8 Key Points in assessment of Rheumatic Mitral Stenosis

Rheumatic Mitral Stenosis – Key Echocardiographic Assessment Points

1) Morphologic Features (2D Echo – Parasternal & Apical Views)

• Thickened mitral leaflets (especially leaflet tips)

• Diastolic doming of anterior leaflet (“hockey stick” appearance)

• Commissural fusion (best seen in parasternal short axis)

• Reduced leaflet mobility

• Subvalvular involvement: chordal thickening, fusion, shortening

• Calcification (late disease)

Rheumatic MS typically shows leaflet tip restriction with relatively preserved basal leaflet mobility (early disease).

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2) Mitral Valve Area (MVA) – Severity Assessment

• Planimetry (PSAX at leaflet tips in mid-diastole) – Gold standard if image quality good

• Pressure Half-Time (PHT method):

MVA = 220 / PHT

• Continuity equation (if significant MR absent)

Severity grading:

• Mild: MVA > 1.5 cm²

• Moderate: 1.0–1.5 cm²

• Severe: < 1.0 cm²

• Very severe: ≤ 0.8 cm²

Always prefer planimetry when feasible.

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3) Transmitral Doppler Assessment

• Mean transmitral gradient (CW Doppler, apical 4 chamber)

Mild: < 5 mmHg

Moderate: 5–10 mmHg

Severe: > 10 mmHg (at normal HR)

Interpret gradient with:

• Heart rate

• Cardiac output

• Rhythm (AF increases variability)

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4) Left Atrium (LA) Assessment

• LA enlargement (common and often marked)

• Spontaneous echo contrast (“smoke”)

• LA appendage thrombus (best on TEE)

LA size correlates with chronicity and AF risk.

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5) Pulmonary Hypertension

• Estimate RVSP from TR jet

• Secondary PH common in moderate–severe MS

• RV enlargement and dysfunction in advanced disease

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6) Associated Valve Lesions

• Mitral regurgitation (often mild–moderate)

• Aortic valve involvement (rheumatic multivalvular disease)

• Tricuspid regurgitation secondary to PH

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7) Wilkins Score (Balloon Valvotomy Suitability)

Four components (1–4 each):

• Leaflet mobility

• Leaflet thickening

• Calcification

• Subvalvular thickening

Total score ≤ 8 → favorable for PTMC

Score > 10 → less favorable outcome

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8) Important Pitfalls

• Tachycardia overestimates gradient

• AF → average 5–10 beats

• Significant MR → PHT unreliable

• Severe LA compliance changes affect Doppler interpretation

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Practical Structured Reporting Template

1. Morphology consistent with rheumatic disease (yes/no)

2. MVA (planimetry + PHT)

3. Mean gradient at HR ___ bpm

4. LA size and thrombus status

5. PASP/RVSP

6. MR/TR severity

7. Wilkins score

Comments

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𝘼𝙣𝙩𝙞𝙘𝙤𝙖𝙜𝙪𝙡𝙖𝙩𝙞𝙤𝙣 𝘼𝙛𝙩𝙚𝙧 𝙎𝙩𝙧𝙤𝙠𝙚 in Patient with AF and acute IS/TIA European Heart Association Guideline recommends: • 1 days after TIA • 3 days after mild stroke • 6 days after moderate stroke • 12 days after severe stroke Early anticoagulation can decrease a risk of recurrent stroke and embolic events but may increase a risk of secondary hemorrhagic transformation of brain infarcts. The 1-3-6-12-day rule is a known consensus with graded increase in delay of anticoagulation between 1 and 12 days after onset of ischemic stroke or transient ischemic attack(TIA), according to neurological severity based on European expert opinions. However, this rule might be somewhat later than currently used in a real-world practical setting.

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