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MITRAL STENOSIS

Nick Tehrani, MD

Epidemiology of MS

Hx of Rheumatic fever is elicited in only 50% of


path proven cases
Other causes
Severe MAC
Congenital MS

Clinical Diagnosis of Rheumatic Fever

Diagnosis of acute rheumatic fever


Two major Jones criteria, OR
One major criterion, and two minor criteria

Major

Minor

Carditis
Fever
Erythema marginatum
PR prolongation
Chorea
ESR elevation
Subcutaneous nodules
Hx of Rheumatic fever

Clinical Diagnosis of Acute Rheumatic


Fever
Additionally, serologic evidence of recent
streptococcal infection is needed:
Positive bacteriologic culture
Increase in ASO titers
Increase in anti-DNAse B titers

Histopathology
The acute valvular pathology caused by Rheumatic fever is:

Mitral Regurgitation
Over the next several decades stenosis accrues by:
Thickening of the leaflets
Fusion of the commisures
Fusion or shortening of the chordae

Definitions of severity of Mitral


Stenosis
Valve Area:
<1.0 cm2 Severe
1.0-1.5 cm2 Moderate
>1.5-2.5 cm2 Mild
Mean gradient:
>10 mmHg Severe
5-10 mmHg Moderate
<5 mmHg Mild

Flow Across a Normal Mitral Valve in


Diastole

Flow Across the Stenotic Valve


Persistent LA-LV gradient
in diastole sustained
flow throughout diastole
The slope of the envelope
is proportional to the
severity of stenosis

Flow Across the Stenotic Valve

Note the A in patient


who is in sinus

Diastolic Transmitral Pressure


Gradient due to Limited LV Filling

Pathophysiology

Limited flow into the LV has 3 major sequale:


Elevation of Lt. Atrial pressure
Secondary RV pressure overload
Reduced LV ejection performance
Due to diminished preload
Tachycardic response to compensate to
decreased SV worsens the transmitral
gradient

Determinants of Transmitral Pressure


Gradient
Increased
Flow, OR
Decreased
orifice size

Incr. Gradient.

Elevated LA
pressure

HR=72

HR=100

Problems
are
Variability
Introduced by:
The three inter-related parameters are:
HR

Heart rate variability

CO

CO measurement and reproducibility

Trans-mitral gradient
Mitral valve area

Different ways of Measuring Mitral


Valve Area
Echocardiographic:
PISA
2-D
Pressure half-time
Cath:
Gorlins Equation
Pressure half time

The Gorlin Equation

Torricellis Law:
Cc =Coefficient of
Orifice contraction

The Second Equation:


Cv=Coefficient of
Velocity

Area

Flow

V x Cc

V Cv

2 gh

The Gorlin Equation

Substituting for V, in Torricellis Eq.


Flow
Area
Cv x Cc x 2 x 980 x h

C
Simplification of the above:

44.3

Flow
Area
C x 44.3

The Numerator of the Equation


Area

Flow Across any Valve:

Flow
C x 44.3

CO
Flow
(SEP or DFP) (HR)
For Mitral (and Tricuspid) valve:
CO
Flow
DFP x HR

The Gorlin Equation


Substituting for Flow and h in the first Eq.:

Flow
Area
44.3 x C

CO
Flow
DFP x HR

h P

Gorlins Formula for Mitral Area


The Gorlin Formula for Mitral Valve area:

Valve Area

CO
DFP x HR
44.3 x C P

Gorlins Formula for Mitral Area

CO
DFP
HR
44.3
C

Cardiac output
Diastolic Filling Period
Heart Rate
Derived Constant
Correction factor for valve type
C=1.0 for all valves except Mitral
C=0.85 for Mitral valve

Mean pressure gradient

How Do you use this Eqn.?


Step 1: Figure out the Numerator First:

CO
Flow
DFP x HR
Dimensional analysis:

cc/min
cc/sec
(sec/beat) x (beats/min)

Valve Area

CO

DFP x HR

44.3 x C P

Figure out the DFP


DFP in
Sec/beat
Measure the Distance in mm from MV opening to MV
closing in one beat
Convert distance to time

Paper speed in mm/Sec

DFP in mm / beat

100 speed= 100 mm/sec, makes life easy


50 speed= 50 mm/sec, tough life

CO

DFP x HR
Valve Area

44.3 x C P

Figure out the Heart Rate


Assuming Patient is in Sinus
Measure the RR interval
in mm
Convert to Beats/min by

60 Sec/min Paper Speed in mm/Sec


RR mm/beat

HR in Beats/min

In 100 speed just divide


6,000 by the RR in mm

Valve Area

CO

DFP x HR

44.3 x C P

Lets Figure out the Denominator

Valve Area

CO
DFP x HR
44.3 x C P

No Mitral Stenosis

Diastolic Transmitral Pressure


Gradient due to Limited LV Filling
Left Atrial
Tracing

Need to Left Shift the PCWP Tracing

C
V

Planimeter
DFP
Shifted Over

Instrumentation

The trickiest part is to set up the instrument


correctly:
The reading must be adjusted to

0.0000

From Planimetered Area to Mean


Pressure Gradient
Area as provided by the instrument is in (in)x(in)
Must convert to (cm)x(cm)
Multiply by 6.45 cm2/In2
To obtain mean Area under the curve
Divide the Area by the DFP in cm
To convert cm of pressure to mm of Hg
Multiply the above # in cm, by the scale factor
Get Scale factor from the tracing: mm Hg/cm

How many tracings to Planimeter

If patient is in sinus =>

5 tracings

If patient is in A-Fib.=>

10 tracings

Putting things in Perspective


CC/Sec
cm2

Valve Area

CC/sec.cm2.(mm Hg)P0.5

CO
DFP x HR
44.3 x C P
mm Hg

Potential Pitfalls
Wedge vs. LA Pressure
Stiff End-hole catheter:
Cournand
Verify true wedge by checking O2 Sat
Mean Wedge should be less than Mean PA
Cardiac Output
True Fick vs. Thermodilution vs. Green dye
Concurrent MR with MS:
Gradient across the valve reflects forward and
regurgitant flow
CO reflects the net forward flow only
Likely underestimation of the true valve area

Mitral Stenosis and the LA

Even in sinus rhythm, the low velocity flow


predisposes to formation of atrial thrombi.
Low flow pattern is seen as spontaneous contrast on
echocardiography
17% of patients undergoing surgery for MS have
LA thrombus
In one third of cases thrombus restricted to the
LAA

Pulmonary Hypertension

Normal pressure drop across pulmonary bed:

10-15 mm Hg
Expected mean PA in Mitral Stenosis:
Mean LA (elevated of course) + (10-15 mm Hg)
In MS, Mean PA pressure often exceed the
expected.

Pulmonary Hypertension
This pulmonary hypertension has two components:
Reactive pulmonary arterial vasoconstriction,
Potentially Fixed resistance, secondary to
morphologic changes in the pulmonary
vasculature

How Do you use this Eqn.?


Step 1: Figure out the Numerator First:

CO
Flow
DFP x HR
Dimensional analysis:

cc/min
cc/sec
(sec/beat) x (beats/min)

Valve Area

CO

DFP x HR

44.3 x C P

Figure out the DFP


DFP in
Sec/beat
Measure the Distance in mm from MV opening to MV
closing in one beat
Convert distance to time

Paper speed in mm/Sec

DFP in mm / beat

100 speed= 100 mm/sec, makes life easy


50 speed= 50 mm/sec, tough life

CO

DFP x HR
Valve Area

44.3 x C P

Figure out the Heart Rate


Assuming Patient is in Sinus
Measure the RR interval
in mm
Convert to Beats/min by

60 Sec/min Paper Speed in mm/Sec


RR mm/beat

HR in Beats/min

In 100 speed just divide


60,000 by the RR in mm

Valve Area

CO

DFP x HR

44.3 x C P

C
A

Planimeter
DFP

From Planimetered Area to Mean


Pressure Gradient
Area as provided by the instrument is in (in)x(in)
Must convert to (cm)x(cm)
Multiply by 6.45 cm2/In2
To obtain mean Area under the curve
Divide the Area by the DFP in cm
To convert cm of pressure to mm of Hg
Multiply the above # in cm, by the scale factor
Get Scale factor from the tracing: mm Hg/cm