemodynamic consequences

Symptoms

At risk of MR

• Mild mitral valve prolapse with normal coaptation

• Mild valve thickening and leaflet restriction

• No MR jet or small central jet area <20% LA on Doppler

• Small vena contracta <0.3 cm

• None

Progressive MR

• Severe mitral valve prolapse with normal coaptation

• Rheumatic valve changes with leaflet restriction and loss of central coaptation

• Prior IE

• Central jet MR 20–40% LA or late systolic eccentric jet MR

• Vena contracta <0.7 cm

• Regurgitant volume <60 mL

• Regurgitant fraction <50%

• ERO <0.40 cm²

• Angiographic grade 1–2+

• Mild LA enlargement

• No LV enlargement

• Normal pulmonary pressures

• None

Asymptomatic severe MR

• Severe mitral valve prolapse with normal coaptation

• Rheumatic valve changes with leaflet restriction and loss of central coaptation

• Prior IE

• Thickening of leaflets with radiation heart disease

• Central jet MR >40% LA or holosystolic eccentric jet MR

• Vena contracta ≥0.7 cm

• Regurgitant volume ≥60 mL

• Regurgitant fraction ≥50%

• ERO ≥0.40 cm²

• Angiographic grade 3–4+

• Moderate or severe LA enlargement

• LV enlargement

• Pulmonary hypertension may be present at rest or with exercise

• C1: LVEF >60% and LVESD <40 mm

• C2: LVEF ≤60% and LVESD ≥40 mm

• None

Symptomatic severe MR

• Same as stage C

• Moderate or severe LA enlargement

• LV enlargement

• Pulmonary hypertension present

• Decreased exercise tolerance

• Exertional dyspnea

Adapted from [5]

Abbreviations: ERO effective regurgitant orifice, IE infective endocarditis, LA left atrial, LV left ventricular, LVEF left ventricular ejection fraction, LVESD left ventricular end-systolic dimension, MR mitral regurgitation

^aSeveral valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence

Table 6.2

Stages of mitral stenosis

Grade	Definition	Valve anatomy	Valve hemodynamics	Hemodynamic consequences	Symptoms
A	At risk of MS	• Mitral valve doming during systole	• Normal transmitral flow velocity	• None	• None
B	Progressive MS	• Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets • Planimetered MVA >1.5 cm²	• Increased transmitral flow velocities • MVA >1.5 cm² • Diastolic pressure half-time <150 ms	• Mild-moderate LA enlargement • Normal pulmonary pressure at rest	• None
C	Asymptomatic severe MS	• Rheumatic valve changes with commissural fusion and diastolic doming of the mitral valve leaflets • Planimetered MVA ≤1.5 cm² • MVA ≤1.0 cm² with very severe MS	• MVA ≤1.5 cm² • MVA ≤1.0 cm² with very severe MS • Diastolic pressure half-time ≥150 ms • Diastolic pressure half-time ≥220 ms with very severe MS	• Severe LA enlargement • Elevated PASP >30 mmHg	• None
D	Symptomatic severe MS	• Same as stage C	• Same as stage C	• Same as stage C	• Decreased exercise tolerance • Exertional dyspnea

Adapted from [5]

Abbreviations: LA left atrial, LV left ventricular, MS mitral stenosis, MVA mitral valve area, PASP pulmonary artery systolic pressure

Etiology and Classification

Mitral Regurgitation

There is a fundamental distinction between primary and secondary MR . Primary MR was often referred to as organic MR, whereas secondary MR (addressed in Chap. 7) was commonly described as functional MR. The two diseases have different etiologies, pathophysiology, natural history, and a different response to and indications for medical, transcatheter, and surgical therapies. Primary MR is a disease of the valve, including the leaflets, chordae tendineae, papillary muscles, or annulus. Because valve abnormalities and the regurgitation they cause are the disease, treating the valve can be curative. The most common cause of primary MR, and the most common etiology leading to surgery, is mitral valve prolapse (MVP) [1, 6]. Abnormal elongation and redundancy of the leaflets accompanied by elongation of chordae and dilatation of the annulus leads to prolapse of the valve past its coaptation point causing MR. Primary MR presents as a spectrum of lesions [7]. On one end are older patients with fibroelastic deficiency , inadequate tissue and localized pathology of a single scallop or a single chord (Fig. 6.1). At the other end of the spectrum are younger patients with excess tissue, extensive, diffuse, and marked myxomatous changes of the leaflets and chordal apparatus associated with billowing leaflets, often referred to as Barlow’s disease (Fig. 6.1).

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig1_HTML.jpg — Fig. 6.1

Spectrum of degenerative/myxomatous mitral valve disease . From Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: best practice revolution. Eur Heart J. 2010;31(16):1958–1966. Reprinted with permission from Oxford University Press. *FED* fibroelastic deficiency disease

Secondary MR is a disease of the LV that has led to abnormal shape/structure and function that cause displacement of one or both papillary muscles, leaflet tethering and inadequate coaptation, and often annular dilatation [8, 9]. Secondary MR may result from ischemic or nonischemic ventricular disease. Because the mitral valve itself is not the origin of the disease, therapy directed only at MR may reduce regurgitation but cannot cure the basic underlying pathology.

The Carpentier classification of the types of mitral valve pathologies is commonly used today (Fig. 6.2) [10]. Type I exhibits normal leaflet motion but annular dilation or leaflet perforation. Type II is leaflet prolapse. Type III describes leaflet restriction. Type III is further divided into IIIa (restricted opening) and IIIb (restricted closing).

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig2_HTML.jpg — Fig. 6.2

Carpentier classification of mitral valve regurgitation . Type I exhibits normal leaflet motion but annular dilation or leaflet perforation. Type II is leaflet prolapse. Type III describes leaflet restriction. Type III is further divided into IIIa (restricted opening) and IIIb (restricted closing)

Mitral Stenosis

Mitral stenosis most commonly occurs as a consequence of rheumatic fever, a history of which is noted in approximately 60% of patients with pure MS [3, 5]. Significant annular calcification causing calcific MS is the next most common cause, but relatively infrequently leads to obstruction severe enough to warrant valve replacement.

Diagnosis

Imaging Assessment

Mitral Regurgitation

Two-Dimensional Transthoracic Echocardiography

Transthoracic echocardiography (TTE) is readily available and usually the initial diagnostic test to evaluate MR. The mitral valve apparatus includes the leaflets, the chordae tendineae, annulus, papillary muscles, and the insertions into the LV wall [11]. Because the diseases are so different, it is important to distinguish between primary and secondary MR, a distinction that can usually be made from two-dimensional (2D) TTE. In primary MR the diagnosis of prolapse is made on the TTE parasternal long view where the mitral leaflets are displaced >2 mm into the left atrium during systole [12]. Often, TTE can identify pathology of the specific scallops responsible for the leak. The six scallops of the mitral valve can be identified in the parasternal short axis view and color Doppler can then be used to confirm the origin of the MR jet and the scallops involved. In the parasternal long view, the A2 and P2 scallops can be visualized. The apical four chamber view allows for visualization of the A3, A2, and P1 scallops; while the TTE two chamber view displays P3, A2, P1 (Fig. 6.3). Unlike in primary MR where distinct valvular pathology is found, in secondary MR the valve itself is usually normal. Tethering of the valve by distorted LV geometry prevents leaflet coaptation causing a centrally directed jet.

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig3_HTML.png — Fig. 6.3

Panel a: Transthoracic parasternal long axis view demonstrating the posterior leaflet prolapse. The scallops at the mitral leaflet tips are A2 and P2. Panel b is an apical four chamber view demonstrating the scallops seen in this view are A1, A2, and P1

TTE can provide guidance as to the feasibility of mitral valve repair by providing assessment of scallop anatomy or leaflet tethering and demonstrates the extent of mitral annular calcification. In addition to an assessment of the etiology and anatomy of the MR, TTE provides an accurate assessment of LA and LV size, LV function, and pulmonary artery pressures, all of which are important in clinical management.

Two-Dimensional Transesophageal Echocardiography

2D transesophageal echocardiography (TEE) can be used to evaluate the mitral valve apparatus and often adds important anatomical information in the assessment of mitral valve pathology in cases of moderate to severe MR. The echocardiographer should be familiar with mapping of the mitral valve using 2D TEE [13]. In the midesophageal four chamber view, typically at 0°, the tips of the leaflets are the A2 and P2 scallops. When the transducer is withdrawn slightly from the esophagus with the LV outflow tract in view, the A1 and P1 scallops are visualized. When the transducer is advanced further past the midesophageal view, the A3 and P3 scallops are then visualized. At the 60° view, also termed the bicommissural view, the scallops visualized are the P1, A2, and P3 scallops with the P1 scallop being closest to the left atrial appendage (LAA) and the P3 scallop the furthest from the LAA. Finally, at the 120° view, the A2 and P2 scallops are visualized (Fig. 6.4). Using this strategy the entire mitral valve can be visualized for the presence of prolapse and/or flail segments.

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig4_HTML.png — Fig. 6.4

Transesophageal echocardiogram (TEE) demonstrating the different mitral scallops. Panel a: at 0°, A1 and P1 scallops are seen in the high esophageal view with the left ventricular outflow tract in view. Panel b: at 90°, the P3 scallops is seen which appears to prolapse. Panel c: at 120°, A2 and P2 scallops are seen. P2 scallop is flail

Three-Dimensional (3D) Echocardiography: Advantages and Pitfalls over 2D

Three-dimensional (3D) echocardiography has significantly improved the assessment of mitral valve disease [14]. With multiplane 2D TEE, the echocardiographer has to be familiar with the different mitral scallops and construct a map of the mitral valve to convey the valve pathology to surgeons or interventionalists. 3D TEE enables better communication between the surgeon and the echocardiographer by providing “the surgeon’s view” of the mitral valve. In this view, the mitral valve is visualized from the LA perspective with the aortic valve at the 12 o’clock position (Fig. 6.5). Advances in 3D echocardiography allow for excellent spatial and temporal resolution so that a very accurate assessment of mitral valve structure, function, and dynamic changes can be recorded [15]. 3D echocardiography allows for better characterization of leaflet pathology compared to 2D TEE. Due to the saddle shape of the mitral annulus, distortion in the mitral anatomy can lead to misinterpretation of scallops with 2D TEE (Fig. 6.6). In addition, 3D echocardiography allows for better characterization of lesions such as mitral clefts and commissural scallops which are not easily identifiable by 2D echocardiography alone (Fig. 6.7). Moreover 3D echo with color can identify the exact location of the regurgitant jet (Fig. 6.8).

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig5_HTML.jpg — Fig. 6.5

3D echocardiogram demonstrating the mitral valve in the “surgeon’s view” with the aortic valve (AoV) at the 12 o’clock location and left atrial appendage (LAA) on the lateral aspect. One can now visualize all six scallops of the mitral valve. Note that the P3 scallop prolapses and is flail

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig6_HTML.jpg — Fig. 6.6

Transesophageal echocardiogram (TEE) demonstrating that 2D TEE by itself may lead to misrepresentation of scallops. In panel a at 120°, the P2 scallop appears to be flail. However in panel b when 3D echocardiogram is utilized, it is actually the P3 scallop (which is very large) that prolapses rather than the P2 scallop

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig7_HTML.jpg — Fig. 6.7

3D echocardiography can be utilized to identify mitral clefts, which would not be seen on 2D TEE. Panel a demonstrates 3D of the mitral valve showing indentations between the mitral scallops (red arrows) that extend from the mitral leaflet tips to the annulus. Panel b demonstrates the clefts as seen from the ventricular aspect

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig8_HTML.jpg — Fig. 6.8

3D echocardiography with color can be used to identify the origin of mitral regurgitation. Shown is an example of P2 prolapse. When 3D with color is used, one can visualize the mitral regurgitation originating from the P2 scallop and directed anteriorly

However, 3D echocardiography has its limitations [15, 16]. It requires that the echocardiographer be familiar with image acquisition and manipulation. Errors in manipulation of the image can lead to misinterpretation of the lesions. The echocardiographer should routinely position the aortic valve at the 12 o’clock position relative to the mitral valve when using 3D TEE in mitral valve assessment. 3D echocardiography frequently involves combining several volumes of image sectors, so any patient movement or irregular heart rhythm can produce what is termed “stitch artifact ” (Fig. 6.9). Finally, the echocardiographer has to be aware of image dropout, which may once again lead to misinterpretation of lesions (Fig. 6.10).

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig9_HTML.jpg — Fig. 6.9

“Stitch artifact ” (yellow arrows) can occur in 3D images as a result of an irregular heart rhythm, patient movement or breathing

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig10_HTML.jpg — Fig. 6.10

When utilizing 3D echocardiography, the echocardiographer has to be able to differentiate echocardiographic drop out (yellow arrow) from true defects

Computed Tomography and Magnetic Resonance Imaging in Assessment of Mitral Regurgitation

Computed tomography (CT) and magnetic resonance imaging (MRI) are infrequently utilized in the evaluation of the mitral valve, but can provide important, complementary information to echocardiography. CT can be utilized for diagnosis of mitral valve prolapse [17]. An advantage of CT over echocardiography is that it not only can help in the diagnosis of mitral valve prolapse, but also can concomitantly assess coronary anatomy [18], LV function [19, 20], and the presence of left atrial appendage thrombus [21]. CT can also be used to evaluate the extent of mitral annular calcification, which may help plan surgery and assess the feasibility of mitral repair. MRI is also useful for the assessment of MR, particularly in patients with poor echocardiographic views. MRI provides an assessment of mitral valve anatomy, quantification of MR severity, and accurate assessment of LV size and function [22].

Left Ventriculography in Assessment of Mitral Regurgitation

Left ventriculography can qualitatively assess severity of mitral regurgitation [23]. With regurgitation that is classified as mild (1+), contrast clears from the LA with one beat, and does not opacify the LA; 2+ regurgitation is classified as moderate, and contrast does not clear with one beat and faintly opacifies the entire LA; 3+ regurgitation is classified as moderate to severe, contrast opacifies the entire LA in one beat; 4+ regurgitation is classified as severe, and contrast densely opacifies the entire LA into the pulmonary veins (Fig. 6.11). The regurgitant volume can also be calculated by subtracting the stroke volume obtained by the Fick or thermodilution method from the difference between end diastolic volume and end systolic volume. Common pitfalls in the use of ventriculography in assessing MR are (1) induction of ventricular extrasystoles that can cause factitious MR and (2) injecting too little contrast to opacify both LA and LV (at least 50 cc should be injected), thereby underestimating MR severity.

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig11_HTML.jpg — Fig. 6.11

A left ventriculogram demonstrating a hyperdynamic left ventricle with dense opacification of the left atrium in systole consistent with severe mitral regurgitation

Doppler Quantitation of Mitral Regurgitation

Qualitative and quantitative indices of MR severity are shown in Table 6.1 [5, 12, 24]. One of the more commonly used qualitative parameters is regurgitant jet area. Large jets represent a greater severity of MR than smaller jets but this method has several pitfalls. The Nyquist limit is often set too low, which (falsely) increases the jet area. Jet area may be deceptively underrepresented in acute severe MR where there is rapid rise in left atrial pressure diminishing the transvalvular driving gradient and confining MR to early systole. In addition, central jets usually appear larger than eccentric jets due to entrainment of red blood cells on either side of the jet. Thus the echocardiographer must use caution in interpreting highly eccentric jets when using color Doppler and jet area alone (Fig. 6.12).

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig12_HTML.jpg — Fig. 6.12

Highly eccentric jets may lead to underestimation of the degree of mitral regurgitation not only by color Doppler but also by the PISA method. In this figure, there is a flail posterior leaflet leading to a highly eccentric jet of severe mitral regurgitation. However, color Doppler appears to underestimate the severity of MR

Color Doppler can also be used to assess the size of the vena contracta, which is the narrowest portion or neck of the regurgitant jet as it crosses the mitral annular plane into the LA and reflects MR severity by implying the size of the regurgitant orifice (Fig. 6.13). One advantage of the vena contracta method is that it can be used in eccentric jets. The cutoff values for the different degrees of MR are listed in Table 6.1.

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig13_HTML.jpg — Fig. 6.13

Quantification of mitral regurgitation requires identification of the zone of flow convergence. One should identify the narrowest portion of the jet as demonstrated by the yellow arrow (vena contracta). Also, one should identify the PISA radius (white arrow) to allow for calculation of the effective regurgitant orifice area (EROA) using the PISA method. The echocardiographer should also obtain a continuous wave Doppler of the mitral regurgitation since the peak velocity and the velocity time integral are also used to calculate the EROA and the regurgitant volume

The proximal isovelocity surface area (PISA) or flow convergence method is utilized in the quantitative assessment of the severity of MR (Fig. 6.13). This method is based on the premise that as blood approaches a regurgitant orifice it forms hemispheric shells of increasing velocity and decreasing surface area [25]. If the Nyquist limit is known, then the area of the hemisphere, which provides an effective regurgitant orifice area (EROA) , can be calculated using the formula [24, 25]:

$\mathrm{EROA}=\left(2\varPi {r}^2\ast {V}_{\mathrm{a}}\right)/\mathrm{Pk}{V}_{\mathrm{reg}}$

where r represents the radius of the hemisphere, V _a represents the velocity of the Nyquist limit, and PkV _reg represents the peak MR velocity obtained by continuous wave Doppler. A limitation of the PISA method is the need to use a correction factor if the base of the hemisphere is not a flat surface. In addition, in highly eccentric jets, 2D EROA may underestimate the severity of MR; thus, this method is more applicable to central jets. Because the true shape of the EROA may not actually be a hemisphere, 3D EROA maybe more useful in the true quantitative assessment of MR severity (Fig. 6.14) [26]. In addition, any error made in measurement of the PISA radius will lead to a substantial error in the EROA calculation because the radius is squared in the flow convergence equation.

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig14_HTML.jpg — Fig. 6.14

3D echocardiography can be utilized to measure the EROA. One can align orthogonal planes to the regurgitant jet to identify the EROA. The EROA can then be traced. In this figure, the EROA can be visualized en face and reveals an area of 0.24 cm²

Pulsed wave Doppler is another method to qualitatively assess MR severity [24]. In patients with severe MR, the E wave velocity is usually greater than 1.2 m/s; the presence of an A wave dominant mitral inflow pattern virtually excludes the presence of severe MR [27]. Pulsed wave Doppler can also be used to calculate the MR regurgitant volume and fraction using the continuity equation [25]. This method is useful when the MR jet is highly eccentric. However, since the annular measurement is a key component of the analysis, any error in its measurement can produce large errors in the calculation of the regurgitant volume and fraction.

Lastly, pulsed wave Doppler can be used to assess pulmonary vein flow. In patients with severe MR, forward systolic pulmonary vein flow can be reversed or blunted (Fig. 6.15). Caution should be used when using this method as the sole criteria for assessing MR severity since elevations in LA pressure and atrial fibrillation may also cause the systolic flow in the pulmonary vein to be blunted [25].

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig15_HTML.jpg — Fig. 6.15

One of the suggestive signs of severe mitral regurgitation is systolic reversal in pulmonary veins, shown here with flow below the baseline when pulse wave Doppler is placed in the pulmonary vein

Common pitfalls in the echocardiographic assessment of MR severity are shown in Table 6.3.

Table 6.3

Common pitfalls in the echocardiographic assessment of MR severity

• Relying on color Doppler to assess the severity of MR, particularly when the Nyquist limit is too low

• Color Doppler is inadequate when jets are highly eccentric

• Quantification of MR severity can be limited with an eccentric jet or multiple jets

• Underestimating MR severity based on a TEE due to anesthesia and lower blood pressure

• EROA may not be a true hemisphere as previously thought

• Failure to recognize imaging artifacts (stitch, drop out, etc.) on 3D TEE

• Mitral gradients for MS can vary and are highly dependent on heart rate and cardiac output

• 2D TEE is limited in the diagnosis of mitral clefts or commissural scallops

• Color Doppler to assess MR severity may be deceptive in the setting of acute severe MR

Echocardiographic Evaluation of Mitral Stenosis

It is important to distinguish between calcific and rheumatic MS because it has implications for treatment strategies wherein balloon valvuloplasty is ineffective in calcific disease. Calcific MS mainly involves annular calcification and is seen in elderly patients, those with renal disease, hypertension, and atherosclerotic disease [28]. The commissures are usually spared in this disease and valve thickening, if present, predominates at the base of the leaflets while the leaflet tips are usually spared (Fig. 6.16a). This is in contrast to rheumatic MS where there is commissural fusion, chordal calcification, leaflet thickening, and calcification that predominates at the leaflet tips (Fig. 6.16b) [3].

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig16_HTML.jpg — Fig. 6.16

Differentiating calcific mitral stenosis (MS) from rheumatic MS. Panel a demonstrates a patient with calcific MS. The arrow demonstrates the calcium at the mitral annulus which is classic for calcific MS where the leaflets are generally spared. Panel b demonstrates a patient with rheumatic MS with the calcification most prominent at the leaflet tips. The calcification may also extend into the subvalvular apparatus

Transthoracic Echocardiographic Evaluation of Mitral Stenosis

TTE is not only used to assess the etiology of MS (calcific versus rheumatic) but is also used to determine the severity and hemodynamic consequences of MS [25]. Continuous wave Doppler (CWD) should be used to assess peak and mean mitral gradients (Fig. 6.17). In addition, the heart rate at which the gradients are measured should be noted as tachycardia can increase the gradient. Anemia, hyperthyroidism, fever, pregnancy, or significant MR can also increase the transvalvular gradient due to increased flow.

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig17_HTML.jpg — Fig. 6.17

Continuous wave Doppler should be utilized to assess mitral gradients. In this example, there was a mean mitral valve gradient of 4 mmHg

The mitral valve area is commonly calculated from the pressure half-time (T _1/2), which is defined as the time required for the maximum pressure gradient to decrease by half of its original value. The pressure half-time is determined by measuring the slope of E wave obtained by CWD (Fig. 6.18). Mitral valve area can then be calculated by the formula [29]:

$\mathrm{MVA}=220/{T}_{1/2}$

where T _1/2 represents the pressure half-time. However, pressure half-time can be affected by changes in LV compliance and moderate or severe aortic regurgitation. Thus, pressure half-time should not be the sole criterion used to assess the severity of MS. In rheumatic MS, mitral valve area can also be determined by planimetry [25, 30], performed in the parasternal short axis view at the level of the mitral valve, taking care to measure at the leaflet tips (Fig. 6.19). The transmitral pressure gradient is determined by the modified Bernoulli equation and valve area can be determined using the continuity equation. This method is most accurate in the absence of mitral regurgitation. TTE is also used to assess pulmonary artery pressures since pulmonary hypertension is a known complication of significant MS.

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig18_HTML.jpg — Fig. 6.18

The slope of the E wave can be measured (yellow line) which gives the deceleration time. This can be used to calculate the pressure half-time by multiplying the deceleration time by 0.29. The pressure half-time can then be used to calculate the mitral valve area

../images/301959_1_En_6_Chapter/301959_1_En_6_Fig19_HTML.jpg — Fig. 6.19

The mitral valve area can be measured via planimetered in the parasternal short axis view

Transesophageal Echocardiography in Assessment of Mitral Stenosis

TEE is usually employed prior to balloon valvuloplasty to confirm the absence of an LA appendage thrombus, assess the degree of concomitant mitral regurgitation, better assess the degree of leaflet and subvalvular calcification and thickening [31], and develop the Wilkins score for predicting the outcome of percutaneous balloon mitral valvuloplasty [32]. In this evaluation, one to four points each is given according to ascending severity for leaflet mobility, leaflet calcification, leaflet thickening and subvalvular disease yielding a score ranging from 4–16. A score of 8 or less is predicts a suitable percutaneous valvuloplasty. In contrast, a valve with a score of 12 or more portends an unfavorable outcome. Contraindications for percutaneous balloon mitral valvuloplasty include the presence of moderate or more mitral regurgitation and the presence of a left atrial appendage thrombus. 3D TEE can also be used to assess the mitral orifice area and is more accurate than 2D planimetric measurements.

Strengths and limitations of various echocardiographic modalities for assessing MR and MS are shown in Table 6.4.

Table 6.4

Strengths and limitations of various echocardiographic modalities for assessing mitral regurgitation and stenosis

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Apr 23, 2020 | Posted by admin in CARDIOLOGY | Comments Off

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