Mitral valve training › Guides › Rheumatic mitral disease
Rheumatic mitral stenosis and regurgitation on echo
What to look for: Thick tips, a domed anterior leaflet, a fish-mouth in PSAX.
Watch it in the simulator →Practise random casesCarpentier Type IIIa: restricted in systole and diastole. Thick, stiff leaflets: rheumatic, with fused commissures, or calcific. Jet: often posterior. The classification
Key findings
- Rheumatic disease: thickened leaflet tips, fused commissures and thickened, shortened chords. In diastole the anterior leaflet domes (the hockey-stick shape) and the parasternal short axis shows a fish-mouth orifice. Motion is restricted in systole and diastole (type IIIa).
- The Wilkins score (leaflet mobility, thickening, calcification and subvalvular thickening, each 1–4) helps judge suitability for balloon valvotomy; a low score (≤8) favours it.
- Look at the other valves: rheumatic disease often involves the aortic valve, and pulmonary hypertension brings tricuspid regurgitation. Any MR jet is often directed posteriorly.
Grading the stenosis
- Planimetry in parasternal short axis at the leaflet tips gives the reference valve area: mild >1.5 cm², moderate 1.0–1.5 cm², severe <1.0 cm²; a valve area ≤1.5 cm² is clinically significant.
- The mean gradient and the pressure half-time (valve area ≈ 220 / PHT) support it, but depend on heart rate, cardiac output, aortic regurgitation and chamber compliance; the PHT is unreliable straight after balloon valvotomy. Always state the heart rate with the gradient.
Grading the regurgitation (primary MR)
- Severe: vena contracta ≥7 mm, EROA ≥0.40 cm², regurgitant volume ≥60 ml, regurgitant fraction ≥50%. Mild: vena contracta <3 mm, EROA <0.20 cm², regurgitant volume <30 ml.
- Specific signs of severe MR: a flail leaflet or ruptured papillary muscle, a large flow convergence, and systolic flow reversal in the pulmonary veins; a dense, triangular CW signal and an E-wave-dominant inflow support it.
- Integrate several signs: no single measurement grades MR on its own.
Pitfalls
- Measure planimetry at the leaflet tips, where the orifice is smallest: a cut through the leaflet bodies overestimates the area.
In the simulator every case varies the anatomy, the jets and the measurements: watch the lesion in Learn, then grade new cases in Practice and compare your answer with the exact one.
Related
Educational simulation to use under the supervision of a clinical tutor — not for clinical use.