How to Diagnose Rheumatic Heart Disease (RHD) on Echocardiography

Rheumatic Heart Disease (RHD) on Echocardiography

(Guideline-oriented, practical approach)

1. Mitral Valve – Most Commonly Involved

Morphologic Features (Highly Suggestive of Rheumatic Etiology)

• Leaflet thickening (≥3 mm at leaflet tip in diastole)

• Anterior leaflet doming (“hockey-stick” appearance)

• Commissural fusion

• Subvalvular thickening and chordal shortening

• Restricted posterior leaflet motion

Mitral Stenosis (Rheumatic Pattern)

• Planimetry: Reduced MVA

• Mean gradient elevated

• Pressure half time prolonged

• Funnel-shaped valve in diastole

Rheumatic Mitral Regurgitation

• Eccentric MR jet

• Leaflet restriction rather than prolapse

• Thickened tips with preserved base (early disease)

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2. Aortic Valve Involvement

Typical Features

• Cusp thickening

• Commissural fusion

• Restricted cusp motion

• Central AR jet (coaptation defect)

Rheumatic AR often coexists with rheumatic MS.

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3. Multivalvular Disease Pattern (Clue to RHD)

• Mitral + Aortic involvement common

• Tricuspid usually secondary (functional)

• Pulmonary hypertension may be present

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4. World Heart Federation (WHF) 2012 Echo Criteria

Diagnosis based on:

A. Pathological MR or AR

PLUS

B. Morphological features of RHD

Pathological MR (All 4 Required)

• Seen in ≥2 views

• Jet length ≥2 cm

• Peak velocity >3 m/s

• Pansystolic jet

Pathological AR (All 4 Required)

• Seen in ≥2 views

• Jet length ≥1 cm

• Peak velocity >3 m/s

• Pandiastolic jet

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5. Chronic vs Acute Rheumatic Changes

Acute Carditis Chronic RHD

Leaflet edema Thickened fibrotic leaflets

Elongation Chordal shortening

Severe MR MS ± mixed lesions

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6. Practical Diagnostic Approach in Echo Lab

Step 1: Assess morphology first (commissures, chordae, leaflet tips)

Step 2: Quantify stenosis or regurgitation as per ASE

Step 3: Look for multivalve involvement

Step 4: Estimate PASP

Step 5: Exclude degenerative / congenital mimics

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Key Echo Clues That Strongly Suggest Rheumatic Etiology

• Commissural fusion (most specific sign)

• Subvalvular fusion

• Hockey-stick anterior mitral leaflet

• Multivalve disease

• Young patient with MS

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