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Transcript of Quantification of Mitral Stenosis - Wake Forest Baptist … of Mitral Stenosis: Planimetry, pressure...
Quantification of Mitral Stenosis:
Planimetry, pressure Half time, Continuity Common Errors
Christopher J Kramer RDCSAdvanced Cardiovascular Services
Aurora Health CareMilwaukee, WI
• No Disclosures
Baumgartner, H., et al JASE January 2009
How to Grade Mitral Stenosis
• Routine evaluation of MS severity should combine:
• Mean Gradient and Valve area using Planimetry and Pressure 1/2t methods.
• In case of discrepancy the result of planimetry is the reference measurement, except with poor acoustic windows.
• Continuity equation or PISA not recommended for routine use but may be useful in certain patients when standard measurements are inconclusive.
Quantification Methods
• Valve Area• Planimetry • Pressure Half Time (PHT)• Continuity Equation• Proximal Isovelocity Surface Area (PISA)
• Mean Gradient
Recommended Recordings Mitral Stenosis
• Apical window• CW Doppler• PW Doppler
• Leaflet tips
• Use Color Doppler to line up with MV inflow jet
• Parallel to Flow• Parasternal short-axis MV level / long-
axis
Mitral Stenosis: Game Plan
Normal Sinus Rhythm and Rapid Atrial Fibrillation
Echocardiographic Quantification
Pathophysiology of MS
Right Heart
Failure
↑ RA Size
RV Hypertrophy
↑ RV Volume
Pulmonary
Edema
“Backward Failure”
into Right Heart
↑ LA Size
↑ LA Pressure
Narrowed MV
Orifice
Kinney MR & others: Comprehensive cardiac care, 7th ed. St. Louis, 1991, Mosby.
PulmonaryHypertension
Case #1
49 year old femaleHistory significant for rheumatic feverVitals – 72 bpm– Sinus rhythm– BP 132/80– Grade 1/6 diastolic rumble
Planimetry
Minimum Diameter = 1.2cm
Planimetry
Minimum Diameter = 1.2cm
Planimetry
Planimetry
Area = 1.8cm2
Mitral StenosisSeverity Guidelines
Severity Mean Gradient MVA (cm2) PHT(msec)
Mild < 4 mmHg > 1.5 <150 Moderate 5 - 9 mmHg 1.1 - 1.5 150- 219 Severe > 10 mmHg < 1.0 > 220
Pressure Half Time
Pressure Half Time
V1 0.7V1PHT
Time for the pressure to drop in halfVelocity
Time
MV PHT= 120ms
MVA= 1.8cm2
Mitral StenosisSeverity Guidelines
Severity Mean Gradient MVA (cm2) PHT(msec)
Mild < 4 mmHg > 1.5 <150 Moderate 5 - 9 mmHg 1.1 - 1.5 150- 219 Severe > 10 mmHg < 1.0 > 220
Continuity Equation
X MVA
SV
CP935823-29
MVA= LVOTSV/MVTVI
LVOTTVI= 25cm
Continuity Equation
LVOT= 2.1cm
Continuity EquationMVPeak=1.5m/s
MVTVI= 52cm
Continuity Equation
LVOTTVI= 25cm
LVOT= 2.1cm
MVTVI= 52cm
x x.785( )2
=1.7cm2
Mitral StenosisSeverity Guidelines
Severity Mean Gradient MVA (cm2) PHT(msec)
Mild < 4 mmHg > 1.5 <150 Moderate 5 - 9 mmHg 1.1 - 1.5 150- 219 Severe > 10 mmHg < 1.0 > 220
Vp
θrVa
PISA
MVA = 6.28 x r2 x Aliasing velocity x θ MV peak velocity 180
Rifkin RD et al. JACC 1995
PISA
PISA
MVA = 6.28 x (1.1cm)2 x (39cm/s) x 150 150cm/s 180
θ=150o
=1.6cm2
Mitral StenosisSeverity Guidelines
Severity Mean Gradient MVA (cm2) PHT(msec)
Mild < 4 mmHg > 1.5 <150 Moderate 5 - 9 mmHg 1.1 - 1.5 150- 219 Severe > 10 mmHg < 1.0 > 220
Mean Pressure GradientMVPeak=1.5m/s
MVMean= 4mmHg
Mitral StenosisSeverity Guidelines
Severity Mean Gradient MVA (cm2) PHT(msec)
Mild < 4 mmHg > 1.5 <150 Moderate 5 - 9 mmHg 1.1 - 1.5 150- 219 Severe > 10 mmHg < 1.0 > 220
Case #1Quantification
– PlanimetryMVA= 1.8cm2
Mild MS
– PHTMVA= 1.8cm2
Mild MS
– Continuity Equation
MVA= 1.7cm2
Mild MS
– PISAMVA= 1.6cm2
Mild MS
– Mean GradientMild MS
Case #2
69 year old femaleHistory significant for Rheumatic feverVitals – 110bpm– Atrial fibrillation– BP 140/84
Planimetry
Planimetry
Planimetry
Minimum
Diameter= .85cm Area=1.2cm2
Pressure Half Time
Pressure Half Time
MVPV=2.4m/s
PHT=188ms
MVA=1.2cm2
MVPV=2.2m/s
PHT=177ms
MVA=1.2cm2
MVPV=2.2m/s
PHT=196ms
MVA=1.1cm2
MVPV=2.6m/s
PHT=186ms
MVA=1.2cm2
MVPV=2.6m/s
PHT=185ms
MVA=1.2cm2
MVPV=2.6m/s
PHT=191ms
MVA=1.2cm2
Average MVAPHT=1.2cm2
LVOTDiam=1.9cm
Continuity Equation
PV=1.3m/s
TVI=20cm
PV=1.3m/s
TVI=20cm
PV=1.2m/s
TVI=18cmAverage TVI=19cm
Continuity Equation
MVPV=2.4m/s
MnGr=14mmHg
MVTVI=34cm
MVPV=2.2m/s
MnGr=11mmHg
MVTVI=43cm
MVPV=2.2m/s
MnGr=11mmHg
MVTVI=69cm
MVPV=2.6m/s
MnGr=16mmHg
MVTVI=52cm
MVPV=2.6m/s
MnGr=15mmHg
MVTVI=70cm
MVPV=2.6m/s
MnGr=12mmHg
MVTVI=68cm
Average MVTVI=56cm
Continuity Equation
MVA=(1.9cm)2 x .785 x 19
56cm
=.96cm2
PISA
PISA1.1cm
θ=165o
PISA
MVA = 6.28 x (1.1cm)2 x (34cm/s) x165 240cm/s 180
=.99cm2
MVPV=2.4m/s
MnGr=14mmHg
MVTVI=34cm
MVPV=2.2m/s
MnGr=11mmHg
MVTVI=43cm
MVPV=2.2m/s
MnGr=11mmHg
MVTVI=69cm
MVPV=2.6m/s
MnGr=16mmHg
MVTVI=52cm
MVPV=2.6m/s
MnGr=15mmHg
MVTVI=70cm
MVPV=2.6m/s
MnGr=12mmHg
MVTVI=68cm
Mean Pressure Gradient
Average Mean Gradient=13mmHg
Mitral StenosisSeverity Guidelines
Severity Mean Gradient MVA (cm2) PHT(msec) Mild < 4 mmHg > 1.5 <150 Moderate 5 - 9 mmHg 1.1 - 1.5 150- 219 Severe > 10 mmHg < 1.0 > 220
NOTE:Heart rate dependent!
Case# 2Quantification– Planimitery
MVA=1.2cm2
Moderate MS
– PHTMVA=1.2cm2
Moderate MS
– Continuity Equation
MVA=.96cm2
Severe MS
– PISAMVA=.99cm2
Severe MS
– Mean GradientMean PG=13mmHgSevere MS
Indicators
LA Volume (ml/m2)RVSPRV SizeRV Function
Average TR Velocity=3.4m/s
MV 3D
MV 3DQ
Take Home Points
• Use all tools in your toolbox, Mean Gradient, MVA; P1/2 time, Planimetry
• Know your limitations of MS• Always record the HR when reporting
the mean pressure gradient • Measure a minimum of 5 beats when
atrial fibrillation is present• Incorporate the supportive indicators
when determining the severity of stenosis