Mitral Valve Stenosis: What do I need to know? ACC Latin American Conference 2017
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1 Mitral Valve Stenosis: What do I need to know? ACC Latin American Conference 2017 Athena Poppas, MD FACC FASE Past ACC Scientific Sessions Chair, ACC Board of Trustee Professor of Medicine, Brown University School of Medicine Director, Lifespan Cardiovascular Institute Rhode Island, Miriam and Newport Hospitals Disclosures: GE stock, Philips research grant-in-kind
2 Severity of MS Nishimura RA. JACC 2014:63(22): 2438
3 Severity of MS MVA cm 2 PASP rest mmhg Mean Grad mmhg* Mild > 1.5 <30 < 5 Moderate Severe (very severe) < 1.0 >50 > 10 EAE/ASE Guidelines.JASE 2009;22:1. *Sinus rhythm and HR 60-80
4 Case presentation 26 yo woman presents at 32 weeks gestation with progressive fatigue, SOB and new PND/orthopnea. PMHx: heart murmur as a child SHx/FHx: negative PE: 100/62, 108, 18, afebrile, O2 sat=84% 3/6 HSM apex, PMI laterally displaced, -S3 JVP-6cm, carotids 2+ Lungs: diffuse rales, Ext: no CCE CXR: pulmonary edema vs patchy airspace disease
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8 LAVi= 45ml/M 2 PASP= 48mmHg Mean MVG=17mmHg MVA plan= 1.9 cm 2 MVA PHT=1.9 cm 2
9 What is the real MVA? 1. Mild mitral stenosis 2. Severe mitral stenosis 3. Mixed moderate regurgitation and stenosis 4. Normal variant of pregnancy
10 Repeat TTE after betablockers and diuretics Mean MVG=10mmHg MVA plan= 0.8cm 2 MVA PHT=1.04
11 What happened? Physiology of pregnancy and MVA Poppas Circ Rahimtoola.Circ. 2005
12 PHT is less flow dependent than gradients Hatle L.Doppler 1983
13 MVA: EAE/ASE recommendations INTEGRATED or COMBINED assessment Mean gradients Pressure half time MVA Planimetry MVA Secondary assessment Continuity equation Pisa Supporting data PASP and LA size Anatomy and structure
14 Mitral Valve Gradients Easy to obtain Tips: trace outer edge grey scale Mean not peak gradients Peak, driving pressure Coorelate with invasive Nishimura JACC Dependent upon flow: Heart rate Cardiac output Regurgitation
15 Simultaneous LA and LV pressure tracings Short RR interval Higher gradient Longer RR interval Lower gradient Kern, Hemodyanmic Rounds Uptodate
16 Pressure half time Easy and reproducible Tips: linear slope Longer RR interval MVA=220/PHT Derived from Gorlin eq Correlates with anatomic MVA EAE/ASE JASE 2009
17 MVA in MS: pressure half time Dependent on other factors Net LV-LA compliance MVA= 11.6*Cnet* MGp PHT chronic increase in pressure, decrease in compliance >2-3+AR Shortens PHT, overest MVA ASD Shortens PHT, overest MVA Diastolic dysfunction *elderly Thomas JD Weyman AE. JACC 1987
18 MVA in MS: planimetry Anatomic MVA Gold standard Independent of conditions Tips: scan plax to find smallest orifice Zoom, mid diastole Biplane & 3D Fusion of commissures Zamorano JACC 2004 Sebag AJC 2005 Limitations: Calcified valves Windows & experience SalcedoJASE 2009
19 MVA: planimetry
20 MVA in MS: continuity equation MVA= r 2 (VTIao/VTImv) Conservation of mass SV across LVOT level 2 recommendation Caveats: Cannot use in AI/MR Effective MVA, 15% smaller than anatomic Coefficient of discharge
21 MVA in MS: PISA
22 MVA in MS: Supportive Data Pulmonary pressures <30 mild mod > 50 severe LA size Anatomy 3D commissural fusion M-mode Block Weyman score AV and TV involvement
23 MVA in specific situations ASD and AI MVA PHT is overestimated, graded fashion After PBMV PHT unreliable Congenital/parachute valve After MV repair Mixed valvular disease
24 MVA after MV repair: PHT intraop TEE correlated with postop TTE 25 MVR patients. Maslow JCTVA 2010
25 MVA after MV repair: 3D and PHT Hoole EJE 2008
26 MVA in combined MS and MR Mean mitral diastolic gradient 10mmHg NOT MS High forward stroke volume due to 4+ MR Moderate MR and MS Severe symptoms
27 MVA in Mitral Stenosis: This is what I need to know! INTEGRATED assessment Planimetry 2D & 3D PHT Mean gradients Secondary assessment CE or PISA Supporting data PASP and LA size Special situations PMBV, MV repair
28 Thank you for you attention!
29 Case 2: What is wrong with this valve?
30 St Jude MVR with intermittent obstruction open closed
31 Congenital MS parachute MV
32 CO, HR and TPR in Pregnancy 30-50% in cardiac output 30-50% in peripheral resistance 10-20% in heart rate Poppas A.Circ.1997;95:2407
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