Mitral stenosis: Quantification and treatment

Παρασκευή Κουτρολού-Σωτηροπούλου MD, FACC

Καρδιολόγος, 3η Καρδιολογική Κλινική, Νοσοκομείο Υγεία

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Etiology of Mitral Stenosis

✓Rheumatic heart disease (RHD)

✓Mitral annular calcification

✓Radiation heart disease

✓Congenital heart disease

✓Other rare conditions: Fabry disease, carcinoid valve disease, endomyocardial fibrosis, Systemic inflammatory disease (e.g., systemic lupus erythematosus & rheumatoid arthritis),drug-induced

✓RHD is the result of an exaggerated immune response to specific bacterial epitopes in a susceptible host

Inflammatory process initiated by cross-reactivity between streptococcal antigen & valve tissue; no active infection of valve leaflets

Mitral Stenosis

Rheumatic mitral stenosis

✓Leaflet thickening starts at the tip

✓Commissural fusion

✓Short posterior leaflet

✓Calcification starts late

✓Chordae: thick/ retracted

Mitral Stenosis

Degenerative mitral stenosis

✓Leaflet thickening starts at the base

✓Calcification

✓Associated with HTN and AS

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary Nishimura, Circulation 2014

Baumgartner et al. Eur J Echocardiography 2009

Mitral Stenosis

✓Anatomy first…..

✓And then… Quantification

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Mitral Valve Area

✓Planimetry

✓Continuity equation

✓Pressure half-time

✓PISA

25 year old Female with rheumatic mitral

stenosis

MVA

Continuity Equation for MVA

x

0.7cm²

Problems with

Continuity:

✓ Additional

source of errors

(LVOT)

✓ Unreliable

✓ MR / AR

✓ Atrial fibrillation

PHT method in patients with rheumatic mitral

stenosis

PHT= The time required for the velocity to drop to ½ the peak pressure

✓ PHT only applies to

rheumatic mitral

stenosis

✓ Diastolic pressure half-time ≥150 msec>>> severe MS

✓ Diastolic pressure half-time ≥220 msec>>>very severe MS

Pressure Half Time Method

Affected by:

✓AR (short PHT)

✓Sudden changes in LV-LA compliance (immediately after BMVP)

✓Diastolic dysfunction (increased LV filling pressure) : avoid in degenerative MS

Mitral Stenosis in calcific MS

✓ MVA planimetry if

possible

✓ Assess gradient

but dot rely on it

✓ Stress test

Severe Mitral Annular Calcification. Multimodality Imaging for Therapeutic Strategies and InterventionsMackram F. Eleid, Thomas A. Foley, Sameh M. Said, Sorin V. Pislaru and Charanjit S. Rihal. JACC 2016

✓Exercise hemodynamic bike

Increase in mean gradient of >15mmHg or PASP>60mmHg

Lancellotti et al. JASE 2017

Increased filling pressures

✓ In patients presenting with dyspnea, with both significant MS and hypertension, increased left ventricular (LV) filling pressure due to hypertension could influence assessment of the severity of MS.

✓Severity of MS could be underestimated because the increased diastolic pressure reduces the mitral valve gradient, and the increased LV stiffness shortens pressure half-time (PHT)

✓ Cardiac catheterization can be useful to determine whether pulmonary hypertension is secondary to the mitral stenosis or left ventricular diastolic dysfunction

Hemodynamics in the Cardiac Catheterization Laboratory of the 21st Century Rick A. Nishimura, MD; Blase A. Carabello, MD. Circulation 2012

Management of Mitral Stenosis✓ Anticoagulation (warfarin preferred)

Atrial fibrillation

Prior embolic event

Left atrial thrombus

LA enlargement & spontaneous echo contrast predictors of thromboembolism

Risks and benefits of anticoagulation in patients in sinus rhythm with these findings uncertain

✓ Diuretic therapy (usually a loop diuretic)

✓ Dietary salt restriction

✓ Beta blockers

✓ Digoxin in selected patients

Commissural calcification

✓ Absence of MR

AND

✓ LA thrombus

Feasibility of percutaneous mitral commissurotomy

Valve Guidelines 2017

2014 AHA/ACC Valvular Heart Disease Guideline: Executive Summary

62 year old Female with history of rheumatic MS

PHT: 202

MVA by PHT:1

Mean gradient:

10mmHg 72bpm

PASP: 83mmHg

Wilkins score: >8

Echo guidance during PMBV

Before valvuloplasty

After Valvuloplasty

Surgery for MS

✓In patients with suboptimal valve anatomy for PMBV

✓LA thrombus that persists despite anticoagulation

✓If significant mitral regurgitation is present

✓In patients with significant tricuspid regurgitation who have better outcomes with surgery that includes a tricuspid valve repair

Calcific Mitral StenosisMitral Annular Calcification (MAC)

✓Reduced normal annular dilatation during diastole

✓Impaired anterior mitral leaflet mobility

✓ Calcium extension more than half-way onto 1 or both leaflets

✓Posterior mitral leaflet usually involved

✓Reduced maximal leaflet opening angle in both the anterior and posterior segments

✓Older age, female sex, diabetes mellitus, presence of coronary artery calcification, hypertension, smoking, and high CRP, chronic kidney disease and increased body mass index have been shown to be independent predictors of MAC

Degenerative Mitral Stenosis Unmet Need for Percutaneous Interventions Circulation 2016

✓Debridement of the calcified tissue is risky because it may result in separation of the atrium and ventricle or damage the circumflex coronary artery✓Usually high risk patients

Current and evolving strategies in the management of severe mitral annular calcification. J Thorac Cardiovasc Surg 2019

An alternate approach to valve replacement in patients with mitral stenosis and severely calcified

annulus. Sameh M. Said, MD, and Hartzell V. Schaff, MD, Rochester, Minnesota

Russell, Guerrero et al JACC 2018

Guerrero et al JACC 2016

✓ 94% had MS

✓ 8% female

✓ 53% CKD

✓ Technical success 77%

✓ 14.7% needed a second THV

✓ 11.2% (13 patients) LVOT obstruction

after

✓ 30 day all cause mortality 25%

✓ 1 year all cause mortality 53,7%

✓ LVOT obstruction was the most

important and independent predictor

of 30 day and 1 year mortality

✓ Need of patient selection

Three-dimensional prototyping for procedural simulation of transcatheter mitral valve replacement in patients with mitral annular

calcification. Sabbagh et al. Catheter Cardiovasc Interv. 2018

Τhank you!