Degenerative Mitral Stenosis-Diagnostic Challenges and Future Directions

Overview

Journal Rev Cardiovasc Med

Specialty Cardiology & Vascular Diseases

Date 2024 Jul 30

PMID 39077129

Authors

Abdulaziz Joury

Christopher Puleo

Anjani Golive

Yvonne Gilliland

Gregg S Pressman

Salima Qamruddin

Affiliations

Soon will be listed here.

Abstract

Determining the severity of stenosis in degenerative mitral stenosis (DMS) is fraught with challenges. Neither a high trans-mitral gradient nor a small valve area calculation is sufficiently diagnostic for DMS due to variable left atrial and left ventricular compliance in the setting of diastolic dysfunction, and the variable flow seen in patients with chronic kidney disease (i.e., high flow state) and elderly women (low flow state). Three-dimensional measurement of mitral valve area may be underestimated due to shadowing from basal calcium, and mitral valve annulus (MVA) by continuity equation (CEQ) or dimensionless mitral valve index can be erroneous in the presence of significant regurgitation of left-sided valves. The proposed dimensionless mitral stenosis index (DMSI) can be an easy echocardiographic tool to use in daily practice but needs further validation and is limited in the setting of significant regurgitation of left sided valves. Mean trans-mitral gradients 8 mmHg and pulmonary artery pressure 50 mmHg are independent predictors of mortality in those with MVA 1.5 derived by CEQ. In patients who have symptoms that are out of proportion to the degree of stenosis reported, exercise stress testing may help determine the physiologic effects of the stenotic valve. A combination of MVA by CEQ or DMSI and mean transmitral gradient at a given left ventricle stroke volume (flow) should be evaluated in larger studies.

References

Barreiro-Perez M, Caneiro-Queija B, Puga L, Gonzalez-Ferreiro R, Alarcon R, Parada J . Imaging in Transcatheter Mitral Valve Replacement: State-of-Art Review. J Clin Med. 2021; 10(24). PMC: 8706772. DOI: 10.3390/jcm10245973. View

Fox C, Vasan R, Parise H, Levy D, ODonnell C, DAgostino R . Mitral annular calcification predicts cardiovascular morbidity and mortality: the Framingham Heart Study. Circulation. 2003; 107(11):1492-6. DOI: 10.1161/01.cir.0000058168.26163.bc. View

Arbab-Zadeh A, Dijk E, Prasad A, Fu Q, Torres P, Zhang R . Effect of aging and physical activity on left ventricular compliance. Circulation. 2004; 110(13):1799-805. DOI: 10.1161/01.CIR.0000142863.71285.74. View

Silbiger J . Advances in Rheumatic Mitral Stenosis: Echocardiographic, Pathophysiologic, and Hemodynamic Considerations. J Am Soc Echocardiogr. 2021; 34(7):709-722.e1. DOI: 10.1016/j.echo.2021.02.015. View

Flachskampf F, Weyman A, Gillam L, Liu C, Abascal V, Thomas J . Aortic regurgitation shortens Doppler pressure half-time in mitral stenosis: clinical evidence, in vitro simulation and theoretic analysis. J Am Coll Cardiol. 1990; 16(2):396-404. DOI: 10.1016/0735-1097(90)90592-d. View

Unger P, Clavel M, Lindman B, Mathieu P, Pibarot P . Pathophysiology and management of multivalvular disease. Nat Rev Cardiol. 2016; 13(7):429-40. PMC: 5129845. DOI: 10.1038/nrcardio.2016.57. View

Sengupta A, Alexis S, Zaid S, Tang G, Lerakis S, Martin R . Imaging the mitral valve: a primer for the interventional surgeon. Ann Cardiothorac Surg. 2021; 10(1):28-42. PMC: 7867432. DOI: 10.21037/acs-2020-mv-16. View

Baumgartner Chair H, Hung Co-Chair J, Bermejo J, Chambers J, Edvardsen T, Goldstein S . Recommendations on the echocardiographic assessment of aortic valve stenosis: a focused update from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging. 2017; 18(3):254-275. DOI: 10.1093/ehjci/jew335. View

Cheitlin M . Stress echocardiography in mitral stenosis: when is it useful?. J Am Coll Cardiol. 2004; 43(3):402-4. DOI: 10.1016/j.jacc.2003.11.012. View

10.

Nishimura R, Rihal C, Tajik A, Holmes Jr D . Accurate measurement of the transmitral gradient in patients with mitral stenosis: a simultaneous catheterization and Doppler echocardiographic study. J Am Coll Cardiol. 1994; 24(1):152-8. DOI: 10.1016/0735-1097(94)90556-8. View

11.

Bertrand P, Churchill T, Yucel E, Namasivayam M, Bernard S, Nagata Y . Prognostic importance of the transmitral pressure gradient in mitral annular calcification with associated mitral valve dysfunction. Eur Heart J. 2020; 41(45):4321-4328. PMC: 7735814. DOI: 10.1093/eurheartj/ehaa819. View

12.

Pibarot P, Dumesnil J . Aortic stenosis suspected to be severe despite low gradients. Circ Cardiovasc Imaging. 2014; 7(3):545-51. DOI: 10.1161/CIRCIMAGING.113.001375. View

13.

Horn B, Lo K, Sengupta S, Pressman G . Exercise behavior of degenerative mitral stenosis. Int J Cardiovasc Imaging. 2020; 36(10):1845-1853. DOI: 10.1007/s10554-020-01898-2. View

14.

Al-Taweel A, Almahmoud M, Khairandish Y, Ahmad M . Degenerative mitral valve stenosis: Diagnosis and management. Echocardiography. 2019; 36(10):1901-1909. DOI: 10.1111/echo.14495. View

15.

Carpentier A, Pellerin M, Fuzellier J, RELLAND J . Extensive calcification of the mitral valve anulus: pathology and surgical management. J Thorac Cardiovasc Surg. 1996; 111(4):718-29; discussion 729-30. DOI: 10.1016/s0022-5223(96)70332-x. View

16.

Bavry A, Arnaoutakis G . Perspective to 2020 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Management of Patients With Valvular Heart Disease. Circulation. 2020; 143(5):407-409. DOI: 10.1161/CIRCULATIONAHA.120.051501. View

17.

Sud K, Agarwal S, Parashar A, Raza M, Patel K, Min D . Degenerative Mitral Stenosis: Unmet Need for Percutaneous Interventions. Circulation. 2016; 133(16):1594-604. DOI: 10.1161/CIRCULATIONAHA.115.020185. View

18.

Oktay A, Riehl R, Kachur S, Khan Z, Tutor A, Chainani V . Dimensionless index of the mitral valve for evaluation of degenerative mitral stenosis. Echocardiography. 2020; 37(10):1533-1542. DOI: 10.1111/echo.14847. View

19.

Oktay A, Gilliland Y, Lavie C, Ramee S, Parrino P, Bates M . Echocardiographic Assessment of Degenerative Mitral Stenosis: A Diagnostic Challenge of an Emerging Cardiac Disease. Curr Probl Cardiol. 2017; 42(3):71-100. DOI: 10.1016/j.cpcardiol.2017.01.002. View

20.

Anwar A, Attia W, Nosir Y, Soliman O, Mosad M, Othman M . Validation of a new score for the assessment of mitral stenosis using real-time three-dimensional echocardiography. J Am Soc Echocardiogr. 2009; 23(1):13-22. DOI: 10.1016/j.echo.2009.09.022. View