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PubMed1991

Endpoints of treadmill exercise testing for functional evaluation of patients with mitral stenosis.

The study was performed on 122 patients proved by catheterization to have dominant mitral stenosis so as to define proper endpoints of exercise testing for functional evaluation. This represents the 14-year experience with mitral stenosis in our exercise laboratory. Of them, we investigated 126 who completed clinically event-free Naughton treadmill exercise tests. Excess peak exercise heart rates (over 150 beats per minute, 63%) and exertional hypotensive responses (59%, probably including factitious responses due to unreliable indirect pressure readings) did not correlate with the severity of mitral stenosis. Without limiting symptoms and major ventricular arrhythmias, either of the above as endpoints may cause the test to be halted prematurely in half the cases. Ventricular arrhythmias (60%; in complex forms, 20%; possibly contaminated by aberrancy in atrial fibrillation and aggravated by digitalis/diuretics) did not correlate with severity of stenosis either, but the only one major complication we met was secondary to ventricular tachyarrhythmia. Limiting symptoms (83%; of them 94% being dyspnea/fatigue correlating with severity at P less than 0.01) and complex ventricular arrhythmias as endpoints terminated 85% of the tests safely in this series. Atrial thrombuses (34%, all non-floating) did not cause any related complications. Thus, we concluded that limiting symptoms and complex ventricular arrhythmias are the proper endpoints in evaluating the exercise capacity of patients with mitral stenosis after prior echocardiographic exclusion of those with potentially risky floating thrombus.

Adolescent↗
PubMed2004

Regression of significant tricuspid regurgitation after mitral balloon valvotomy for severe mitral stenosis.

BACKGROUND: Significant tricuspid regurgitation (TR) is occasionally associated with severe mitral stenosis and has an adverse impact on morbidity and mortality in patients undergoing mitral valve surgery. However, the effect of successful mitral balloon valvotomy (MBV) on significant TR is not fully elucidated. The aim of this study was to investigate TR after MBV in patients with severe mitral stenosis. METHODS: We analyzed the data of 53 patients with significant TR (grade > or =2, on a 1 to 3 scale) from the mitral balloon valvotomy database at our hospital. Patients were evaluated by Doppler echocardiography before valvotomy and at follow-up 1 to 13 years after MBV. Patients were divided into group A (27 patients), in whom TR regressed by > or =1 scale, and group B (26 patients), in whom TR did not regress. RESULTS: The Doppler-determined pulmonary artery systolic pressure was initially higher and decreased at follow-up more in group A (from 70.7 +/- 23.8 to 36.5 +/- 8.3 mm Hg; P < .0001) than in group B (from 48.7 +/- 17.8 to 41.6 +/- 13.1 mm Hg; P = NS). Compared with patients in group B, patients in group A were younger (25 +/-10 vs 35 +/- 11 years; P < .005), had higher prevalence of functional TR (85% vs 8%; P < .0001), and had lower incidence of atrial fibrillation (7% vs 38%; P < .005). Significant decrease in right ventricular end-diastolic dimension after MBV was noted in group A but not in group B. The mitral valve area at late follow-up was larger in group A than in group B (1.8 +/- 0.3 vs 1.6 +/- 0.3 cm2; P < .05). CONCLUSIONS: Regression of significant TR after successful MBV in patients with severe mitral stenosis was observed in patients who had severe pulmonary hypertension. This improvement in TR occurred even in the presence of organic tricuspid valve disease.

Adult↗
PubMed2005

Improvement in sympatho-vagal imbalance and heart rate variability in patients with mitral stenosis after percutaneous balloon commissurotomy.

Elevated sympathetic nerve activity in patients with mitral stenosis (MS) may be an index of the severity of the disease. Percutaneous mitral balloon commissurotomy (PMBC) is now a standard treatment for many patients with symptomatic MS. We aimed to show the effects of PMBC on autonomic nervous system activity in the patients with MS by heart rate variability (HRV) analysis. Fifty-four consecutive patients with mitral stenosis and sinus rhythm who underwent percutaneous mitral commissurotomy were enrolled. Apart from significant haemodynamic improvements, mean heart rate (HR), LF day, LF night, LF/HF day and night significantly decreased and SDNN, RMSSD, PNN50, HF day and night significantly increased in the early period after PMBC and these changes were preserved for up to one month. SDNN was positively correlated with left ventricle ejection fraction (LVEF) but negatively correlated with mean valve area (MVA), left atrial (LA) diameter and pressure, right atrial (RA) pressure; LF/HF day ratio was positively correlated with LA diameter and pressure, mean transmitral gradient and negatively correlated with LVEF; LF/HF night ratio was positively correlated with LA pressure and mean transmitral gradient. The increase in SDNN was correlated with the change in LA and RA pressure. The decrease in LF/HF ratio after PMBC was significantly correlated with the changes in the mean transmitral gradient, LA pressure and RA pressure. As a result, the heart rate variability and autonomic nervous system function in patients with mitral stenosis are correlated with the atrial pressures and left ventricular function. These parameters significantly change in the early period after PMBC and are preserved at one month. The improvement in the heart rate variability and sympatho-vagal balance are significantly affected by the early changes in atrial pressures after PMBC.

Adult↗
PubMed1993

Echocardiographic study of left atrial thrombi in mitral stenosis.

Sixty-nine patients with predominant mitral stenosis were examined by echocardiographic means to detect the presence of left atrial thrombi. Forty-nine of these patients were in sinus rhythm and twenty in atrial fibrillation. Four percent of patients in the sinus rhythm group and 45% of those in the atrial fibrillation group had left atrial thrombi. The two risk factors identified for left atrial thrombi in mitral stenosis were atrial fibrillation and left atrial enlargement.

Adult↗
PubMed1979

Progression of mild mitral stenosis and incidence of restenosis after open commissurotomy: a study using echocardiography.

Thirteen patients with mild mitral stenosis and 21 asymptomatic patients after commissurotomy were studied by echocardiography in order to assess the rate of progression of mitral stenosis and the incidence of restenosis after successful open mitral commissurotomy. In the group with mitral stenosis there was a decrease of the diastolic closing velocity (E-F slope) from 35.7 to 29.5 mm./sec. (p less than 0.0005) over a period of 37 months. In 23% of the patients the stenosis increased significantly (p less than 0.0005) by echocardiographic parameters. Forty-eight months after commissurotomy we noted a significant over-all slowing of the diastolic closing velocity (from 52.6 to 44.8 mm./sec., p less than 0.0005) and a decrease of the mitral valve closure index DE/MAIC (from 1.7 to 1.5, p less than 0.0025). Five of 21 patients (24%) showed a change in one or both of these parameters which was greater than 2 standard deviations of the mean change. Based on echocardiographic criteria, we conclude that patients with mild mitral stenosis and asymptomatic patients following successful commissurotomy need only be checked approximately every 3 years.

Adult↗
PubMed1975

Pulmonary vascular changes associated with isolated mitral stenosis in India.

Pulmonary vascular changes were studied in 100 cases of isolated mitral stenosis; these included 90 patients in whom lung biopsies were obtained at valvotomy and 10 patients who came to necropsy. Medial thickness of the pulmonary arteries was measured in each case and in 12 cases was correlated with the haemodynamic data. Most patients were young, 78 being 30 years of age or less and 42 under 20 years or less. Males predominated 2:1. All patients with mitral stenosis showed varying degrees of vascular and other associated parenchymal changes. The most conspicuous were those observed in the muscular branches of the pulmonary artery in which the media was thickened in all cases, moderately in 44 and considerably in 28 cases. Dilation lesions representing grade 4 lesions of hypertensive pulmonary vascular disease (Heath and Edwards, 1958), hitherto not described in mitral stenosis, were observed in 4 cases. The intima was found to be frequently abnormal, showing oedema, fibrosis, and, more importantly, variable degrees of muscularization, often suggesting the incipient formation of a second media. Arteries and arterioles were often occluded by thrombi in various stages of organization, and the freshly formed channels tended to acquire a muscular lining. Arterioles were muscularized in all cases, and in many there was a pronounced intimal proliferation. Other changes included medial hypertrophy in the veins and and occasional muscularization and dilatation of the lymphatics. A notable feature was hypertrophy of the musculature of the bronchiolo-alvelar system seen in a majority of cases. The alveolar walls showed variable degrees of thickening and fibrosis, intimal proliferation of alveolar capillaries, and "epithelialization" of alveoli. Haemosiderosis was present in 70 cases. On the whole the more severe changes were observed more often in the younger subjects, further supporting the observation that rheumatic mitral stenosis in India commonly affects the juvenile age groups and is characterized by association with severe pulmonary hypertension. Medial hypertrophy was proportional to the level of pulmonary artery pressure.

Adolescent↗
PubMed1995

Effects of atenolol on rest and exercise hemodynamics in patients with mitral stenosis.

Beta-blocker therapy remains controversial in patients with mitral stenosis. In this randomized, double-blind, crossover, placebo-controlled study, the effects of atenolol (50 and 100 mg/day) were assessed in 15 patients (aged 46 +/- 11 years) with mitral stenosis (mean valve area 1.0 +/- 0.4 cm2; New York Heart Association class II or III) at rest and during upright bicycle ergometry. Doppler echocardiography was used to compare heart rate, cardiac and stroke volume indexes, diastolic filling period, and peak and mean transmitral gradients; a metabolic cart was used to obtain maximal oxygen consumption, carbon dioxide production, and anaerobic threshold. Beta-blocking therapy did not improve exercise time, external work, maximal oxygen consumption rate, or anaerobic threshold. Compared with placebo, maximal oxygen consumption rate and cardiac index decreased (p < 0.05) > 11% and > 20%, respectively, with atenolol at peak exercise. Although heart rate was reduced > 20% and diastolic filling period prolonged > 40% by atenolol at rest and exercise (p < 0.05), stroke volume index changed little compared with placebo. The data suggest that despite lower transvalvular pressure gradients, little benefit in exercise performance is achieved with beta-blocker therapy in patients with severe mitral stenosis.

Adult↗
PubMed1993

Effect of exercise on valvular resistance in patients with mitral stenosis.

OBJECTIVES: This exercise study assessed the relation between valvular resistance and flow in patients with mitral stenosis. BACKGROUND: Valvular resistance has been proposed as an alternative measure of stenotic valvular lesions, which is speculated to remain stable under changing hemodynamic conditions. METHODS: In 35 of 40 patients with pure or predominant mitral stenosis, continuous wave Doppler measurements of the mitral stenotic jet were possible at rest and during supine bicycle ergometry. Simultaneously, transvalvular flow was assessed by thermodilution technique. For calculation of valvular resistance, the mean mitral valve pressure gradient was determined according to the simplified Bernoulli equation and divided by transvalvular flow. Additionally, effective mitral valve area was calculated according to the continuity equation method, dividing flow by the mean diastolic flow velocity. RESULTS: Valvular resistance was 65 +/- 32 dynes.s.cm-5 at rest and increased to 82 +/- 43 dynes.s.cm-5 at 25 W (p < 0.001). The most prominent increase in valvular resistance (rest to 25 W 63 +/- 28 to 95 +/- 48 dynes.s.cm-5, p < 0.001) was found in those patients who had no or only a moderate (< 20%) change in effective mitral valve area. In contrast, valvular resistance remained constant (67 +/- 36 vs. 70 +/- 32 dynes.s.cm-5) in patients with a significant (> or = 20%) increase in mitral valve area with exercise. CONCLUSIONS: In patients with mitral stenosis, the exercise-induced changes in valvular resistance are heterogeneous. This is the result of the variable response of mitral valve area to an increase in flow. In the individual patient, mitral valve area can significantly increase, a factor that has to be taken into account when interpreting the hemodynamic relevance of the obstruction. Calculated valvular resistance is flow dependent and has no advantage over valve area calculations for quantifying mitral stenosis.

Adult↗
PubMed2003

Comparative assessment of chordal preservation versus chordal resection in mitral valve replacement for mitral stenosis (long-term follow-up: 8 years).

Carrying out a mitral valve replacement (MVR) while preserving all chordae tendineae in patients with mitral regurgitation has been proven beneficial to the left ventricular performance. To evaluate the effectiveness of this technique in patients with mitral stenosis, a comparison of the echocardiographic data between patients who were operated on using this technique (Group Preservation = GroupP, n = 15), and those operated on using the conventional method of MVR (Group Conventional = GroupC, n = 15) was made. All patients were examined before surgery, 6 months after surgery and 8 years after surgery. The study population was limited to patients who had no evidence of coronary artery disease, aortic stenosis and/or regurgitation and patients who had pure mitral stenosis. Echocardiographic measurements obtained both 6 months and 8 years postoperatively revealed a significant decrease in the left ventricular ejection fraction in GroupC (61.33+/-9.29% preoperatively, 53.2+/-10.3% postoperatively). The difference between the decrease in the left ventricular ejection fraction of the two groups was statistically significant (-0.71+/-6.28% in GroupP, -8.07+/-13.35% in GroupC). There was no evidence of prosthetic valve dysfunction and no operative deaths. Two patients died in GroupP, 3 patients died in GroupC within the 8 year period. The conclusion was reached, that if suitable, mitral valve replacement while preserving the chordae tendineae is expected to have a beneficial effect on postoperative left ventricular performance in patients with mitral stenosis.

Adult↗
PubMed1995

Papillary fibroelastoma of the mitral valve associated with rheumatic mitral stenosis.

Papillary fibroelastoma of the mitral valve diagnosed and treated in life is extremely rare. There have been eight cases documented so far. We report the first case of a mitral valve papillary fibroelastoma associated with severe rheumatic mitral stenosis and tricuspid regurgitation with stenosis. The tumor arose from the posteromedial papillary muscle of the mitral valve. The mitral valve was replaced after excising the valve with the tumor and the tricuspid valve was repaired. The patient did well and remains asymptomatic.

Echocardiography, Transesophageal↗
PubMedDate not supplied

[Usefulness of real time 3D echocardiography in assessment of rheumatic mitral stenosis].

To date, the assessment of rheumatic mitral stenosis has been based on Doppler methods, which have a high dependence on the hemodinamic conditions and on the planimetry obtained from 2D echo images. Real Time 3D echocardiography has been implemented in the daily clinical practice. It provides high quality 3D images and the acquisition time is very short. In the present work, we try to show the "state of the art" of Real Time 3D echocardiography in the assessment of rheumatic mitral stenosis. These findings are based on the experience of our "Unidad de Imagen Cardiovascular" at the Hospital Clinico San Carlos de Madrid.

Echocardiography, Doppler↗
PubMed1991

Intracardiac mobile thrombus and D-dimer fragment of fibrin in patients with mitral stenosis.

OBJECTIVE: To investigate the relation between intracardiac thrombus and blood coagulability in patients with mitral stenosis. DESIGN: Prospective study. Cross sectional echocardiography and plasma concentrations of the D-dimer fragment of fibrin were used concurrently to detect intracardiac thrombus in patients with mitral stenosis. SETTING: Department of Medicine, National Cardiovascular Centre, Osaka, Japan. PATIENTS: 63 patients with mitral stenosis. None of them had been receiving any anticoagulants or antiplatelet agents. MAIN OUTCOME MEASURES: Plasma concentrations of D-dimer in patients with a mobile intracardiac thrombus, those in patients with a non-mobile intracardiac thrombus, and those in patients without an intracardiac thrombus. RESULTS: A mobile intracardiac thrombus was found in 10 patients and a non-mobile thrombus in eight. The remaining 45 patients had no intracardiac thrombi. Plasma concentrations of D-dimer in the 10 patients with a mobile thrombus were all greater than 300 ng/ml (mean 983.3, 95% confidence interval 498.9 to 1467.7 ng/ml) and they were significantly higher than those in the patients with a non-mobile thrombus (226.2, 33.6 to 418.8 ng/ml) and the patients without an intracardiac thrombus (147.2, 110.4 to 184 ng/ml). CONCLUSIONS: A high plasma concentration of D-dimer seemed to reflect a hypercoagulable intracardiac state and may be a helpful indicator of the possible presence of mobile intracardiac thrombus in patients with mitral stenosis.

Antifibrinolytic Agents↗
PubMed1990

Ultrastructural pathological study of left ventricular myocardium in patients with isolated rheumatic mitral stenosis with normal or abnormal left ventricular function.

An electron microscopic study of left ventricular myocardium was carried out in 15 patients who had isolated rheumatic mitral stenosis, with particular reference to the relation among ultrastructural pathological findings, the severity of mitral stenosis and left ventricular function. They were divided into 2 groups based on left ventricular performance evaluated by 2-dimensional echocardiography and angiocardiography. The severity of mitral stenosis was determined by hemodynamic data and mitral valve areas measured by 2-dimensional echocardiography. Regardless of the level of left ventricular contractile function we consistently demonstrated varying degrees of ultrastructural pathological alterations of left ventricular muscle cells, involving the myofibrils, mitochondria, nuclei and other elements of the sarcoplasm and membranes surrounding the myocardial cells in all specimens examined. The ultrastructural pathological findings did not correlate with the severity of mitral stenosis reflected in the echocardiographic and hemodynamic data. However, those patients with abnormal left ventricular function always exhibited more extensive loss of myofibrils resulting from either disproportion of the mitochondria-to-myofibril ratio or myofibrillar degeneration. The present investigation provides the morphological data at the ultrastructural level to support the widely held concept of a myocardial factor i.e., the extent of myocardial involvement by the rheumatic process as the basic pathogenetic mechanism responsible for left ventricular dysfunction in patients with isolated rheumatic mitral stenosis. Furthermore, it is suggested that pathological alterations of myocardial ultrastructure were related to the extent of myocardial involvement by the rheumatic process rather than being structural adaptations in response to the hemodynamic derangement.

Adult↗
PubMed1987

Role of exercise Doppler echocardiography in isolated mitral stenosis.

This study reports the role of Doppler ultrasound during exercise for assessment of patients with mitral stenosis. Doppler echocardiography was performed at rest and during symptom-limited supine bicycle exercise in ten patients with isolated mitral stenosis. The mean mitral valvular gradient was calculated using modified Bernoulli's equation, and the mitral valvular area was estimated from the equation, 220/pressure half-time. During exercise the heart rate increased from 74 +/- 14 beats per minute (mean +/- SD) at rest to 110 +/- 8 beats per minute (p less than 0.001) during exercise. The mean mitral gradient increased from 9 +/- 5 mm Hg at rest to 18 +/- 7 mm Hg (p less than 0.01) during exercise. The mitral pressure half-time decreased from 225 +/- 62 msec at rest to 190 +/- 42 msec during peak exercise (p less than 0.005). This corresponded to a reduction of 15 percent. The estimated mitral valvular area increased from 1.0 +/- 0.4 sq cm at rest to 1.2 +/- 0.3 sq cm at peak exercise (p less than 0.005). In conclusion, Doppler echocardiography can be used to evaluate patients with mitral stenosis, with the response of the mitral valvular gradient being the index of obstruction; however, caution should be used in applying the mitral pressure half-time for estimation of the mitral valvular area at high heart rates and flows.

Adult↗
PubMed2004

Effects of percutaneous mitral commissurotomy on longitudinal left ventricular dynamics in mitral stenosis: quantitative assessment by tissue velocity imaging.

OBJECTIVE: We hypothesized that mitral annular velocities would improve immediately after relief of mitral stenosis and that serial assessment could be used as an index for quantifying functional changes after percutaneous mitral commissurotomy (PMC). METHODS: Longitudinal left ventricular annular velocities were quantified by spectral pulsed wave Doppler tissue velocity imaging in 25 patients (16 women; mean age [+/-SD], 29.2 +/- 8.6 years) who had isolated mitral stenosis and were in sinus rhythm, and were compared with 30 age- and sex-matched control subjects. Echocardiography was performed 1 to 24 hours before PMC and 48 to 72 hours after, and changes in velocities from the lateral and septal corners of the mitral annulus in early diastole, late diastole, isovolumic contraction, and ejection were recorded. RESULTS: Systolic and diastolic mitral annular velocities were significantly less in patients with mitral stenosis than in control subjects. After PMC, peak annular velocity of systolic excursion in ejection and peak annular velocity in early diastole showed significant improvement. The change in peak annular velocity in early diastole in the lateral wall correlated well with improvement in the mitral valve orifice area by planimetry (ratio of mitral valve orifice area, 1.92 +/- 0.42; ratio of peak annular velocity in early diastole, 1.36 +/- 0.22; r = 0.65; P <.001). CONCLUSION: Serial evaluation of changes in mitral annular velocities by Doppler tissue imaging aids clinical assessment of immediate improvement in left ventricular function after PMC.

Adult↗
PubMed1982

Left ventricle in mitral stenosis.

The authors investigated the left ventricular systolic function and diastolic characteristic in 25 patients with mitral stenosis and compared the results with findings in 25 healthy subjects. The patients with mitral stenosis differed from the control group by elevated left ventricular filling pressure, greater left ventricular end-diastolic volume, reduced ejection fraction, and decreased calculated left ventricular compliance. Pathological values of these indicators, however, were infrequent and as a rule only slightly exceeded the normal limits. The decrease in left ventricular compliance had significant correlations with the degree of pulmonary arterial hypertension, elevation of right ventricular filling pressure, the ratio of filling pressures of both ventricles, and left ventricular end-systolic eccentricity. Consequently, the authors infer that the main factor decreasing the left ventricular compliance in mitral stenosis is the aberrant geometry of the ventricle. The authors also point out the correlations between the left ventricular systolic function and diastolic characteristics in mitral stenosis, and assume that this affection represents a complex, although not too advanced, disturbance of left ventricular function.

Adult↗
PubMed1986

Exercise radionuclide angiography in patients with mitral stenosis: value of right ventricular response.

We observed 26 patients with mitral stenosis and 19 normal volunteers with exercise gated radionuclide angiography. Although no differences were seen between normal subjects and patients with mitral stenosis at rest in left (LV) and right (RV) ventricular ejection fraction, significant differences were found for exercise change in ejection fraction for both ventricles, exercise time, exercise workload, and the percent change in LV end-diastolic, LV stroke, and RV end-systolic counts (ESC). Because nearly all of the normals (18/19) had a decrease in RVESC, patients with stenosis were divided into two groups according to whether RVESC increased or decreased. Significant differences were found between these two groups for age, New York Heart Association class, prevalence of atrial fibrillation, echocardiographic mitral valve area, and prognosis, that is, number undergoing catheterization and surgery. We conclude that exercise radionuclide angiography does yield information that has significant clinical and prognostic value in patients with mitral stenosis.

Adult↗