Radiation induced degenerative mitral stenosis: added value of three-dimensional echocardiography

by Ana Paula dos Reis Velloso Siciliano, MD, PhD, and Claudia Maria Santos, MD
National Institute of Cardiology and Ecocardiografia, Americas Medical City/Samaritano, Rio de Janeiro, Brazil

Clinical Case

  • 71-year-old woman
  • Ovarian cancer (first diagnosed at the age of 21) with lung and liver metastases
  • Chemotherapy and mediastinal radiotherapy
  • Worsening dyspnea on exertion (NYHA class II/III)

Two-dimensional transesophageal echocardiography, apical 4-chamber view showing thickening, calcification and reduced mobility of both leaflets, with main involvement of the aorto-mitral continuity and the body of the anterior leaflet. The white arrow shows a shadowing artifact due to the calcification of the aorto-mitral continuity

Two-dimensional transesophageal echocardiography, apical 2-chamber view and color Doppler flow mapping showing the obstruction to anterograde flow and mild regurgitation.

Continuous-wave spectral Doppler of transmitral flow showing severe mitral stenosis

Transthoracic three- dimensional full volume acquisition. En face view of the mitral valve from the atrial (left panel) and ventricular (right panel) perspectives. The white arrow shows the large plaque of calcium extending from the aortic root to the aorto-mitral continuity and the body of the anterior leaflet and the asterisks show the commissure that are open to distinguish degenerative from rheumatic mitral stenosis.

The flexi-slice tool allows to obtain a cut plane of the mitral orifice (left upper and right lower panels) by orienting the cut planes at the tip of the leaflets (green dotted lines showed by the green arrows) and along the opening axis of the valve (yellow dotted lines shown by the yellow arrows) to see Neuman and Neuman in San Diego and the true anatomical orifice of the mitral stenosis that can be planimetered to assess the severity of the stenosis independent on any geometric or flow assumption (mitral valve area = 0.7 cm2). The position and the orientation of the longitudinal planes are shown by the white (left lower panel) and the yellow (right upper panel) lines on the volume rendered image

The surgical specimen confirmed the diagnosis and all anatomical features identified by 3D echocardiography. Comparison of surgical specimen (lower panels) and volume rendered 3D echocardiography images (upper panels) show impressive similarities of the valves visualized from both atrial (left panels) and ventricular perspectives (right panels)

Key messages

2D/Doppler echocardiography enabled:

  • Location and assessment of the extension of calcifications
  • Visualization of the thickening and restricted motion of the leaflets
  • Estimation of transvalvulare gradient and degree of regurgitation

3D echocardiography allowed:

  • Direct visualization of mitral valve leaflet anatomy and motion
  • Direct visualization and functional assessment of mitral valve commissures
  • Accurate planimetry of the residual mitral orifice area


  1. Malanca M, Cimadevilla C, Brochet E, Iung B, Vahanian A, Messika-Zeitoun D. Radiotherapy-Induced Mitral Stenosis: A Three-Dimensional Perspective. J Am Soc Echocardiogr 2010; 23; 108.e1-108.e2
  2. Bastiaenen R, Sneddon J, Sharma R. Echocardiographic Assessment of Mantle Radiation Mitral Stenosis. Echocardiography 2016; 33; 317-9
  3. Lancellotti P, Nkomo VT, Badano LP et al. Expert consensus for multi-modality imaging evaluation of cardiovascular complications of radiotherapy in adults: a report from the European Association of Cardiovascular Imaging and the American Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2013; 14: 721-40

Ana Paula dos Reis Velloso Siciliano, MD, Phd

Dr Siciliano is a cardiologist and staff member at National Institute of Cardiology, Hospital Samaritano and Americas Medical City, in Rio de Janeiro, Brazil. She was awarded with a Master degree in cardiology in 2005 and a PhD degree in 2010 by the Federal University of Rio de Janeiro. She is member of the Cardiovascular Imaging Department (DIC) of the Brazilian Society of Cardiology. In 2013, dr Siciliano attended the 3D Echo Intensive course at the University of Padua.