Wilkins Score Calculator for Mitral Valvuloplasty
Wilkins Score Calculator for Mitral Valvuloplasty
Four echocardiographic features of the mitral valve, graded 1 to 4, with the long-term outcomes published by score — and the five limitations the score’s own literature lists, including the one it never looks at.
Wilkins echocardiographic score
4 items → 4–16 pointsRheumatic mitral stenosis: leaflet tips and mid portions restricted; margins considerably thickened at 6 mm with normal mid-leaflets; a single bright focus; chordal thickening reaching the distal third
Scoring, and the five published limitations
each graded 1–4 · total 4–16 · 8 or less favourable, 9–11 grey zone, 12 or more unfavourable
- the minimum is 4, not 0
- every column starts at 1, so a completely normal valve scores 4. There is no way to express “absent” on any of the four features, which is a design choice and not an omission — the score was built to grade rheumatic valves, all of which have some abnormality in every column
- the five limitations, as its own literature lists them
- echocardiography is “limited in ability to differentiate nodular fibrosis from calcification”; the score “does not account for uneven distribution of pathological abnormalities”; it “does not assess commissural involvement”; there is “frequent underestimation of subvalvular disease”; and it “does not use results from transesophageal or 3D echocardiography”. The third is usually judged the most important: the location of the disease relative to the commissures is what determines how a balloon splits the valve, and the score is blind to it
- what it does not predict
- the score grades morphology and predicts the haemodynamic result and long-term event-free survival. It is not a predictor of post-procedural mitral regurgitation, which has its own published scores, and it is not a measure of stenosis severity — valve area is a separate quantity and belongs to valve area by the Gorlin equation and to the Doppler methods
- how the number was read for this page
- the 1988 derivation paper could not be read for this record: the British Heart Journal archive sits on a server this project cannot reach. The four columns above come from a reproduction of the table as real text, with the leaflet-thickness figures corroborated from an independent source after that reproduction was found to repeat the subvalvular grade 4 wording in the thickening column. Both readings of that cell are on this page
Worked example
Rheumatic mitral stenosis: leaflet tips and mid portions restricted; margins considerably thickened at 6 mm with normal mid-leaflets; a single bright focus; chordal thickening reaching the distal third
Mobility — mid portion and base have reduced mobility: 2
Thickening — mid-leaflets normal, margins considerably thickened at 5–8 mm: 2
Calcification — a single area of increased echo brightness: 1. Note there is no score of 0 for a valve with none
Subvalvular — thickening extending to the distal third of the chordae: 3
Total 8 points, the top of the favourable band — and the one value at which the published sources disagree about which side of the boundary it sits on
Grade the subvalvular column one step higher, which the literature says is the column most often graded too low, and the total becomes 9 and the band becomes the grey zone. One column, one step, on the feature hardest to see from the chest wall
The score says nothing about the valve area: 8 points can sit on a valve of 0.8 cm² or 1.6 cm², and area is what the guidelines threshold at 1.5 cm². Compute it separately with valve area by the Gorlin equation or by Doppler
The four columns, graded 1 to 4
| Grade | Mobility | Thickening | Calcification | Subvalvular |
|---|---|---|---|---|
| 1 | Highly mobile, only the leaflet tips restricted | Leaflets near normal, 4–5 mm | A single area of increased echo brightness | Minimal thickening just below the valve |
| 2 | Mid portion and base have reduced mobility | Mid-leaflets normal, considerable thickening of the margins, 5–8 mm | Scattered brightness confined to the leaflet margins | Thickening of chordae up to one third of their length |
| 3 | Leaflets move forward in diastole mainly at the base | Thickening through the entire leaflet, 5–8 mm | Brightness extending into the mid portion of the leaflets | Thickening extending to the distal third of the chordae |
| 4 | No or minimal forward movement in diastole | Considerable thickening of all leaflet tissue, over 8–10 mm | Extensive brightness through most of the leaflet tissue | Extensive thickening and shortening of all chordae down to the papillary muscle |
Published outcomes by score
| Score | Immediate result | Longer term |
|---|---|---|
| 8 or less | Best results; comparable with surgical commissurotomy | 82% survival and 57.4% event-free survival at 12 years |
| Above 8 | 56.4% successful in one review’s body text, “only a 50% chance” in the same review’s abstract | 57% survival and 43.1% event-free survival at 12 years (p < 0.0001 against 8 or less) |
| 9 to 11 | 61% with a good immediate outcome | 39% event-free at 5 years |
| 12 or more | 36% successful | 10% event-free at 4 years |
Four features, and the one the score never looks at
The Wilkins score — often called the Wilkins–Abascal or simply the echocardiographic score — grades four features of a rheumatic mitral valve from 1 to 4 each: leaflet mobility, leaflet thickening, calcification and subvalvular thickening. The total runs from 4 to 16, because none of the columns has a zero. It was published in 1988 from an analysis of which echocardiographic variables predicted the outcome of balloon dilatation, and it has been the standard morphological assessment before percutaneous mitral valvuloplasty ever since.
The number everybody quotes is 8. Below and including it, the published immediate and long-term results are close to those of surgical commissurotomy — 82 per cent survival and 57.4 per cent event-free survival at 12 years in the largest long-term series, against 57 and 43.1 per cent above 8. Between 9 and 11 is a named grey zone where 61 per cent have a good immediate result and 39 per cent are event-free at 5 years, and a 124-patient series found grey-zone patients did as well as those scoring 8 or less on every measure it looked at. At 12 and above, 36 per cent of procedures succeeded and 10 per cent of patients were event-free at 4 years.
The score’s own literature lists five limitations, and the one that matters most is that it does not assess commissural involvement. A balloon splits a stenotic mitral valve along its commissures, so where the fibrosis and calcium sit relative to them largely determines whether the valve opens cleanly, tears a leaflet, or does nothing — and none of the four columns asks. The others are that echocardiography cannot reliably separate nodular fibrosis from calcification; that the score does not account for uneven distribution of disease; that subvalvular disease is frequently underestimated; and that the score predates and ignores transoesophageal and three-dimensional imaging.
Two boundaries to keep clear. This score is about valve morphology, not valve severity: the same 8 points can sit on an area of 0.8 cm² or 1.6 cm², and it is the area that guidelines threshold at 1.5 cm². Compute that separately — valve area by the Gorlin equation is the catheter method and lives in the haemodynamics category, which owns valve area on this site. And the score does not predict post-procedural mitral regurgitation, which has separate published instruments. A score’s output is a cohort frequency, not this patient’s probability: a stratum in which 9 per cent had an event describes that stratum, not which 9 per cent. Every figure here comes from a named cohort, and cohorts differ in case mix, era, outcome definition and treatment; where your own institution’s protocol differs, it takes precedence. This page reports what a stratum predicted in a named study. It recommends no action.
Frequently asked questions
Why is the minimum score 4 and not 0?
Because all four columns are graded 1 to 4 with no zero. A valve with no calcification visible still scores 1 for calcification. The score was designed for rheumatic valves, which have some abnormality in every column, so the floor was never meant to represent a normal valve.
Is the favourable cut-off 8 or under 8?
The sources disagree, and only at a score of exactly 8. Most text, including the long-term outcome series, dichotomises at “8 or less” against “above 8”; one series’ own table instead uses “under 8”. This page uses 8 or less, which is the majority. For a patient scoring exactly 8 the distinction is worth knowing about rather than resolving from a web page.
Does a high Wilkins score mean valvuloplasty will fail?
It means the published success rate in that stratum was lower. At 12 or more, 36 per cent of procedures in the reported series succeeded and 10 per cent of patients were event-free at 4 years; between 9 and 11, 61 per cent had a good immediate result. Those are frequencies in cohorts, and a 124-patient series found grey-zone patients doing as well as low scorers. This page does not render a procedural decision.
Which column is most often scored wrong?
Subvalvular thickening. Its own literature names “frequent underestimation of subvalvular disease” as a specific limitation: chordal thickening is hard to resolve from the chest wall and is systematically graded low. On the worked example above, moving that one column up a single step takes the total from the favourable band into the grey zone.
Does the Wilkins score tell me the valve area?
No, and conflating the two is the commonest error around this score. Morphology and area are independent: a valve scoring 8 may have an area of 0.8 or 1.6 cm². Valve area is computed by the Gorlin equation at catheter or by Doppler methods, and the 1.5 cm² threshold the guidelines use is about area, not about this score.
Related calculators
References
- Wilkins GT, Weyman AE, Abascal VM, Block PC, Palacios IF. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988;60(4):299–308. The derivation paper. It could NOT be read on this project — the archive is on PubMed Central — and the descriptors below come from reproductions.
- The four columns of grade descriptors were read as real text in an echocardiography reference’s valvuloplasty chapter, and the leaflet-thickness figures corroborated from an independent echocardiography study guide. The two disagree on one cell and both readings are printed on this page.
- Percutaneous mitral balloon valvuloplasty: state of the art — an open-access review carrying the Palacios group’s long-term outcomes by echocardiographic score, including the 12-year survival and event-free survival figures quoted here. Its own text and abstract disagree about the success rate above a score of 8, and both are printed.
- Selection of patients for percutaneous balloon mitral valvuloplasty — a retrospective series of 124 patients, November 1991 to March 2008, in the Revista Portuguesa de Cardiologia, comparing scores of 8 or less against the 9–11 grey zone, and the source for the five stated limitations of the score.
Not medical advice. For healthcare professionals and education. Reference intervals vary by laboratory and assay — always use your own laboratory's. Never base a dose or a treatment decision on this page alone. Full disclaimer at calcengines.com/disclaimer/