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Hockey Puck Appearance Mitral Valve

Systole

Hockey Stick Mitral

Fig. 1. Echocardiographic features of rheumatic mitral stenosis. (A) Diastolic doming of the thickened anterior mitral valve leaflet ("hockey stick" appearance, curved arrow) is indicative of restricted anterior leaflet motion. Note the thickened subvalvular structures, including the chordae (arrow). Note also the posterior pericardial effusion (PE). (B) A systolic frame showing thickened mitral valve leaflets. (C) Commissural fusion (arrowheads) and bilateral leaflet thickening (curved arrows) resulting in "fish mouth" appearance of the mitral valve leaflets during diastole (parasternal short-axis [PSAX] views). Dilated right ventricle (RV) with flattened interventricular "D-shaped" septum throughout the cardiac cycle (triple arrows) is indicative of right ventricular pressure and volume overload. A small posterior pericardial effusion (*) is present. (Please see companion DVD for corresponding video.)

pulmonary capillary wedge pressure, an elevated pulmonary vascular resistance and right heart chamber dysfunction. The patient's shortness of breath was likely related to an increase in her pulmonary capillary wedge pressure during exertion. An increased heart rate with activity gave her LA less time to empty and pressure would then "back-up," possibly leading to pulmonary edema and shortness of breath. Rheumatic heart disease, although now far less common in the industrialized world, remains the most common cause of mitral stenosis (Table 1).

Echocardiography has an important role in the diagnosis and assessment of mitral stenosis (Table 2).

Key aspects of the echocardiographic evaluation of mitral stenosis include the assessment of:

1. Valve and supporting structure morphology.

2. LA morphology, pulmonary arterial pressure, and right heart function.

3. Pressure gradients across the MV.

valve and supporting structure morphology

The morphology of the MV and its supporting structures provides diagnostic and therapeutic insights.

Table 1 Etiology of Mitral Stenosis

Acquired

• Rheumatic heart disease (vast majority of cases)

• Calcific mitral stenosis

• Hypereosinophilia

• Cafergot toxicity

• SLE, malignant sarcoid, mucopolysaccharidosis

• Active infective endocarditis, Whipple's disease Congenital

• Parachute mitral valve complex

• Shone's anomaly: parachute mitral valve with supra-valvar mitral ring, sub-valvular aortic stenosis and coarctation of the aorta

Table 2

Echocardiographic Features of Rheumatic Mitral Stenosis

• Thickened/calcified mitral leaflets

• Diastolic doming with "hockey stick" deformity of anterior leaflet

• Parallel anterior motion of both mitral valve leaflets

• Thickened/calcified subvalvular apparatus

• Decreased EF slope on M-mode

• Left atrial dilatation

• Atrial fibrillation with loss of A-waves on spectral Doppler

• Spontaneous echocontrast and left atrial thrombus (best observed by transesophageal echocardiography)

• Mitral regurgitation

• Signs of increased right-sided pressure and volume overload secondary to pulmonary hypertension— sequelae of chronic significant mitral stenosis—e.g., right ventricle hypertrophy, tricuspid regurgitation, dilatation of right heart chambers

For example, fused leaflet tips and a "hockey stick" appearance of the anterior mitral leaflet implicate rheumatic fever (Figs. 1A and 2; please see companion DVD for corresponding video for Fig. 1), whereas marked mitral annular echodensities implicate mitral annular calcification.

Therapeutically, when mechanical treatment options are being considered, the morphology of the MV and its supporting structures influences the choice between MV replacement and PMV. Grossly, a thin mobile noncalci-fied MV without subvalvular thickening is amenable to

PMV. Whereas, a thickened, nonmobile, calcified MV with subvalvular thickening is not a good PMV candidate. The MV score, which is derived from the morphology of the MV and its supporting structures, helps to more objectively guide this decision by predicting the outcome after PMV (Table 3). Overall, as the MV score increases, the potential for procedural success decreases. A valve score of less than eight is associated with a good outcome. However, the decision regarding which mechanical option to utilize is a highly individualized one (Fig. 3C-E; please see companion DVD for corresponding video).

Two factors whose presence weigh strongly against (if not preclude) proceeding with PMV are co-existent LA thrombus and moderate to severe mitral regurgitation. First, a LA thrombus may become dislodged and embolize during PMV. Consequently, anticoagulation before PMV or surgical correction in lieu of PMV may be considered. Frequently, a transesophageal ECHO is necessary to evaluate fully for the presence of LA and LA appendage thrombus, as the standard transthoracic ECHO lacks sensitivity for this finding (Fig. 3A,B; please see companion DVD for corresponding video). Secondly, mitral regurgitation may be increased by PMV. Hence, coexistent moderate to severe mitral regurgitation may render PMV undesirable.

la morphology, pulmonary arterial pressure, and right heart function

Mitral stenosis may impact "proximal" cardiac chambers and blood vessels, such as the LA, pulmonary vas-culature and right ventricle (Fig. 3; please see companion DVD for corresponding video). For example, elevated LA pressure may lead to LA enlargement, as noted in the above patient's ECG. This enlargement may predispose the patient to atrial fibrillation and its pathological sequelae, such as thromboembolism.

Elevated LA pressure is also transmitted back to the pulmonary vasculature. Although initially reversible, these elevated pressures may become largely fixed as the pulmonary vasculature remodels, and permanent pulmonary hypertension can ensue.

PASP is estimated by summing (1) the pressure gradient between the pulmonary artery and right atrium, as derived from the modified Bernoulli equation, 4 V2, where V is the tricuspid regurgitant jet velocity (assuming no pulmonary stenosis) and (2) the estimated right atrial pressure (RAP). In other words, PASP = 4 V2 + RAP. With

Mode Image Pulmonary Stenosis

Fig. 2. M-mode echocardiogram in mitral stenosis. The M-mode echocardiogram in rheumatic mitral stenosis typically shows prolongation of the ejection fraction slope (arrow). Note the "hockey stick" appearance of the anterior leaflet of the mitral valve in the parasternal long axis (PLAX) still-frame image.

Fig. 2. M-mode echocardiogram in mitral stenosis. The M-mode echocardiogram in rheumatic mitral stenosis typically shows prolongation of the ejection fraction slope (arrow). Note the "hockey stick" appearance of the anterior leaflet of the mitral valve in the parasternal long axis (PLAX) still-frame image.

Table 3

Mitral Valve Scoring Criteria for Predicting Outcome of Balloon Valvuloplasty

Table 3

Mitral Valve Scoring Criteria for Predicting Outcome of Balloon Valvuloplasty

Grade

Leaflet mobility

Subvalvular thickening

Valve leaflet thickening

Calcification

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