What are the 4 main components of the Wilkins score in mitral stenosis?

The Four Main Components of the Wilkins Score in Mitral Stenosis

The four main components of the Wilkins score in mitral stenosis are leaflet mobility, subvalvular thickening, leaflet thickening, and leaflet calcification. 1

Detailed Breakdown of the Wilkins Score Components

The Wilkins score is a 16-point scoring system used to assess mitral valve morphology and predict outcomes after percutaneous mitral balloon valvotomy (PMBV). Each of the four components is graded from 1 to 4 points, with higher scores indicating more severe abnormalities:

1. Leaflet Mobility

• Grade 1: Highly mobile valve with only leaflet tips restricted
• Grade 2: Leaflet mid and base portions have normal mobility
• Grade 3: Valve continues to move forward in diastole, mainly from the base
• Grade 4: No or minimal forward movement of the leaflets in diastole

2. Subvalvular Thickening

• Grade 1: Minimal thickening just below the mitral leaflets
• Grade 2: Thickening of chordal structures extending up to one-third of the chordal length
• Grade 3: Thickening extending to the distal third of the chords
• Grade 4: Extensive thickening and shortening of all chordal structures extending down to the papillary muscles

3. Leaflet Thickening

• Grade 1: Leaflets near normal in thickness (4-5 mm)
• Grade 2: Mid-leaflets normal, considerable thickening of margins (5-8 mm)
• Grade 3: Thickening extending through the entire leaflet (5-8 mm)
• Grade 4: Considerable thickening of all leaflet tissue (>8-10 mm)

4. Leaflet Calcification

• Grade 1: A single area of increased echo brightness
• Grade 2: Scattered areas of brightness confined to leaflet margins
• Grade 3: Brightness extending into the mid-portions of the leaflets
• Grade 4: Extensive brightness throughout much of the leaflet tissue

Clinical Significance of the Wilkins Score

The Wilkins score has important implications for treatment decisions and outcomes:

• A total score ≤8 is associated with better outcomes after PMBV, with 84% of patients achieving good results (final valve area ≥1.5 cm² and increase in valve area ≥25%) 2
• A total score >8 predicts suboptimal results with PMBV, with only 42% achieving good outcomes 2
• Of the four components, leaflet thickening correlates best with absolute change in valve area after valvotomy (r = -0.47) 2

Practical Application in Clinical Decision-Making

The Wilkins score guides the selection of appropriate intervention:

• Patients with a low total score (<8) and elastic symmetric commissures are good candidates for PMBV 3
• Patients with a high total score (>10) and more than mild mitral regurgitation or calcification of both commissures may be better suited for surgical valve replacement 3
• The score helps predict the risk of developing significant mitral regurgitation after PMBV 4

Important Considerations and Pitfalls

• The Wilkins score should be assessed using transthoracic echocardiography, with transesophageal echocardiography reserved for cases with suboptimal imaging or to exclude left atrial thrombus before PMBV 1
• Accurate scoring requires careful assessment of the smallest mitral orifice in space and the largest opening in time 1
• 3D echocardiography may provide more accurate assessment of valve morphology but is not yet routinely used 1
• Training and experience are essential for accurate scoring, as demonstrated by educational modules that have been developed to improve scoring accuracy 5

The Wilkins score remains a cornerstone in the evaluation of mitral stenosis, guiding treatment decisions and helping predict procedural outcomes in patients with rheumatic mitral valve disease.