Assessing Mitral Valve Area and Orifice Geometry in Calcific Mitral Stenosis: A New Solution by Real-Time Three-Dimensional Echocardiography


      Planimetry of mitral valve area (MVA) is difficult in calcific mitral stenosis (CaMS) in which limiting orifice is near the annulus, and unlike rheumatic mitral stenosis (RhMS), does not present an area for planimetry at the leaflet tips. Moreover, pressure half time (PHT)-derived MVA (MVAPHT) has limitations in patients with CaMS in whom there are coexisting conditions that affect LV chamber compliance. We tested the hypothesis that real-time 3-dimensional echocardiography (RT3D) can guide measurement at the narrowest orifice in CaMS.


      In 34 patients with CaMS, MVA by RT3D (MVART3D) was obtained using a color-defined planimetry technique performed “en face” at the smallest annular orifice cross-section (diastolic maximum). MVART3D and MVAPHT were compared with an independent standard: MVA by continuity equation (MVACEQ). In a subgroup of 10 patients with CaMS or RhMS, the 3-dimensional shape of the stenotic mitral valve was examined, guided by color flow mapping.


      MVAPHT overestimated the mitral orifice area compared with MVACEQ (2.01 ± 0.52 cm2 vs 1.75 ± 0.46 cm2; P = .037), whereas there was no significant difference in MVART3D and MVACEQ (1.83 ± 0.52 cm2 vs 1.75 ± 0.46 cm2, respectively, P = .61). MVART3D had a greater correlation with MVA CEQ than MVAPHT (R = 0.86 vs 0.59 MVART3D vs MVAPHT, respectively). There was better agreement between MVA by RT3D and MVA by continuity equation than MVA by PHT and MVA by continuity equation (difference in MVA: 0.23 ± 0.15 cm2 vs 0.43 ± 0.29 cm2; P < .0001, MVART3D − MVACEQ vs MVAPHT − MVACEQ, respectively). In CaMS, there was a tubular geometry to the valve shape. In contrast, RhMS had a doming funnel-shaped geometry.


      RT3D provides an accurate measurement of MVA in CaMS. In contrast with the doming valve shape present in RhMS, the limiting anatomic orifice area occurs at the annulus in CaMS as measured by RT3D and reflects the effective orifice area as present in a tubular valve geometry.


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        • Geill T.
        Calcification of the left annulus fibrosus (230) cases.
        Acta Med Scand Suppl. 1950; 239: 153
        • Simon M.A.
        • Liu S.F.
        Calcification of the mitral valve annulus and its relation to functional valvular disturbance.
        Am Heart J. 1954; 48: 497
        • Kirk R.S.
        • Russell J.G.B.
        Subvalvular calcification of mitral valve.
        Br Heart J. 1969; 31: 684
        • Otto C.
        The practice of clinical echocardiography.
        3rd ed. WB Saunders, Philadelphia2004
        • Weyman A.E.
        Principles and practices of echocardiography.
        2nd ed. Lea & Febiger, Boston1994
        • Fulkerson P.K.
        • Beaver B.M.
        • Auseon J.C.
        • et al.
        Calcification of the mitral annulus: etiology, clinical associations, complications and therapy.
        Am J Med. 1979; 66: 967-977
        • Waller B.F.
        The old-age heart: normal aging changes which can produce or mimic cardiac disease.
        Clin Cardiol. 1988; 11: 513-517
        • Chu J.
        • Hung J.
        • Levine R.A.
        Pressure half-time for calculating mitral valve area: Is it valid in patients with calcific mitral stenosis?.
        J Am Soc Echocardiogr. 2005; 18: 550
        • Ota T.
        • Kisslo J.
        • von Ramm O.T.
        • et al.
        Real-time, volumetric echocardiography: usefulness of volumetric scanning for the assessment of cardiac volume and function.
        J Cardiol. 2001; 37: 93-101
        • Ahmad M.
        Real-time three-dimensional echocardiography in assessment of heart disease.
        Echocardiography. 2001; 18: 73-77
        • Zamorano J.
        • Cordeiro P.
        • Sugeng L.
        • et al.
        Real-time three-dimensional echocardiography for rheumatic mitral valve stenosis evaluation: an accurate and novel approach.
        J Am Coll Cardiol. 2004; 43: 2091-2096
        • Sebag I.A.
        • Morgan J.G.
        • Handschumacher M.D.
        • et al.
        Usefulness of three-dimensionally guided assessment of mitral stenosis using matrix-array ultrasound.
        Am J Cardiol. 2005; 96: 1151-1156
        • Thuillez C.
        • Theroux P.
        • Bourassa M.G.
        • et al.
        Pulsed Doppler echocardiographic study of mitral stenosis.
        Circulation. 1980; 61: 381-387
        • Hatle L.
        • Angelsen B.
        • Tromsdal A.
        Noninvasive assessment of atrioventricular pressure half time by Doppler ultrasound.
        Circulation. 1979; 60: 1096-1104
        • Quinones M.A.
        • Otto C.M.
        • Stoddard M.
        • et al.
        Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American society of Echocardiography.
        J Am Soc Echocardiogr. 2002; 15: 167-184
        • Hatle L.
        • Angelsen B.
        Doppler ultrasound in cardiology: physical principles and clinical applications.
        2nd ed. 1985 (115–22)
        • Oh J.
        • Seward J.B.
        • Tajik A.J.
        The echo manual.
        2nd ed. Lippincott-Raven, Philadelphia1999
        • Nichol P.M.
        • Gilbert B.W.
        • Kissio J.A.
        Two-dimensional echocardiographic assessment of mitral stenosis.
        Circulation. 1977; 55: 120-128
        • Martin R.P.
        • Rakowski H.
        • Kleiman J.H.
        • et al.
        Reliability and reproducibility of two dimensional echocardiograph measurement of the stenotic mitral valve orifice area.
        Am J Cardiol. 1979; 43: 560-568
        • Bland J.A.
        • Altman D.G.
        Statistical methods for assessing agreement between two methods of clinical measurement.
        Lancet. 1986; 1: 307-310
        • Peterson K.L.
        • Tsuji J.
        • Johnson A.
        • et al.
        Diastolic left ventricular pressure-volume and stress-strain relations in patients with valvular aortic stenosis and left ventricular hypertrophy.
        Circulation. 1978; 58: 77-89
        • Flachskampf F.
        • Weyman A.E.
        • Guererro J.L.
        • et al.
        Influence of orifice geometry and flow rate on effective valve area: an in vitro study.
        J Am Coll Cardiol. 1990; 15: 1173-1180
        • Thomas J.
        • Weyman A.E.
        Doppler mitral pressure half-time: a clinical tool in search of theoretical justification.
        J Am Coll Cardiol. 1987; 10: 923-929
        • Fox R.
        • McDonald T.A.
        Introduction to fluid mechanics.
        2nd ed. John Wiley & Sons, New York, NY1978
        • Daughtery R.
        • Franzini J.B.
        • Finnemore E.J.
        Fluid mechanics with engineering applications.
        McGraw-Hill, New York, NY1985
        • Gilon D.
        • Cape E.G.
        • Handschumacher M.D.
        • et al.
        Insights from three-dimensional echocardiographic laser stereolithography.
        Circulation. 1996; 94: 452-459