Reading Your Echocardiogram Report

An echocardiogram (or “echo”) is an ultrasound of your heart that allows doctors to see exactly how rheumatic heart disease has changed the structure of your heart. In rheumatic disease, the immune system’s attack causes the valves to become thick, stiff, and scarred ^[1][2].

How Rheumatic Valves Change

The echo looks for a specific “look” that identifies rheumatic damage. As the valves try to heal from inflammation, they undergo three main changes:

• Thickening: The delicate, tissue-paper-thin leaflets of the valve become thick and bulky ^[1].
• Commissural Fusion: This is a hallmark of rheumatic disease. The “commissures” are the corners where the valve leaflets meet. In RHD, these corners scar and fuse together, making the opening smaller ^[2][1].
• Calcification: Over time, the scarred tissue can turn hard and “bony” due to calcium deposits, making the valve even less flexible ^[1][3].

While the mitral valve is the most commonly affected, rheumatic disease frequently affects the aortic valve and sometimes the tricuspid valve ^[4][5]. Your report should assess all four heart valves.

Understanding Your Echo Numbers

Your report will contain several measurements that determine how advanced your condition is. Doctors never use just one number to make a decision; they look at the whole picture.

1. Mitral Valve Area (MVA)

This is a measurement of the actual size of the valve opening. In a healthy heart, the mitral valve is quite large (4.0 to 6.0 cm²).

• Clinically Significant (Moderate-to-Severe): MVA ≤ 1.5 cm². This is often the threshold where doctors begin considering treatments closely ^[6].
• Severe Stenosis: Often defined as MVA ≤ 1.0 cm² ^[7].
• Note: MVA is not interpreted alone. Your doctor must weigh it against how much blood is flowing and your symptoms.

2. Transmitral Mean Gradient

This measures the “pressure drop” across the valve. Because the opening is narrow, the heart has to build up pressure to push blood through. A higher gradient usually means more severe narrowing. However, this number can fluctuate wildly based on your heart rate or if you are in atrial fibrillation during the test ^[8][9].

3. Pulmonary Artery Systolic Pressure (PASP)

When the mitral valve is blocked, pressure “backs up” into the blood vessels of your lungs. An echo PASP above 40 mmHg is an estimate that pulmonary pressures might be high ^[10][11]. However, this is just an estimate with technical limitations, not a definitive diagnosis. If your doctor suspects severe pulmonary hypertension, they may order a right-heart catheterization to confirm it.

Secondary Changes: The “Back-Up” Effect

The echo also looks at how the rest of your heart is reacting to the damaged valve.

• Ejection Fraction (EF): This measures how well the left ventricle pumps with each beat. A normal EF is usually 50% or higher.
• Left Atrial Dilation: Because blood gets stuck waiting to go through the mitral valve, the left atrium (the chamber above the valve) stretches out and becomes enlarged ^[12].
• Thrombus (Clot) Check: An enlarged left atrium is a high-risk area for blood clots. Crucially, a routine standard echo (transthoracic) cannot reliably see the left atrial appendage where most clots hide. Just because your routine echo doesn’t mention a clot does not mean one isn’t there ^[13]. Doctors often order a Transesophageal Echo (TEE)—an ultrasound down the throat—to definitively check for clots before a procedure.

Echo Report Completeness Checklist

A high-quality echo report for rheumatic heart disease should evaluate:

1. Valve Anatomy: Detailed description of thickening, fusion, and calcification for all four valves ^[1].
2. MVA Measurement & Regurgitation: How narrow the valve is (MVA) and grading of any leaking (mild/moderate/severe) ^[14].
3. Mean Gradient: The average pressure difference across the valves ^[8].
4. Chamber Sizes & Function: Measurements of the left atrium, right ventricle, and left ventricular ejection fraction (EF) ^[15].
5. Lung Pressures: An estimate of the PASP ^[10].
6. Rhythm: Whether your heart was in a normal rhythm or atrial fibrillation during the test ^[1].