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Contemporary Topic

How to Assess Mitral Stenosis by Echo ‑ A Step‑by‑Step

Approach
Gnanavelu Ganesan1
1
Institute of Cardiology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India

Abstract
Rheumatic mitral stenosis is the commonest valvular heart disease in developing countries. Other causes include congenital abnormalities and
degenerative mitral valve disease. Mitral stenosis when it is due to rheumatic process, can be managed by percutaneous transvenous mitral
commissurotomy. Echocardiography remains the most important investigation in diagnosing and planning the managemnt of mitral stenosis.
This review highlights stepwise approach for comprehensive assessment of mitral stenosis by echocardiography.

Keywords: Mitral stenosis, pressure half time, rheumatic valve disease

Introduction thickening, and mobility restriction. All the modalities such as

Mitral stenosis (MS) is the most common valvular heart
disease encountered in developing countries. The cause
of MS is almost always chronic rheumatic heart disease.
Rarely, MS could be due to degenerative mitral annulus
calcification and congenital abnormalities like single
papillary muscle, mitral arcade, parachute mitral valve
[Table 1 and Figure 1]. Some of the extremely rare
causes of MS include systemic lupus erythematosus,
mucopolysaccharidosis, large vegetation, left atrial (LA)
myxoma, and ball valve thrombus. The incidence of
isolated MS is about 25%. Combined MS and mitral
regurgitation (MR) account for 40% of cases. Associated
aortic valve involvement is seen in 35% of cases.
Objectives of Echocardiographic Assessment
Echocardiography is the single most important diagnostic tool
in the evaluation of MS. The objectives are:
1. To confirm the etiology
2. To assess the severity of stenosis
3. To recommend the type and timing of intervention
4. To assess other valvular lesions, presence of thrombus,
and vegetation.
Chronic rheumatic activity results in commissural, cuspal,
chordal, and combined changes in the form of fusion,
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M‑mode, two‑dimensional (2D) echo, and Doppler evaluation
should be used in the assessment.
Wilkins score[1] [Table 2] and Padial score[2] are particularly
useful to assess the suitability for balloon mitral valvotomy
(BMV) and predict MR following valvotomy.
Step 1: Two‑dimensional Echocardiography
The following parameters need to be assessed about the valve
morphology:
• Thickening
• Mobility
• Subvalvar fusion
• Commissural fusion
• Calcification.
Thickness of valve leaflet
Rheumatic activity increases the thickness and restricts
mobility of mitral leaflets. Commissural fusion leads to
doming of the anterior leaflet which gives “hockey stick
appearance” [Figure 2a].
Address for correspondence: Dr. Gnanavelu Ganesan,
No. 7, Kanakkar Street, Tiruvottiyur, Chennai ‑ 600 019, Tamil Nadu, India.
E‑mail: gnanaveluganesan61@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the new
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Ganesan G. How to assess mitral stenosis by
10.4103/jiae.jiae_38_17 echo - A step-by-step approach. J Indian Acad Echocardiogr Cardiovasc
Imaging 2017;1:197-205.

© 2017 Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging | Published by Wolters Kluwer - Medknow 197
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Ganesan: Echo assessment of mitral stenosis
Figure 1: Upper panel: Parasternal long‑axis view; Middle panel:
Parasternal short‑axis view; Lower panel: A4C view. Rheumatic mitral
stenosis: Typical doming of pliable anterior mitral leaflet, fish mouth
orifice, dilated left atrium with doming leaflets. Congenital mitral stenosis:
Anterior mitral leaflet domes with eccentric location of orifice, Bulging
interatrial septum to right; both leaflets attached to single‑papillary muscle.
Degenerative mitral stenosis: Dense calcification with restricted opening,
spared commissures from calcification; dilated left atrium
Table 1: Comparison of three causes of mitral stenosis
Rheumatic Congenital Degenerative MS
MS MS
Calcification Leaflets and Rare Annulus towards
commissures leaflets
Commissures Fused Variable Usually free
Leaflet Restricted Restricted Tips are usually free
mobility
MS: Mitral stenosis
The normal thickness of mitral leaflet is 2–4  mm. Usually,
thickness of mitral leaflets increases at the margins in MS and
extend toward body and whole leaflet is thickened in severe
cases. Depending on the thickness, four grades are given in
Wilkins score. Mitral leaflet thickness can be compared to
posterior aortic wall thickness, and the ratio gives an objective
assessment. Normally, the ratio of valve thickness/posterior
aortic wall thickness is <1.4. The ratio between 1.4 and 2.0
indicates mild thickening, the ratio between 2 and 5 indicates
moderate thickening, and ratio >5 indicates severe thickening.
Mobility of the valve
The mobility of leaflets is assessed in both parasternal long
axis (PLAX) and apical four‑chamber views. The extent of
doming of anterior leaflet can be assessed objectively by Reid
grading system.[3] A line is drawn from the junction of the
posterior wall of aortic root and anterior mitral leaflet to the
198 Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging  ¦  Volume 1  ¦  Issue 3  ¦  September-December 2017
a b
Figure 2: (a) Measuring thickness of the tip of anterior leaflet in
diastole. (b) Objective measurement of leaflet mobility (ab/xy)
tip of the mitral leaflet (xy‑H). A perpendicular line is drawn
to the leading edge of the maximum dome (ab‑L). Mobility is
expressed as a slope by dividing the height of the dome by the
length of the dome – H/L [Figure 2b and Table 3].
Subvalvar pathology
Rheumatic process although affects the whole mitral apparatus,
it is the subvalvar pathology that carries a significant impact
on the outcome of BMV. Chordae undergo thickening, fusion,
shortening, and calcification. 2D echo assessment of subvalvar
structures is essential. Usually, visual assessment is sufficient
to make a decision regarding management. However, objective
assessment can be done using Iung et al. score[4] [Table 4]. The
chordal length is measured in four‑chamber or two‑chamber
view. Mild subvalvar disease is indicated by chordal length
more than 10 mm. Severe subvalvar disease is diagnosed by
thickened chordae measuring <10 mm [Figure 3]. Calcification
of valve of any extent by fluoroscopy carries high risk of MR
following BMV. Wilkins score also helps assess subvalvar
pathology‑vide table. Modified long axis and four‑chamber
views are used to properly visualize the chordae and their
abnormalities.
Calcification
Calcification is identified by bright echogenic spots over
the leaflets. The presence of calcium over commissures
is an absolute contraindication for BMV; however, some
experienced operators do perform BMV when only one
commissure is calcified. Calcium restricted to the body of the
leaflets is not a contraindication for BMV.
Step 2: Severity of Mitral Stenosis
MS is graded as mild, moderate, and severe depending on
valve area, mean gradient across mitral valve and tricuspid
regurgitation (TR) peak gradient [Table 5] as per the guidelines
laid down by the European Association of Echocardiography
and American Society of Echocardiography (ASE).[5] There
are other parameters to assess the severity of MS such as
mitral leaflet separation and valve area estimation by Doppler
pressure half time and continuity equation.
Two‑dimensional echocardiography
Assessment by planimetry
Mitral valve area (MVA) measured by planimetry in short‑axis
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Ganesan: Echo assessment of mitral stenosis

Table 2: Wilkins scoring system for mitral valve characteristics by echocardiography

Grade Mobility
1 Highly mobile valve with
only leaflet tips restricted
2 Leaflet mid and base
portions have normal
mobility
3 Valve continues to move
forward in diastole mainly
from the base
4 No or minimal forward
movement of the leaflets in
diastole
Thickening
Leaflets near normal in
thickness (4-5 mm)
Mid leaflets normal,
considerable thickening
of margins (5-8 mm)
Thickening extending
through the entire leaflet
(5-8 mm)
Considerable thickening
of all leaflet tissue
(>8-10 mm)
Calcification
A single area of increased echo
brightness
Scattered areas of brightness
confined to leaflet margins
Brightness extending into the mid
portions of the leaflets
Extensive brightness throughout
much of the leaflet tissue
Subvalvular thickening
Minimal thickening just below the mitral leaflets
Thickening of chordal structures extending to
one‑third of the chordal length
Thickening extending to distal third of the chords
Extensive thickening and shortening of all
chordal structures extending down to the
papillary muscles

Table 3: Objective grading of mobility of mitral

valve ‑ Reid system
H/L ratio (ab/xy) Grade Score
<0.25 Mild 0
0.25-0.44 Moderate 1
>0.45 Severe 2

Table 4: Lung and Cormier score: The French

three ‑ group grading
Echocardiographic Mitral valve anatomy
group
Group 1 Pliable noncalcified AML and mild subvalvular
disease (thin chordae, ≥10 mm long)
Group 2 Pliable noncalcified AML and severe subvalvular
Figure 3: Moderate subvalvar thickening
disease (thick chordae, <10 mm long)
Group 3 Calcification of mitral valve of any extent, as
assessed by fluoroscopy, whatever the state of Gray‑scale gain should be lowered since increased gain leads to
subvalvular apparatus blooming of echoes and underestimates the area. Inner contour
AML: Anterior mitral leaflet of mitral orifice is planimetered and commissures are to be
included if open. Three measurements on an average are taken
when the patient has sinus rhythm and five to ten measurements
Table 5: European association of echocardiography/
while the patient has atrial fibrillation. Calcification makes the
American society of echocardiography classification of
tracing difficult.
severity of mitral stenosis*
Mild Moderate Severe Mitral leaflet separation index
Specific findings (cm )2 It is measured in PLAX view and apical four‑chamber view.
Valve area >1.5 1.0-1.5 <1.0 The distance between the tips of both leaflets when widely
Supportive findings (mmHg) separated in diastole is measured for at least three cardiac
Mean gradient <5 5-10 >10 cycles, and then, the average is taken. An index of 0.8 cm or
Pulmonary artery pressure <30 30-50 >50 less predicts severe MS. 1.1–1.2 or more indicates mild MS.
*Heart rate between 60-80 in sinus rhythm
Doppler assessment
view of mitral valve correlates best with explanted valves and
Doppler gradients
Continuous wave Doppler and color‑guided parallel alignment
is the reference standard. This measurement is not affected by
of Doppler beam in apical four‑chamber view are necessary
flow conditions, compliance of LA, and presence of associated to achieve maximum velocity across mitral valve. Pulse wave
valve lesions. Doppler or high pulse repetition frequency can be of value
Smallest orifice is the maximum opening in mid‑diastole at the and give better spectral Doppler waveform because of better
tips of mitral leaflets. This is identified while scanning from signal to noise ratio.
LA to left ventricular (LV) apex and frozen for planimetry in Maximum and mean gradients are calculated by tracing the
short axis of mitral valve [Figure 4]. diastolic flow waveform. Mean gradient is hemodynamically

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Ganesan: Echo assessment of mitral stenosis
Figure 4: Planimetry of narrowest mitral valve orifice
more relevant than peak gradient because maximal gradient
depends on LA compliance, LV diastolic function, and
associated MR. Mean gradient more than 10 mmHg indicates
severe MS [Figure 5a].
Pressure half time
Pressure half time (P1/2t) is the time interval between the
maximum mitral gradient in early diastole and the time point
where the gradient becomes half of the peak initial value,
expressed in milliseconds.
Valve area is inversely related to the decline of the velocity
of diastolic transmitral blood flow. MVA is derived using an
empirical formula: MVA = 220/P1/2t cm2. P1/2t is derived by
tracing the slope of deceleration of E wave on Doppler spectral
display of transmitral flow, and the valve area is calculated
automatically by the software [Figure 5a].
When the contour of deceleration slope has two slopes, usually
the slope in mid‑diastole is traced to derive the P1/2t. In
atrial fibrillation, slope of longer diastole and an average of
five cycles should be taken. Sometimes, mid diastolic flow is
higher than early diastole, then P1/2 t method cannot be used
to assess MS [Figure 5b].
P1/2t depends mainly on mitral valve orifice. However, diastolic
compliance of LA and LV, initial gradient across mitral valve,
and contractile force of LA also contribute to P1/2t.
P1/2t is less dependent on heart rate, and flow across mitral
valve and can be used in varying R‑R intervals such as atrial
fibrillation.
Pitfalls of P1/2 t:
1. If significant aortic regurgitation (AR) coexists, increase
in LV end‑diastolic pressure decreases the late diastolic
gradient between LA and LV, leading to decrease in P1/2t
thus overestimating MVA
2. If atrial septal defect (ASD) coexists, left to right shunt
decompresses LA and decreases gradient between LA and
LV, leading to decrease in P 1/2t, thus overestimating MVA
3. If LV relaxation is abnormal, for example, LV hypertrophy,
200 Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging  ¦  Volume 1  ¦  Issue 3  ¦  September-December 2017
b
Figure 5: (a) Measuring peak, mean gradients, and pressure half time.
Mean gradient measures 14 mmHg and P1/2t of 264 ms suggesting
severe mitral stenosis. (b) In this spectral Doppler waveform, only
gradients can be measured. P1/2 t cannot be measured
then deceleration time and P1/2t are both prolonged,
leading to underestimation of MVA.
When transmitral flow does not have homogeneous deceleration,
the initial part of the slope can be ignored (first 300 ms) and
P1/2t can be obtained from the slope in mid‑diastole.
Mitral valve area by continuity equation
Continuity equation is based on the law of conservation of
mass and assumes that volume of blood flow through the
mitral annulus should be equal to flow across the mitral
orifice. LV outflow tract (LVOT) can be substituted for mitral
annulus. This substitution is valid only if there is no significant
AR [Figure 6].
Flow across LVOT = LVOT area (LVOT diameter2 × 0.785)
× LVOT velocity time integral (VTI).
Then MVA = LVOT flow/MS VTI.
Step 3: Size of Left Atrium and Spontaneous
Echo Contrast
LA size should be assessed in PLAX view. The widest
dimension anteroposteriorly is measured. Although the
American Society of Echocardiography does not recommend
this dimension as a standard measure of LA, it is an important
parameter for BMV. LA size <5 cm predicts better procedural
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Ganesan: Echo assessment of mitral stenosis

success of BMV. Aneurysmally dilated LA (>6 cm), however,
predicts unfavorable results after BMV and procedural failure.
Spontaneous echo contrast (SEC) may be present within LA.
Objective assessment of SEC is available and may be used.
LA should be carefully examined along its free wall, roof,
near appendage, and near pulmonary veins for the presence
of thrombus [Figure 7a‑e].
LA appendage should be carefully visualized in parasternal
short‑axis view and apical two‑chamber view. Size of the
appendage and presence of thrombus should be assessed. LA

b c
Figure 6: Mitral valve area by continuity equation (a) parasternal long‑axis view to measure the left ventricular outflow tract diameter (b) A4C view
to measure mitral stenosis velocity time integral (c) A5C view to measure left ventricular outflow tract velocity time integral. Left ventricular outflow
tract diameter = 1.96 cm, left ventricular outflow tract velocity time integral = 17.4 cm, mitral stenosis velocity time integral = 74.9 cm, mitral valve
area = 1.96 × 1.96 × 0.785 × 17.4/74.9 = 0.7 cm2

a b c

d e
Figure 7: (a) Ball valve thrombus (Type V). (b) Transesophageal echocardiography mid esophageal 90° 2 chamber view – pectinate muscle in the left
atrial appendage. (c) Transesophageal echocardiography mid esophageal 60° short‑axis view showing clear left atrial appendage. (d) Transesophageal
echocardiography mid esophageal 60° short‑axis view showing spontaneous echo contrast in the left atrial appendage. (e) Transesophageal
echocardiography mid esophageal 60° short‑axis view showing Type IIb thrombus in the left atrial appendage

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Ganesan: Echo assessment of mitral stenosis
appendage (LAA) thrombus confined within the appendage not
protruding into LA is usually not considered a contraindication
for BMV.
LA thrombus is classified by Prabhavathi into five types
[Table 6].[7]
Experienced operators perform BMV when there is Ia; Ib and
IIa thrombus in LA, using over the wire modification of the
procedure. IIb, III to V are absolute contraindications for BMV.
Step 4: Interatrial Septum
Interatrial septum should be carefully assessed for the presence
of patent foramen ovale or ASD (Lutembacher’s syndrome).
Interatrial septal aneurysm or bulging septum toward the
right atrium should be noted and reported because this feature
may give rise to difficulty in septal puncture. The presence of
thrombus over interatrial septum is a contraindication to BMV.
Step 5: Mitral Regurgitation
The presence and severity of MR should be assessed by
color Doppler echocardiography and Doppler interrogation.
Semi‑quantitative estimation is made by the ratio of MR jet
area and LA area. Dense spectral Doppler signals indicate at
least moderate MR. Patients can undergo BMV if the MR is
less than Grade II and MR with central jets [Figure 8a and b]
without significant calcification of the valve. However, BMV
is a relative contraindication in patients with heavily calcified
valve with more than Grade II MR or MR with eccentric
jets [Figure 9]. Corroborative evidence of significant MR is
suggested by enlarged LV. MR echocardiographic score by
Padial et al.[2] is useful to predict significant regurgitation after
BMV with high sensitivity and specificity. Three characteristics
predict significant MR after BMV. They are uneven mitral
leaflet thickening, severe subvalvar disease, and commissural
calcification. However, the occurrence of MR after BMV
is highly unpredictable. Already existing MR with central
jet may sometimes decrease after BMV because of altered
coaptation points.
Step 6: Assessment of Pulmonary Hypertension
Pulmonary arterial hypertension ensues whenever the
a b
Figure 8: (a and b) Mild mitral regurgitation, central jet – not a
contraindication for balloon mitral valvotomy
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pulmonary venous pressure raises due to increased LA
pressure. The severity of pulmonary hypertension should be
assessed. Right ventricular (RV) systolic pressure is estimated
by Bernoulli equation using TR peak gradient [Figure 10].
There is no correlation between the severity of TR and RV
systolic pressure. Organic tricuspid valve disease may coexist
with MS, and if significant tricuspid stenosis (TS) is noted,
that can also be managed by balloon valvotomy. However,
if more than moderate TR is present along with TS then
surgical management is indicated. Tricuspid annulus diameter
more than 4 cm is an indication for tricuspid annuloplasty.
Commonly right atrium and right ventricle enlarge depending
on the severity of pulmonary hypertension, and paradoxic
septal motion may be seen. In case of poor TR signal, then
pulmonary artery mean and diastolic pressures can be estimated
using pulmonary regurgitation Doppler signal.
M‑Mode echocardiography
In recent times, 2D echo and Doppler echo have taken over
M‑mode echocardiography in the diagnosis and assessment
of severity of MS. Some of the M‑mode features used are
given below.
Diastolic excursion (DE) amplitude and  EF slope can indicate
pliability and severity of MS, respectively. DE amplitude
Table 6: Manjunath classification of the left atrial and left
atrial appendage thrombus
Types I-V
Ia Thrombus confined to LAA
Ib Thrombus in LAA and protruding into LA cavity
IIa Thrombus attached to LA roof but above the plane of fossa
ovalis
IIb Thrombus reaching below the plane of fossa ovalis
III Thrombus attached to IAS
IV Mobile thrombus with attachment to roof or lateral wall
V Ball valve thrombus
LA: Left atrial, LAA: Left atrial appendage, IAS: Interatrial septum
Figure 9: Eccentric moderate mitral regurgitation – balloon mitral
valvotomy may result in severe mitral regurgitation
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Ganesan: Echo assessment of mitral stenosis
more than 18 mm indicates pliable anterior leaflet. EF slope
is decreased proportionately to the severity of MS. Usually,
EF slope 10–20 mm/s indicates severe MS. In the presence of
MR without significant MS, M‑mode feature of the anterior
motion of posterior leaflet indicates restricted mobility and
suggests rheumatic etiology.
Wilkins score
Wilkins et al. proposed a scoring system to predict the outcome
after BMV. The four important mitral valve characteristics,
namely, leaflet mobility, valve thickening, subvalvar
thickening, and calcification are given a score of 1–4 depending
on their severity.
Total echocardiographic score is 16. A score of <9 gives
optimal results after BMV; score >11 gives suboptimal results
after BMV.
Mitral regurgitation echocardiographic score
Uneven mitral leaflet thickening, severe and extensive
subvalvular deformation, and commissural calcification are
the three characteristic anatomic features associated with the
development of significant MR after BMV.
The combination of Wilkins score and Padial MR
echocardiographic score predicts the success of BMV and
occurrence of significant MR.
Step 7: Assessment of Other Valves
Aortic valve
Commonly aortic valve pathology coexists with rheumatic
mitral valve disease. The presence and severity of aortic
stenosis and regurgitation should be carefully assessed by
2D and Doppler examination. Mild degrees of aortic stenosis
and regurgitation are not contraindications for BMV. Age and
sex of the patient should be taken into consideration when
aortic valve disease coexists. For example, young female with
severe MS, mild‑to‑moderate AR with or without mild aortic
stenosis may undergo BMV safely to relieve her symptoms, so
Figure 10: Tricuspid regurgitation peak gradient measures 77 mmHg
suggesting severe pulmonary artery hypertension
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that she may complete her family before she requires another
intervention. Rarely, congenital bicuspid aortic valve may
coexist with rheumatic mitral valve disease.
Tricuspid valve
The rheumatic process affects tricuspid valve in about 7%–10%
of patients, resulting in TS [Figure 11] and/or organic TR.
Functional TR is almost always seen in significant MS. The
severity of TS is usually assessed by Doppler gradients of TS
velocity curve. An empiric constant of 190 is used for tricuspid
valve instead of 220 while calculating valve area by pressure
half time method.
Pulmonary valve
Pulmonary valve involvement is extremely rare in rheumatic
heart disease.
Step 8: Ventricular Function
Assessment of LV systolic function is an important part of
echocardiographic assessment of valvular heart disease. LV
function in MS is usually normal. LV dysfunction may be due
to myocarditis, part of active rheumatic process, or primary
muscle disease. LV dysfunction may adversely affect the
outcome after intervention.
Step 9: Contraindications for Balloon Mitral
Valvotomy
Finally, the contraindications for BMV should be looked for
specifically and reported. Features such as LA thrombus,
especially in the body or attached to interatrial septum,
bicommissural calcification, nonfusion of commissures,
severe subvalvar thickening, more than mild MR, significant
aortic valve, or tricuspid valve involvement are absolute
contraindications for BMV. Associated coronary artery disease
which requires coronary artery bypass surgery is another
contraindication for BMV. Sequelae of coronary artery disease
may be inferred by regional wall motion abnormality.
Figure 11: Apical 4 chamber view showing doming of both mitral and
tricuspid valves
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Ganesan: Echo assessment of mitral stenosis

Table 7: Summary of views and assessment of mitral stenosis

View Qualitative assessment Quantitative assessment Remarks
PLAX Mitral apparatus morphology, aortic valve LA dimension, aortic annulus, LVd, LVs Linear measurements of LV obtained in diastole
morphology, MR by color Doppler dimensions and systole. Assess all four characteristics of
Mitral annulus dimension, mitral leaflet mitral valve. Modify view to assess subvalvar
separation, MR jet area/LA area pathology
PSAX Mitral valve morphology, commissural Mitral valve area by planimetry Trace inner contour of narrowest orifice in
calcification, aortic valve morphology, LA, mid‑diastole
and LAA clot
A4C Mitral valve morphology, MR color jet Peak and mean gradient, MVA by P1/2t, MS In nonlinear mitral flow, slope in mid‑diastole is
direction, MR spectral doppler assessment VTI, TR peak gradient, TR severity, mitral used for P1/2t; TR jet area/RA area
Mitral annulus dimension, tricuspid valve leaflet separation Take average of mitral leaflet separation
morphology, and function obtained from PLAX and A4c views
IAS ‑ aneurysm and thrombus
A5C Aortic valve LVOT VTI, Doppler to assess AS and AR LVOT VTI obtained by placing sample volume
proximal to aortic valve avoiding area of flow
convergence
A2C Mitral valve morphology MR color Doppler and spectral Doppler Modified 2 chamber view used to assess LAA
LAA clot
MR: Mitral regurgitation, LA: Left atrial, LAA: Left atrial appendage, LVs: Left ventriculars, LVd: Left ventricle diameter, P1/2t: Pressure half time,
MVA: Mitral valve area, VTI: Velocity‑time‑integral, TR: Tricuspid regurgitation, RA: Right atrial, PLAX: Parasternal long‑axis view, PSAX: Parasternal
short‑axis view, IAS: Interatrial septum, LVOT: Left ventricular outflow tract, AR: Aortic regurgitation, AS: Aortic stenosis, MS: Mitral stenosis

Mid esophageal aortic short‑axis view and two‑chamber view

Box 1: Steps in approach to mitral stenosis
Assessment of mitral stenosis
Diagnose MS by 2D echo features: Doming and restricted valve
opening
Assess severity: Planimetry; mean gradient, P1/2t
Pulmonary hypertension: TR peak gradient
Coexisting MR: Eccentric or central jet and grading
Other valve disease: Aortic and tricuspid
Left atrium and LAA: Size and presence of thrombus
IAS: Aneurysm, bulge, presence of thrombus
Left and right ventricular function
Recognize contraindications for BMV‑commissural calcification;
>2+ MR; LA clot
MS: Mitral stenosis, IAS: Interatrial septum, MR: Mitral regurgitation,
LA: Left atrial, BMV: Balloon mitral valvotomy, 2D: Two‑dimensional,
P1/2t: Pressure half time, TR: Tricuspid regurgitation, LAA: Left atrial
appendage
Rhythm
Atrial fibrillation is not uncommon in MS. It is more likely
related to age and has poor correlation with the size of LA
and severity of MS. Doppler assessment of severity of MS
in atrial fibrillation requires averaging of at least five beats.
Long‑diastolic period should be selected to estimate Doppler
gradients and pressure half time.
Transesophageal Echocardiography
Transesophageal echocardiography (TEE) is useful in certain
situations, especially before BMV.
1. To rule out LA and LAA thrombus
2. To assess MR
3. To assess interatrial septum.
TEE may be used to aid septal puncture, especially during
BMV.
are used to visualize the LAA. Sometimes, pectinate muscle
within appendage is mistaken for thrombus. Usually, pectinate
muscle has the same echo texture as LAA wall.
Three‑dimensional Echocardiography
Real‑time transthoracic and transesophageal three‑dimensional
(3D) echocardiography may be useful in enhancing the
objective assessment of mitral valve morphology, especially to
visualize the narrowest orifice of mitral valve for planimetry.
Subvalvar fusion is better appreciated by 3D echocardiography.
3D estimation of MVA correlates better with catheter‑derived
values. The advantage of 3D echocardiography is that mitral
valve morphology is assessed in its entirety from single‑imaging
plane. Real‑time 3D echo (RT3DE) scoring system for MS
objectively assess mitral valve morphology.[8] Each scallop of
both leaflets is given a score taking into account, thickness,
mobility, and calcification. Subvalvar apparatus is divided into
three segments – proximal, middle, and distal third and given
score based on thickness and separation. All the score points
are summed to calculate total RT3DE score ranging from 0 to
31 points. Score more than 14 indicates severe mitral valve
involvement.
Conclusion
Echocardiography remains an invaluable tool in the assessment
of valvular heart disease. In MS, all possible echocardiographic
modalities and views [Table 7] are used to evaluate its severity
and assess suitability for BMV [Box 1].
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.

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Ganesan: Echo assessment of mitral stenosis

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