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PubMed1986

Two-dimensional echocardiographic evaluation of the severity of mitral stenosis with reference to the prediction for mitral valve commissurotomy or replacement.

Thirty patients with mitral stenosis were classified into three grades of severity reflected by anterior mitral leaflet and subvalvular apparatus using two-dimensional echocardiography in order to study the possibility of predicting the type of surgery indicated, and were evaluated pre- and postoperatively for systolic and diastolic volumes; left heart function using left ventricular posterior wall movement (LVPWVSmax, LVPWVdmax) and posterior wall excursion (PWE) and newly devised left atrial empty volume ratio (LAEVR). The LVPWVSmax was increased from 57 +/- 7 to 74 +/- 7 mm/s (p less than 0.001) in grade I, from 48 +/- 13 to 63 +/- 9 mm/s (p less than 0.02) in grade II, and from 44 +/- 6 to 64 +/- 7 mm/s (p less than 0.001) in grade III. The LVPWVdmax showed an increase from 68 +/- 15 to 91 +/- 15 mm/s (p less than 0.001) in grade I, from 57 +/- 17 to 86 +/- 18 mm/s (p less than 0.01) in grade II, and from 55 +/- 11 to 83 +/- 6 mm/s (p less than 0.01) in grade III. In the PWE, there was an improvement from 12.4 +/- 1.6 to 15.5 +/- 2.1 mm (p less than 0.01) in grade I; from 10.5 +/- 2.0 to 12.5 +/- 1.5 mm (p less than 0.02) in grade II; and from 9.4 +/- 1.5 to 14.4 +/- 1.5 mm (p less than 0.001) in grade III. In the LAEVR, there was also an improvement from 65 +/- 12 to 39 +/- 21% (p less than 0.01) in grade I.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1977

[Behaviour of erythrocytes in patients with aortic of mitral stenosis (author's transl)].

The behaviour of red blood cells was studied in 17 patients with aortic stenosis and 14 patients with mitral stenosis. Anemia was present only in 1 out of 17 patients with highgraded aortic stenosis. 8 of the 17 patients showed a reduced survival time of the red blood cells indicating hemolysis in a compensated stage. 14 cases of mitral stenosis showed no evidence of hemolysis. There was a significant inverse relationship (r = --0,85) between the valve gradient and the survival time of the erythrocytes in patients with aortic stenosis; valve area and survival time were directly related (r = 0,75). In mitral stenosis, there was no significant correlation between gradient or valve area and survival time. This suggests that the gradient through the valve rather than the reduced valve area is responsible for the damage of the erythrocytes; in addition, hemolysis appears to be dependent on pressure gradient rather than on valve pathology or reduction of valve area per se.

Anemia↗
PubMed2003

Sequential assessment of mitral valve area during diastole using colour M-mode flow convergence analysis: new insights into mitral stenosis physiology.

AIMS: In mitral stenosis (MS) transvalvular flow and velocity continually change throughout diastole but for mitral valve area (MVA), flow-dependent variations (valve reserve) are unknown. These physiologic changes can be studied by the proximal isovelocity surface area (PISA) method, using the high temporal resolution of colour M-mode, essential for simultaneous measurements of flow and velocity. Hence, we aimed to validate the colour M-mode PISA method for measurement of MVA in MS and to define using this method the physiologic flow-dependent changes of MVA during diastole. METHODS AND RESULTS: In 50 patients with native MS, MVA was measured by planimetry (MVA-2D), Doppler pressure half-time (MVA-PHT), and two-dimensional PISA (2D-PISA). MVA measurement by colour M-mode PISA in early diastole (M-PISA) (1.27+/-0.46 cm(2)) with rigorously timed flow and velocity measurements by continuous wave Doppler did not differ and correlated well with MVA-2D (1.29+/-0.44 cm(2), p=0.59; r=0.85, p<0.001) and MVA-PHT (1.30+/-0.41 cm(2), p=0.52; r=0.80, p<0.001). In contrast a trend towards underestimation of MVA by 2D-PISA was observed (1.23+/-0.42 cm(2); p=0.10 and p=0.07). Timed analysis of transvalvular haemodynamics at early, mid, mid-late, and late diastole showed marked changes in flow and velocities (both p<0.0001) but not in MVA (respectively 1.27+/-0.46, 1.29+/-0.47, 1.28+/-0.51 and 1.27+/-0.49 cm(2); ns). CONCLUSIONS: In MS, the high temporal resolution of colour M-mode PISA allows accurate MVA measurements. It also allows for the first time, sequential MVA assessment during diastole. Notwithstanding marked flow and velocities changes, MVA remained unchanged throughout diastole underscoring the lack of flow-related valvular reserve in MS.

Blood Flow Velocity↗
PubMed1979

Changing diastolic closure rates (E to F slopes) in a patient with mitral stenosis: a case report.

A patient with mitral stenosis and atrial flutter was found to have a normal diastolic closure rate (E to F slope). Following cardioversion, the typical echocardiographic features of mitral stenosis were found. After various interventions that increased heart rate, however, the diastolic closure rate increased. This report demonstrates, therefore, that the E to F slope is not always a fixed value in mitral stenosis and that under certain conditions it may even appear to be normal.

Diastole↗
PubMed1975

Posterior mitral leaflet motion in mitral stenosis.

A reduced rate of diastolic closure of the anterior mitral leaflet has been shown to occur in mitral stenosis, primary pulmonary hypertension, and in cases with reduced left ventricular compliance. Posterior notion of the posterior mitral leaflet in diastole has been the distinguishing feature to rule out the diagnosis of mitral stenosis. We have analyzed echocardiograms of 167 patients with mitral stenosis and have found 16 cases where the posterior mitral leaflet moved posteriorly, that is, in an opposite direction from the anterior mitral leaflet. Two other features were found that were helpful in establishing the diagnosis of mitral stenosis in these atypical cases, namely, thickening of the mitral leaflets and reduction or absence of the artrial wave.

Adolescent↗
PubMed1995

Supravalvar mitral stenosis: risk factors for recurrence or death after resection.

OBJECTIVE: To assess the medium term outcome in infants and children after surgical resection of supravalvar mitral stenosis with special reference to risk factors for mortality or recurrence of supravalvar mitral stenosis. No detailed follow up has been previously reported in this uncommon condition. DESIGN: Prospective cross sectional clinical and echocardiographic follow up. SETTING: Paediatric cardiothoracic unit. PATIENTS AND METHODS: 23 consecutive children (14 male, nine female, mean age 3 years 2 months at surgery) who underwent resection of supravalvar mitral stenosis between 1978 and 1993. RESULTS: Follow up was for a mean of 58 months (range 0.5-167) after resection of supravalvar mitral stenosis. Four patients developed recurrent supravalvar mitral stenosis: this has not been reported previously. This was recognised 14-108 months after resection and confirmed at repeat operation. Three of these patients had successful reoperations but one died. Five other patients died. On multivariate analysis the only variable associated with survival free of recurrent supravalvar mitral stenosis was older age (18 months or more) at time of surgery (hazard ratio 0.17, 95% confidence interval (CI) 0.03 to 0.95, P < 0.05). Five year actuarial survival free of recurrent obstruction when supravalvar mitral stenosis was resected at age less than 18 months was only 39% (95% CI 9 to 69%) compared with 73% (95% CI 24 to 93%) in older patients. CONCLUSION: Supravalvar mitral stenosis is part of a spectrum of obstructive lesions affecting the left heart. Recurrent supravalvar mitral stenosis can develop after surgical resection. The prognosis in those who require resection within the first 18 months of life is poor: mortality is high, as is the risk of recurrent supravalvar mitral stenosis in survivors, probably because of continuing turbulent flow across a small left ventricular inflow tract.

Age Factors↗
PubMed1991

Correlation between the position of transducers and mitral valve gradient in mitral stenosis.

To assess the severity of mitral stenosis related to the level of transducers, the mitral valve gradient using pulmonary wedge and left ventricle was obtained from 15 patients. The mitral gradient was obtained with both transducers at mid chest level. Then, the level of each transducer was realigned with the catheter tip in the pulmonary capillary wedge and in the left ventricle using lateral fluoroscopy and the mitral gradient was re-measured. At the mid chest level, the mean mitral valve gradient was 14 +/- 6.2 mm Hg with a mitral valve area of 1.3 +/- 0.6 cm2. With the adjusted level of transducers, the mitral valve gradient was 18.7 +/- 6.8 mm Hg with a valve area of 1.0 +/- 0.5 cm2. The difference was that the level of catheter tip in the wedge was 3.5 cm below the mid chest level and the one in the left ventricle was 2.5 cm higher than the mid chest level. This result suggested that the mitral valve gradient obtained at mid chest level underestimated the severity of mitral stenosis.

Cardiac Catheterization↗
PubMed1981

M-mode echogram as a means of distinguishing between mild and severe mitral stenosis.

Fifty-two patients with pure mitral stenosis (27 with severe stenosis and 25 with mild stenosis) were studied to assess the ability of different M-mode echocardiographic measurements to separate mild and severe disease. Variables related to valve motion, for example diastolic closure rate, the mitral valve closure index, and the amplitude of valve motion, accurately divided patients with mitral stenosis from normal subjects but did not distinguish usefully between mild and severe disease. In contrast, variables dependent on left ventricular dimension change in diastole, for example the rapid filling period and the peak rate of left ventricular diastolic dimension change, accurately separated mild and severe disease. No patient with severe mitral stenosis had a rapid filling period, whereas 21 of the 25 patients with mild disease did have one. The peak rate of left ventricular diastolic dimension change was less than 10 cm/s or less than 2.4 cm/s per cm when normalised for left ventricular dimension in all patients with severe disease and in only six of the 25 patients with mild disease.

Echocardiography↗
PubMed1987

Myocardial enzyme activities in patients with mitral regurgitation or mitral stenosis.

To determine the adaption of myocardial metabolism in mitral regurgitation and mitral stenosis, human papillary muscles obtained during open heart surgery were analysed to measure selective enzyme activities in energy metabolism. All enzyme activities were expressed per unit dry weight muscle, per unit alkali soluble protein, and per unit total creatine and the different results compared. The activities of enzymes concerned with mitochondrial energy production and energy transfer (namely, citrate synthase and mitochondrial creatine kinase) tended to be higher in papillary muscles from hearts with mitral regurgitation than in those with mitral stenosis. The activities of enzymes concerned with cytoplasmic energy production (creatine kinase MM, lactate dehydrogenase, and phosphofructokinase) did not show statistically significant differences between mitral regurgitation and mitral stenosis. The ratio of creatine kinase MB activity to total creatine content showed the greatest difference when papillary muscles from patients with mitral regurgitation and mitral stenosis were compared (31% higher in mitral regurgitation; p less than 0.001). The specific function of creatine kinase MB, which is located in cytoplasm, is not well defined. Creatine kinase MB activity increases with extreme endurance training of human skeletal muscle. Thus the higher creatine kinase MB activity in papillary muscle of mitral regurgitation may represent an adaptation to increased physical demand.

Adult↗
PubMed1976

The effect of nitroglycerin upon pulmonary and left atrial pressures in patients with mitral stenosis.

In all nine patients studied with mitral stenosis and no evidence of left ventricular failure, nitroglycerin caused a decrease in pulmonary arterial, left atrial, and left ventricular pressures and pulmonary vascular resistance. The decrease in left atrial pressure was attributable to the combination of a reduction in left ventricular filling pressure and a reduction in mitral valve gradient. While there was no significant mean change in heart rate, cardiac index, or mitral valve flow, there was a significant correlation between a decrease in each of these determinants of mitral valve gradient and the observed decline in left atrial pressure in individual patients. However, even those patients who had an increase in heart rate or cardiac output, either of which normally aggravates pulmonary congestion in mitral stenosis, had a decrease in their pulmonary and left atrial pressures in response to TNG. It is likely that nitroglycerin reduced pulmonary and left atrial pressures by either (1) systemic venous dilatation, causing a reduction in right heart filling and pulmonary blood volume, or (2) pulmonary arteriolar and venous dilatation, causing a decrease in pulmonary vascular resistance and an increase in pulmonary vascular compliance. Because of the efficacy of TNG in lowering pulmonary and left atrial pressures in this study, TNG may prove useful in the clinical management of symptomatic pulmonary congestion in mitral stenosis.

Blood Pressure↗
PubMed1989

Percutaneous balloon mitral valvuloplasty in children and young adults with rheumatic mitral stenosis.

Twenty-eight patients with mitral stenosis, 17 females and 11 males, underwent percutaneous balloon mitral valvuloplasty (BMV). The age range was 10 to 30 (mean 17.8 +/- 6.7) years and all were symptomatic (New York Heart Association [NYHA] class III, 12 patients; class IV, 16 patients). BMV was done with a single balloon in 10 patients and double balloon in 16 patients. Following BMV, there was a significant reduction in transmitral end-diastolic pressure gradient from 23.1 +/- 5.8 to 7.6 +/- 4.2 mm Hg (p less than 0.001) and a significant increase in mitral valve area from 1.06 +/- 0.29 to 2.64 +/- 1.35 cm2 (p less than 0.001), along with an increase in cardiac index from 3.40 +/- 1.18 to 4.26 +/- 1.46 L/min/m2 (p less than 0.01). Improvement in symptomatic status by at least one NYHA class was seen in all patients. Mild mitral regurgitation developed in four and moderate mitral regurgitation developed in one patient. Angiographic evidence of atrial septal defect was present in one patient. Follow-up at 8 to 12 weeks in 12 patients has shown sustained hemodynamic improvement. These short-term results indicate that BMV is an effective nonsurgical procedure for the management of patients with rheumatic mitral stenosis.

Adolescent↗
PubMed1990

[Value and limitations of the pressure halftime method for quantitating the mitral valve area in mitral stenosis].

To evaluate the accuracy of the pressure half-time (PHT) method in predicting the anatomical mitral valve area (Aa) in mitral stenosis, Doppler echocardiography was performed in 42 cases with mitral stenosis within 48 hours before mitral valve replacement. The diastolic mitral flow velocities were recorded by the continuous wave Doppler technique, and PHT and the derived mitral valve area (Ad) were measured by a computer system from the Doppler spectrum. Aa was measured from a photograph of the mitral valve excited en bloc at surgery. The comparison between Aa and Ad yielded a good correlation (r = 0.85). However, Ad significantly underestimated Aa (P less than 0.001) in cases with combined mitral stenosis and regurgitation, and significantly overestimated Aa in cases with combined mitral and aortic lesions. There was also a large scatter of data obtained by the two measurements (SEE = 0.41 cm2). It is concluded that the PHT method can predict Aa in isolated mitral stenosis with an acceptable accuracy but is of only limited value in combined mitral stenosis and regurgitation or combined mitral and aortic valve lesions.

Adolescent↗
PubMed2003

Mitral stenosis due to fibrous tissue overgrowth after mitral valve repair.

We report an extremely rare case of fibrous tissue overgrowth 3 years after mitral valve repair using a mitral annuloplasty ring in a 53-year-old woman who underwent mitral valve replacement for mitral stenosis. Whitish fibrous tissue had overgrown from the ring on the atrial side of the annulus, and had severely reduced the valvular area. However, the motion of the mitral leaflets was not restricted. Considering the presence of concomitant aortitis syndrome, it is strongly suggested that the overgrowth of fibrous tissue was promoted as a reaction to chronic inflammation.

Cardiac Catheterization↗
PubMed2005

Balance between plasma levels of tumor necrosis factor-alpha and interleukin-10 in rheumatic mitral stenosis.

The study population consisted of 16 patients with rheumatic mitral stenosis undergoing percutaneous transluminal mitral valvuloplasty (group 1). The plasma levels of tumor necrosis factor-alpha (TNF-alpha) and interleukin-10 (IL-10) in the femoral vein and the right and left atria before valvuloplasty were determined by ELISA. Additionally, we measured plasma concentrations of TNF-alpha and IL-10 in the venous blood obtained from 19 control patients, including 12 healthy volunteers in sinus rhythm (group 2) and 7 patients in permanent lone atrial fibrillation (group 3). The venous plasma levels of TNF-alpha were significantly elevated in group 1 patients compared with group 2 patients (p < 0.002). Correlation analysis demonstrated that there was a significantly direct relationship between the plasma TNF-alpha and IL-10 concentrations in the left atrial, right atrial and peripheral venous blood (p < 0.008, r = 0.640; p < 0.04, r = 0.538; p< 0.03, r = 0.571, respectively). In conclusion, the plasma concentrations of TNF-alpha of patients with rheumatic mitral stenosis were significantly higher than those of healthy volunteers. In addition, there was a significantly direct relationship between the soluble TNF-alpha and IL-10 concentrations in the atrial and peripheral venous blood, indicating a balance between circulating TNF-alpha and IL-10 levels in patients with rheumatic mitral stenosis.

Adult↗
PubMed1992

[Echocardiographic study of 53 patients with rheumatoid mitral stenosis].

In 53 patients with rheumatic mitral stenosis we performed echocardiographic study in order to define anatomic and functional alterations. We used 3.5 MHZ probe and obtained images from apical and parasternal windows. Determinations were performed by standards of the American Society of Echocardiography. Thirteen patients were men and forty women. Men's mean age was 43.5 years and women's mean age 40 years. In the men anatomic mitral valve area was 1.1 cm2 and in the women 1.3 cm2. Correlation anatomic to functional valve area was strong (r = 0.9). Mitral diastolic gradient had correlation with cardiac output, mitral valve area and ejection fraction. Pulmonary artery pressure had strong correlation with valve area and cardiac output. In conclusion, our study showed the usefulness of functional valve area in the graduation of mitral stenosis, the dependence of the mitral diastolic gradient of several cardiac events, the independence of the left atrium dimensions and also the strong dependence of pulmonary artery pressure of cardiac output and valve area.

Adult↗
PubMedDate not supplied

[Comparison between echocardiographic and hemodynamic indices in the evaluation of mitral stenosis].

The echocardiographic data (the amplitude of the mitral echogram, the velocity of the E to F slope and the dimension of the left atrium) of 12 patients with mitral stenosis were compared with hemodynamic data obtained during a cardiac catheterization (the mitral valve area and the peak left ventricular filling rate, expressed in millimeters/second [dv/dtD] and normalized by the end-diastolic volume [dv/dtD/VTD seg-1]). None of the echocardiographic variables showed a good correlation with the hemodynamic indices. It is concluded that echocardiography is a useful total in the diagnosis of mitral stenosis, but at the same time there is not a single echocardiographic sign which by itself evaluate correctly the severity of mitral stenosis.

Adult↗
PubMed2003

[Mitral stenosis].

The decrease in the incidence of acute rheumatic fever in western countries has led to a sharp decrease in the incidence of mitral stenosis. This decrease also modifies the clinical presentation and mitral stenosis is now encountered in older patients who have severe impairment of valve anatomy. In developing countries, mitral stenosis remains a frequent disease. The management of patients with mitral stenosis has been modified by the development of percutaneous mitral commissurotomy whose safety and efficacy have been demonstrated in a number of studies with a follow-up of up to ten years. Percutaneous mitral commissurotomy is now the reference treatment for mitral stenosis with pliable valves in young patients and its efficacy has been validated in randomised trials versus surgery. Mitral stenosis in older patients, as it is encountered in western countries, is a more heterogeneous group. Predictive analysis has shown that the predictions of immediate and late results are multifactorial. This has led to consider the indications for percutaneous mitral commissurotomy in patients who do not have ideal anatomic conditions, when their other characteristics are favourable. This is particularly the case in young patients who do not have a very tight mitral stenosis (1-1.5 cm2) and who do not have an advanced heart disease. When the conditions are favourable, percutaneous mitral commissurotomy can be considered in patients who have few symptoms, in particular in order to reduce the thromboembolic risk.

Age Factors↗
PubMed2005

'Frozen' posterior mitral leaflet in rheumatic mitral stenosis: incidence and impact on outcome of balloon mitral commissurotomy.

BACKGROUND AND AIM OF THE STUDY: The incidence and clinical significance of immobile and 'frozen' posterior mitral leaflet (FPML) were evaluated in the pathophysiology and immediate outcome of patients with severe pliable mitral stenosis (MS) undergoing percutaneous balloon mitral commissurotomy (PBMC). METHODS: During the past four years, 30 'ideal' patients (mean age 46 +/- 8 years) with Wilkins' score <8, bilateral commissural fusion and absence of commissural calcification underwent peri-procedural echocardiographic analysis. Anterior mitral leaflet (AML) mobility index (MI), chordae tendineae (CT) length, and mitral valve area (MVA) were evaluated. RESULTS: Pre-procedure FPML was noted in 28 patients (93%). All patients achieved MVA > or = 1.5 cm2. Post-procedure MVA in patients with bilateral commissural splitting was 1.9 +/- 0.2 cm2 versus 1.6 +/- 0.1 cm2 in patients with unilateral commissural splitting (p < 0.05). CT lengths directed to the AML and PML were 15 +/- 2 mm and 8 +/- 2 mm, respectively (p < 0.05). MI of the AML before and immediately after PBMC was 0.4 and 0.6, respectively (p < 0.05). None of the patients with FPML showed improved mobility following successful PBMC. CONCLUSION: FPML may be found in most patients with pliable MS. It is mainly a result of short, rigid and fused CT directed to the PML. A 'single-wing door' or a unicuspid valve may be used as a model for rheumatic pliable MS. It is suggested that pre-procedure leaflet morphology and functional assessment should focus on the AML.

Catheterization↗