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February 26, 2017
Rheumatic Valve Disease Echocardiography

Echocardiography

Echocardiography is the key diagnostic tool used for determination of rheumatic valvular disease. Carpentier's type IIIa is the most common dysfunction seen in patients with rheumatic mitral valve. The characteristic lesions are commissural fusion with or without calcification, leaflet thickening / retraction, and chordae fusion and shortening. The hemodynamic consequence of this valvular dysfunction is mitral regurgitation associated with varying degrees of mitral stenosis.

Type IIIa dysfunction of the posterior leaflet associated with limited prolapse of the anterior leaflet (mostly A2 segment) is very characteristic of rheumatic mitral valve disease.

The presence of associated valvular lesions involving the aortic and tricuspid valves is strongly in favor of rheumatic etiology of valvular heart disease.

Echocardiography is also critical in assessing the mobility of the anterior leaflet, the extent of subvalvular apparatus lesions, and the presence and the extent of valvular calcification as they all predict the feasibility of valve reconstruction.

Finally, echocardiography is used to obtain quantitative measures such as mitral valve orifice area applying the continuity equation. Transvalvular peak and mean gradients are calculated with continuous-wave and pulsed-Doppler echocardiography using the modified Bernoulli equation. In patients with mitral stenosis and minimal symptoms, it is important to calculate transvalvular gradient at rest and during exercise. The table shown below indicates the grading of mitral stenosis.

Cesalpino Andrea
With the permission of the publisher


REFERENCES

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Martin RP, Rakowski H, Kleiman JH, et al. Reliability and reproducibility of two dimensional echocardiograph measurement of the stenotic mitral valve orifice area. Am J Cardiol 1979;43(3):560-568.

Helmcke F, Nanda NC, Hsiung MC, et al. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation 1987;75(1):175-183.

Wilkins GT, Weyman AE, Abascal VM, et al. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J 1988;60(4):299-308

Bargiggia GS, Tronconi L, Sahn DJ, et al. A new method for quantitation of mitral regurgitation based on color flow Doppler imaging of flow convergence proximal to regurgitant orifice. Circulation 1991;84(4):1481-1489.

Garbaz E, Iung B, Cormier B, et al. Echocardiographic criteria in selection of patients for percutaneous mitral commissurotomy. Echocardiography 1999;16(7, Pt 1):711-21

Enriquez-Sarano M, Seward JB, Bailey KR, et al. Effective regurgitant orifice area: a noninvasive Doppler development of an old hemodynamic concept. JACC 1994;23(2):443-451.

Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003;16(7):777-802.

Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/ASNC/SCAI/SCCT/SCMR 2007 appropriateness criteria for transthoracic and transesophageal echocardiography: a report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group, American Society of Echocardiography, American College of Emergency Physicians, American Society of Nuclear Cardiology, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, and the Society for Cardiovascular Magnetic Resonance endorsed by the American College of Chest Physicians and the Society of Critical Care Medicine. JACC 2007;50(2):187-204.


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