The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

Abstract

Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for valve surgery in Europe and despite the decline of rheumatic fever in western societies, mitral stenosis of any aetiology is a regular finding in all echo departments. Mitral valve disease is therefore one of the most common pathologies encountered by echocardiographers, as both a primary indication for echocardiography and a secondary finding when investigating other cardiovascular disease processes. Transthoracic and transoesophageal echocardiography (TOE) play a crucial role in the assessment of mitral valve disease and are essential to identifying the aetiology, mechanism and severity of disease and for helping determine the appropriate timing and method of intervention. This guideline, from the British Society of Echocardiography (BSE), describes the assessment of mitral regurgitation and mitral stenosis and replaces previous BSE guidelines describing the echocardiographic assessment of mitral anatomy prior to mitral valve repair surgery and percutaneous mitral valvuloplasty. It provides a comprehensive description of the imaging techniques (and their limitations) employed in the assessment of mitral valve disease. It describes a step-wise approach to identifying: aetiology and mechanism, disease severity, reparability and secondary effects on chamber geometry, function and pressures. Advanced echocardiographic techniques are described for both transthoracic and transoesophageal modalities, including TOE and exercise testing.

Practical Echocardiographic Approach of the Regurgitant Mitral Valve Assessment

“…The elucidation of the regurgitant mechanism has an impact on the consideration of future therapeutic options [ 3 ]. The first step in a correct filiation of MR is to classify it as primary, secondary, or mixed etiology.…”

“…Commonly, when there is a restriction of the posterior leaflet, the jet is oriented ipso-laterally, pointing out the restricted leaflet. However, in case of prolapsing leaflets, the MR jets points out away from the diseased leaflet to the LA contra-laterally [ 3 ].…”

“…The measure of the VC should be performed perpendicular to the coaptation line, and it is necessary to appreciate the jet convergence surface, the VC, and the jet expansion to the LA in the same place. Attention should be paid to ensure a high frame rate and spatial resolution [ 3 ]. A VC value smaller than 3 mm suggests mild regurgitation and when the width exceeds 6 mm indicates severity.…”

“…Their compromise can lead to mitral valve dysfunction [ 2 ]. Assessing its morphology can reveal various normal and abnormal features, which can be associated with deteriorating clinical outcomes [ 3 ]. The mitral valve has a geometry comprising the mitral annulus, the anterior and posterior leaflets, and the subvalvular apparatus.…”

“…Transthoracic echocardiography is the first diagnosis approach that should be performed to assess the valve disfunction, giving a complete morphological description of the structures, the regurgitant mechanism, and etiology [ 3 ]. In addition, the description of other cardiac structures morphology and function is necessary to make a correct evaluation of the severity of the valve disease and a pathophysiological integration, such as the dimension and remodeling of the left ventricle (LV) and left atria (LA), the filling pressures in both cavities (assessing the response of the volume overload), the existence of pulmonary hypertension, and the study of coexisting other valvular disorders.…”