From the Guidelines
The visible 2D signs of rheumatic mitral stenosis on transthoracic echocardiography (TTE) apical 4-chamber view include thickened and calcified mitral valve leaflets with restricted mobility, particularly during diastole, as described in the most recent study 1. The anterior mitral leaflet typically demonstrates a hockey stick or doming appearance due to fusion of the commissures at the leaflet tips while the base remains mobile.
- The posterior leaflet often shows decreased mobility.
- Mitral valve orifice appears narrowed with a reduced opening area, which can be measured by planimetry.
- Left atrial enlargement is commonly observed as a consequence of increased pressure from the stenotic valve.
- The subvalvular apparatus may show thickening and fusion of chordae tendineae.
- The left ventricle typically appears normal in size or even small due to reduced filling. These findings reflect the pathophysiology of rheumatic heart disease, where chronic inflammation leads to scarring, fibrosis, and calcification of the valve apparatus, resulting in obstruction to left ventricular filling during diastole, as supported by guidelines from the American College of Cardiology/American Heart Association 1. The severity of stenosis correlates with the degree of these morphological changes, and assessment using TTE is essential for diagnosis and characterization, as stated in the guidelines 1. However, it is recognized that assessment of mitral stenosis severity with TTE is limited by several technical factors, thus these values are less well validated than those reported for other valve diseases, as noted in the study 1. In cases where clinical and noninvasive data are discordant, invasive hemodynamic assessment of severity of mitral stenosis may be considered in symptomatic patients, as recommended in the guidelines 1.
From the Research
Visible 2D Signs of Rheumatic Mitral Stenosis on TTE Apical 4 Chamber
- The visible 2D signs of rheumatic mitral stenosis on TTE apical 4 chamber include mitral valve leaflet thickening, calcification, and commissural fusion 2, 3.
- The assessment of subvalvular involvement, particularly chordal adhesion, can be done using 2D echocardiography, but 3D echocardiography is superior for this purpose 2, 3.
- The mitral valvular area can be accurately measured using 2D echocardiography, with a similar measurement obtained using 3D echocardiography 2, 3.
- Commissural involvement and calcification can be better detected using 3D echocardiography 3.
- The Wilkins score, which is based on 2D echocardiography, is widely used to assess the severity of rheumatic mitral stenosis, but a real-time 3D echocardiography-based score has been developed recently 3.
Importance of Echocardiography in Rheumatic Mitral Stenosis
- Echocardiography plays a key role in determining the pattern, extent, and severity of mitral valve apparatus involvement in rheumatic mitral stenosis 2, 3, 4.
- 2D and 3D echocardiography can be used to assess the severity of mitral stenosis and guide treatment decisions 2, 3, 4.
- The choice of treatment, including percutaneous mitral commissurotomy or mitral valve replacement, depends on the severity of the disease and the morphology of the mitral valve 5, 6, 4.