What is the management approach for a patient with a 'hockey stick appearance' on an Apical Four-Chamber (A4C) view of an Apical Mitral Valve Longitudinal (AMVL) echocardiogram (echo) suggesting possible mitral stenosis?

From the Guidelines

Management of a patient with a 'hockey stick appearance' on an A4C view of the AMVL suggesting mitral stenosis requires prompt evaluation and a stepwise approach, with a focus on confirming mitral stenosis and determining its severity through comprehensive echocardiographic assessment with Doppler studies, as recommended by the 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease 1. The initial step in managing such a patient involves a thorough echocardiographic assessment to confirm the diagnosis of mitral stenosis and to assess its severity by measuring the mitral valve area, mean gradient, and pulmonary artery pressure.

• Key considerations include:
  • The severity of mitral stenosis, which can be classified based on the valve area, with mild stenosis typically having a valve area greater than 1.5 cm², and moderate to severe stenosis having a valve area less than 1.5 cm² 1.
  • The presence of symptoms such as dyspnea, fatigue, or atrial fibrillation, which can guide the decision for medical therapy or definitive treatment.
  • The suitability of the valve morphology for percutaneous mitral balloon valvuloplasty (PMBV) or the need for surgical mitral valve repair/replacement. The hockey stick appearance on the echocardiogram is indicative of restricted leaflet motion due to rheumatic inflammation, leading to leaflet thickening and commissural fusion, which restricts normal leaflet mobility and creates the characteristic diastolic doming of the anterior mitral leaflet, as described in the world heart federation criteria for echocardiographic diagnosis of rheumatic heart disease 1. For patients with mild stenosis, periodic monitoring every 1-2 years and endocarditis prophylaxis for high-risk procedures are typically recommended.
• Medical therapy for moderate to severe stenosis may include:
  • Diuretics, such as furosemide, to manage pulmonary congestion.
  • Beta-blockers, such as metoprolol, or calcium channel blockers, such as diltiazem, for rate control in the presence of atrial fibrillation.
  • Anticoagulation with warfarin or direct oral anticoagulants for stroke prevention in atrial fibrillation. Definitive treatment for symptomatic severe mitral stenosis includes percutaneous mitral balloon valvuloplasty for suitable valve morphology or surgical mitral valve repair/replacement for unsuitable valves or when complications exist, as outlined in the ACC/AHA guidelines 1.

From the Research

Management Approach for Mitral Stenosis

The management approach for a patient with a 'hockey stick appearance' on an Apical Four-Chamber (A4C) view of an Apical Mitral Valve Longitudinal (AMVL) echocardiogram suggesting possible mitral stenosis involves several key considerations:

• Percutaneous Mitral Balloon Valvotomy (PMV): This procedure is a viable option for patients with mitral stenosis, particularly those with suitable valve anatomy and no significant comorbidities 2, 3.
• Patient Selection: Echocardiography plays a crucial role in selecting patients for PMV, with factors such as valve leaflet thickening, subvalvular disease, and atrial fibrillation influencing the outcome 3.
• Echocardiographic Evaluation: Conventional echocardiography is essential for diagnosing mitral stenosis, assessing valve anatomy, and guiding intervention decisions 4.
• Alternative Treatment Options: For patients with degenerative mitral stenosis or those who are high-risk candidates for surgery, alternative percutaneous treatment approaches may be necessary 5.
• Complications and Risks: PMV can result in complications such as pericardial tamponade, thromboembolism, and mitral regurgitation, emphasizing the need for careful patient selection and procedural expertise 2, 3.

Key Factors Influencing Management

The following factors influence the management approach for mitral stenosis:

• Valve Anatomy: The presence of severe valve leaflet thickening or immobility, and subvalvular disease, can impact the outcome of PMV 3.
• Comorbidities: Conditions such as atrial fibrillation, mitral regurgitation, and valvular calcification can affect the suitability of PMV 2, 3.
• Symptom Severity: The severity of symptoms, such as heart failure symptoms, can guide the timing and choice of intervention 6.