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PubMed2000

Late results of percutaneous mitral commissurotomy for calcific mitral stenosis.

The aim of this study was to assess late results of percutaneous mitral commissurotomy (PMC) in calcific mitral stenosis and to identify predictors to improve patient selection. We analyzed 422 patients who underwent PMC for calcific mitral stenosis. The extent of calcium was graded from 1 to 4 by fluoroscopy: 227 patients (53%) were graded 1, 125 (30%) graded 2, 55 graded 3 (13%), and 15 graded 4 (4%). The procedure failed in 15 patients, used a single balloon in 11, a double balloon in 126, and the Inoue balloon in 270. In-hospital mortality was 1.2%. Good immediate results (valve area >/=1.5 cm(2) without mitral regurgitation >2/4), were obtained in 321 patients (76%). Multivariate analysis identified 5 predictors of good immediate results: a younger age (p = 0.0004), a lesser degree of stenosis (p = 0.0005), a smaller extent of calcium (p = 0.04), the use of the Inoue balloon (p = 0.015), and a larger effective balloon dilating area (p = 0.006). Good functional results, defined as survival with no further intervention and in New York Heart Association class I or II, were 36 +/- 4% at 8 years. The predictors of good functional results after good immediate results were a younger age (p = 0.04), a lower pre-PMC New York Heart Association class (p <0.0001), sinus rhythm (p = 0.0006), a smaller extent of calcium (p = 0.02), and a lower gradient after PMC (p <0.0001). Despite a frequent deterioration on follow-up after PMC for calcific mitral stenosis, the predictive analysis suggests that PMC may be useful in deferring surgery in selected patients with mild to moderate calcific deposits, who have otherwise favorable characteristics.

Aged↗
PubMed1994

Propranolol for pulmonary oedema in mitral stenosis.

We report the case of a young adult with mitral stenosis and pulmonary oedema who did not respond to conventional antifailure therapy, but improved with intravenous propranolol and later underwent successful balloon mitral valvotomy. Intravenous beta blockade, though contraindicated in most cases of pulmonary oedema, may benefit patients with mitral stenosis and tachycardia.

Adolescent↗
PubMed2001

[Mitral stenosis secondary to Hurler's syndrome].

Valvular disease in mucopolysaccharidosis type I-Hurler (MPS/1H) is relatively common, but mitral stenosis is very rare in this genetic abnormality. The authors describe the case of a 16-year old girl with Hurler's syndrome diagnosed at 4 years of age. The morphological features were characteristic: bridged nose, thickened lips, macroglassia, short neck (gargoylism, short, thick fingers and limitation of brachial and fore-arm flexion. She presented with stage II dyspnoea and paroxysmal nocturnal dyspnoea. Radiological and echocardiographic studies revealed severe mitral stenosis with haemodynamic complications requiring mitral valve replacement. Anatomopathological analysis of the mitral valve confirmed mucopolysaccharide deposits as the cause of this particular case of mitral stenosis.

Adolescent↗
PubMed2005

Left atrial thrombosis in pregnant women with mitral stenosis and sinus rhythm.

OBJECTIVE: The purpose of this study was to describe pregnant patients with mitral stenosis who had intracardiac thrombosis in the absence of atrial fibrillation. STUDY DESIGN: We reviewed the clinical course of 3 pregnant women with severe mitral stenosis and normal sinus rhythm who had clinically significant intracardiac thrombosis. RESULTS: The first patient was examined at 21 weeks of gestation with embolic stroke that was the result of left atrial thrombus. A second patient was found to have a large left atrial thrombus that prevented the performance of balloon valvuloplasty. The third patient had left atrial clot that partially occluded the mitral valve orifice and led to the development of pulmonary edema that resulted in an emergent cesarean delivery and anoxic brain injury in the newborn infant. CONCLUSION: Pregnant patients with mitral stenosis in normal sinus rhythm can experience thromboembolic events that can be detrimental to both the mother and the fetus. Anticoagulation therefore should be strongly considered in this group.

Adult↗
PubMedDate not supplied

Magnetic resonance evaluation of mitral stenosis.

In order to study magnetic resonance (MR) abnormalities in mitral stenosis, electrocardiogram (ECG)-gated MR imaging was performed with a 2.0 T MR system in 41 patients with mitral stenosis before catheterization. Mean transverse diameter of the left atrium was 8.9 +/- 1.4 cm and anteroposterior diameter was 5.1 +/- 1.0 cm, indicating significant enlargement. Homogeneous or inhomogeneous flow-related signals in ventricular diastole were detected in the left atrial cavity in 32 cases (78%), and in the atrial appendage in 35 cases (85%). In 21 patients having a mean wedge pulmonary arterial pressure higher than 20 mm Hg, 20 patients (95%) showed flow-related signals in ventricular diastole. Other MR findings were mitral valve doming in diastole, flow-related signal in the pulmonary artery during systole, and left atrial thrombi.

Adolescent↗
PubMedDate not supplied

Safety and efficacy of enalapril in multivalvular heart disease with significant mitral stenosis--SCOPE-MS.

Angiotensin-converting enzyme inhibitors (ACEI) are often used in preventing and treating heart failure due to regurgitant valve disease. The majority of patients with symptomatic rheumatic heart disease (RHD) have significant mitral stenosis (MS) and are denied ACEI therapy, because of the fear of hypotension in the presence of fixed obstruction. The authors assessed the safety and efficacy of ACEI in 109 consecutive patients with RHD and with significant mitral stenosis (mitral valve orifice, MVO < 1.5 cm2)and with NYHA class III or IV heart failure symptoms. Mean age was 33.1+/-12 years, systolic blood pressure (BP) was 111+/-10, and diastolic BP was 73+/-8 mm Hg. MS was significant in 100 patients with mitral regurgitation in 46, aortic regurgitation in 19, and pulmonary hypertension in 60 patients. After initial stabilization, enalapril 2.5 mg bid was started in hospital and titrated up to 10 mg bid over 2 weeks. NYHA status, Borg score, and 6-minute walk test were assessed at baseline, and at 1, 2, and 4 weeks. Seventy-nine of the 100 patients who completed the study had severe MS (MVO < 1.0 cm2). Enalapril was well tolerated by all study patients without hypotension or worsening of symptoms. NYHA class (3.2+/-0.5 baseline vs 2.3+/-0.5 at 4 weeks, p < 0.01) Borg Dyspnea Index (7.6+/-1.3 vs 5.6+/-1.3, p < 0.01), and 6-minute walk distance (226+/-106 vs 299+/-127 m, p < 0.01) improved significantly with enalapril. Patients with associated regurgitant lesions showed more improvement in exercise capacity (120+/-93 vs 39+/-56 m, p < 0.001). Enalapril was well tolerated in patients with RHD with moderate and severe MS. Irrespective of the valve pathology, enalapril improved functional status and exercise capacity with maximum benefit in patients with concomitant regurgitant valvular heart disease.

Adult↗
PubMed1996

Determination of mitral valve area in patients with mitral stenosis by the flow-convergence-region method during changing hemodynamic conditions.

Twenty-eight patients with mitral stenosis underwent Doppler echocardiography at rest and during exercise to determine the accuracy of mitral valve area determination by the flow-convergence-region method during exercise-induced changing hemodynamic conditions. The mitral valve area calculated by using the flow-convergence-region method correlated strongly with that measured by the Gorlin formula both at rest (r = 0.85) and during exercise (r = 0.92) for all 28 patients studied. Although mitral valve area obtained by the flow-convergence-region method did not change (p = 0.1) in 16 patients with echocardiographic mitral scores > or = 12, it increased significantly during exercise (p = 0.0001) in 12 patients with echocardiographic mitral scores < 12. This study suggests that in mitral stenosis, the mitral valve area can be accurately estimated by the flow-convergence-region method both at rest and during changing hemodynamic conditions induced by supine bicycle exercise.

Adult↗
PubMed1987

Failure of propranolol to improve exercise tolerance in patients with mitral stenosis in sinus rhythm.

Propranolol reduces left atrial pressure at rest and during exercise in patients with mitral stenosis by lowering cardiac output and heart rate. Ten patients (aged 19-56) with moderate to severe isolated mitral stenosis were studied to determine whether propranolol increased their exercise tolerance. All were in sinus rhythm and free of left or right ventricular failure. Patients were trained in an individually graded bicycle or treadmill exercise protocol that provoked a reproducible degree of near maximal dyspnoea during the second three minute stage of exercise. Propranolol (80 mg or 120 mg) or matching placebo in two or three divided daily doses was given for one week in random double blind fashion. Exercise testing and questioning about subjective clinical response were carried out at the end of each week by an investigator who was unaware of the patient's heart rate. During propranolol treatment the heart rate was 19 beats/minute slower at rest and 38 beats/minute slower at peak exercise, but there was no change in mean exercise time to dyspnoea (274 s during propranolol vs 283 s during placebo). Four patients felt worse during the propranolol week, one patient felt better during the propranolol week, and five patients felt no difference between the two weeks. Propranolol did not improve objective or subjective exercise tolerance in patients with isolated mitral stenosis in sinus rhythm.

Adult↗
PubMed1990

[Floating left atrial thrombus in 2 cases of severe mitral stenosis].

The authors report two operated cases of floating left atrial thrombus. Both patients had severe mitral stenosis, atrial fibrillation and dilatation of the left atrium. In the first case, the patient had no anticoagulant therapy; in the second case, the observance of anticoagulant therapy was irregular. Neither patient complained of syncope. The diagnosis was made in both cases by two-dimensional echocardiography which, in addition to confirming the severe mitral stenosis, showed a round, free-floating intra-atrial mass, rebounding from wall to wall and repeatedly engaging itself into the mitral orifice. The risk of prolonged engagement of the thrombus in the mitral orifice, causing syncope or sudden death, justifies urgent surgery associating thrombectomy and treatment of mitral stenosis every time this problem is encountered.

Adult↗
PubMed1976

[The reliability of several polycardiographic indices in the quantitative evaluation of mitral stenosis (author's transl)].

In 21 patients with pure, isolated mitral stenosis, four hemodynamic parameters were studied. They were obtained by left and right cardiac catheterization and were: the mean pulmonary artery wedge pressure, the diastolic mitral gradient, the stroke volume and the mitral valve area with one or more parametres amd polycardiographic indices, to verify the reliability of the quantitative evaluation of mitral stenosis by noninvasive methods. The polycardiographic indices of Yigitbasi (r = 0.76) and Wells (r = 0.65) were best correlated with the mean pulmonary wedge pressure. The only index with a moderate correlation (r = 0.60) with the mitral diastolic gradient was that of Wells. The LVET/PEP index has only a mediocre correlation with the stroke volume (r = 0.50). The Oreshkov index was the only one among those studies to correlate at all significantly with the mitral valve area (r = --0.62). The investigation confirms the practical use of noninvasive methods in predicting the pulmonary wedge pressure, whilst the indices of Wells and Oreshkov seem less satisfactory in prediction both for the mitral diastolic gradient and the mitral valve area.

Adult↗
PubMed2002

Supramitral ring: an unusual cause of congenital mitral stenosis. Case series and review.

Supramitral ring, also known as membranous supravalvular mitral stenosis is a rare cause of congenital mitral stenosis, with less than 100 cases appearing in the literature since its first description in 1902. We present a small series encountered at the university medical center during the last five years. The natural history of the condition is reviewed along with diagnostic tools, aspects of surgical repair, and anesthetic technique that facilitates early extubation and ICU discharge.

Age Factors↗
PubMed1989

[A case of pulmonary arteriovenous fistula with mitral stenosis].

The patient was a 61-year-old female, complaining of cyanosis, dyspnea and shortness of breath on exertion. She was diagnosed as having a pulmonary arteriovenous fistula (PAVF) in combination with mitral stenosis. The fistula was located in the left lower lobe and a right-left shunt of 28.7% was detected. Cardiac catheterization showed a pulmonary artery pressure of 44/22 mmHg (mean pressure, 31 mmHg). By occluding the PAVF using a balloon catheter, PaO2 increased from 47 mmHg to 88 mmHg. The mitral stenosis of this patient was though to be a mild form, and PAVF seemed to be responsible for symptoms. Since left lobectomy together with mitral valve replacement was considered to have a high risk, left lower lobectomy was performed initially. Thereafter mitral valve replacement was done successfully. Separate operations for PAVF and mitral stenosis are likely to be beneficial in patients with mitral stenosis associated with moderate pulmonary hypertension.

Arteriovenous Fistula↗
PubMed2002

Beta-blockade and exercise capacity in patients with mitral stenosis in sinus rhythm.

BACKGROUND AND AIM OF THE STUDY: The study aim was to determine whether beta-blocker treatment (atenolol) improves cardiopulmonary exercise performance and ventilatory response in patients with mitral stenosis in sinus rhythm. METHODS: A prospective study comparing the results of cardiopulmonary exercise tests (CPETs) was performed before and after atenolol therapy in 17 patients in NYHA classes I and II with mitral stenosis in sinus rhythm. Transthoracic echocardiography was performed pre-study, and left ventricular diameters, ejection fraction and mitral valve area monitored. CPETs (Naughton protocol) were performed by two different investigators before and after one-week atenolol therapy (50 mg/day). The second investigator was blinded to the result of the baseline test. O2 consumption, CO2 production, ventilatory parameters and respiratory exchange ratios were measured on line. RESULTS: Maximal O2 uptake (VO2max) did not differ significantly before and after beta-blockade (median 16.8 and 15.0 ml/kg/min, respectively. Median heart rate at rest (72 versus 55 beats/min; p = 0.0003) and during peak exercise (153 versus 105 beats/min; p = 0.0003), and anaerobic threshold (10 versus 8.9 ml/kg/min; p = 0.02) were lower with beta-blockade compared with the baseline state. Minute ventilation at maximum exercise (41 versus 40 l/min) and ventilatory equivalent for CO2 (34 versus 35) were unchanged with atenolol therapy, indicating no improvement in ventilatory performance. When patients were grouped into those in whom VO2max was improved with atenolol therapy (n = 7) and those in whom it was impaired (n = 10), there were no inter-group differences with respect to age, left ventricular function, severity of mitral stenosis, NYHA class and grade of beta-blockade reached. Four patients felt symptomatically worse during atenolol treatment (lower NYHA functional class). CONCLUSION: Beta-blockade does not improve exercise tolerance in patients with mitral stenosis in sinus rhythm. In addition, ventilatory performance does not change with treatment.

Adrenergic beta-Antagonists↗
PubMed2000

Increased left atrial thrombin generation in mitral stenosis is not reflected in arterial prothrombin fragment 1+2 levels.

A proportion of patients with mitral stenosis have increased left atrial thrombin generation, with elevated left atrial but normal peripheral venous levels of prothrombin fragment 1+2 (F1+2). Whether this pattern of left atrial and venous F1+2 levels is related to limited spillover of F1+2 from the left atrium into the systemic circulation, or to washout of increased left atrial F1+2 production into the arterial circulation with subsequent systemic clearance, is unclear. We examined the relationship between arterial and venous F1+2 levels in mitral stenosis patients without left atrial thrombus. The study group comprised 36 patients with either a normal (n=29) or prolonged (n=7) international normalized ratio (INR; a measure of clotting time) who were undergoing percutaneous balloon mitral valvuloplasty. Baseline arterial and venous blood samples were collected at the beginning of the valvuloplasty procedure, and left atrial and venous samples were collected after trans-septal puncture. The left atrial F1+2 level exceeded the corresponding venous level in patients with a normal INR (P<0.03); however, baseline arterial and venous F1+2 levels were similar. Arterial and venous F1+2 levels were also similar in the subgroup of patients with evidence of a regional increase in left atrial thrombin generation, and were not different from arterial and venous F1+2 levels in patients without such an increase. Baseline arterial and venous F1+2 levels were both lower in the presence of a prolonged INR. Thus the pattern of increased left atrial but normal venous F1+2 levels in mitral stenosis is due to limited spillover from the left atrium into the systemic circulation.

Adult↗
PubMed1996

Changes of left ventricular function after percutaneous balloon mitral valvuloplasty in mitral stenosis with impaired left ventricular performance.

The pathophysiological role of mechanical and myocardial factors for impairment of left ventricular performance in mitral stenosis is still not clear. To investigate this controversy, 27 patients of mitral stenosis with left ventricular ejection fraction < 50% were studied. Patients were divided into two groups: Group 1: 20 patients, left ventricular ejection fraction improved to > 50% after valvuloplasty, and Group 2: 7 patients, left ventricular ejection fraction still < 50% after valvuloplasty. The clinical and hemodynamic characteristics were comparable for the two groups before valvuloplasty. Follow-up catheterization done one week later showed similar changes in mitral valve area, cardiac index, pulmonary pressure, left ventricular end-diastolic volume index and systemic vascular resistance between the two groups. However, left ventricular end-systolic volume was significantly decreased after valvuloplasty in Group 1 but not in Group 2, resulting in significantly higher ejection fraction in Group 1 than in Group 2. Postoperatively, regional wall motion scores were lower in Group 1 than in Group 2 (2.0 +/- 0.6 vs. 2.7 +/- 0.5 at the anterolateral wall, P = 0.002; 1.9 +/- 0.6 vs. 2.9 +/- 0.4 at the posterobasal wall, P = 0.0003). Most of our mitral stenosis patients with impaired left ventricular ejection fraction showed improvement after mitral valvuloplasty had released the mechanical obstruction. However, in some patients, impaired ejection fraction persisted after valvuloplasty, suggesting the mechanism of myocardial failure. Thus, both myocardial and mechanical factors play important roles in the pathogenesis of left ventricular ejection performance impairment.

Adult↗
PubMed2006

[Vascular reactivity response to mental stress in pregnant women with mitral stenosis].

OBJECTIVE: To study vascular reactivity according to the analysis of blood flow and peripheral vascular resistance at rest and during mental stress in pregnant women with mitral stenosis. METHODS: Twenty two women with mitral stenosis, 13 of whom were pregnant (PS) and 9 were non-pregnant (MIS), and 9 healthy pregnant women (NP) were studied. During gestation, 9 out of the 13 patients of the PS group required a beta-blocker (PSB) and the remaining 4 progressed without medication (PSWB). Plethysmography at rest and during mental stress analyzed muscle blood flow, peripheral vascular resistance (PVR), mean arterial pressure (MAP) and heart rate (HR) during gestation and puerperium. RESULTS: During gestation of PSWB, muscle blood flow and HR were higher in 1.6% and 20.5% (p = 0.05), and PVR and MAP were lower in 19.3% and 4.4%, respectively, in comparison to the puerperium; during mental stress, the muscle blood flow increased by 55.9%, HR decreased by 30.2% and PVR and MAP were similar. In PSB, muscle blood muscle blood flow and HR were greater in 5.9% and 14.9% (p= 0.001) and MAP and PVR were lower in 10.3% and 9.1%, respectively, when compared to the puerperium. During mental stress, muscle blood flow and MAP increased by 69.8% and 174.1%, respectively. HR was similar and PVR decreased by 53.7%. The comparative study showed that in the NP group the muscle blood flow was higher, PVR was lower, and MAP and HR were similar in relation to the PS group, and that the PS, NP, MIS groups had a similar response to mental stress. CONCLUSIONS: Vascular reactivity in pregnant women with mitral stenosis was preserved and the analysis of measurements showed lower values of muscle blood flow and higher values of PVR when compared to those of healthy pregnant women.

Adolescent↗
PubMed1993

Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis.

OBJECTIVE: This review discusses the latest developments in selected clinical features and catheter-based therapy of mitral stenosis. DATA SOURCES: English-language journal articles and reviews in the clinical and epidemiological literature as related to mitral valve stenosis from 1965 through March 1993, identified by bibliography review and expert consultation. STUDY SELECTION: Selected studies included clinical trials with adequate patient population description and short- and long-term (5 years) follow-up for topics related to mitral valve stenosis in the clinical literature. DATA EXTRACTION: Two reviewers participated in extracting the data with the aim of presenting a balanced and comprehensive review of the subject. DATA SYNTHESIS AND CONCLUSIONS: The main conclusions are (1) mitral stenosis should no longer be viewed as a largely "geriatric disease" in the United States due to a recent inflow many young immigrants from countries where rheumatic fever continues partially or wholly unabated; (2) clinical and anatomical features of mitral stenosis are age-dependent; when clinical presentation occurs at 30 vs 70 years of age, for example, the degree of valve obstruction may be similar but differences exist in the frequency of atrial fibrillation, the magnitude of reduction in cardiac output, the degree of valve deformity and calcification, and the frequency of coexistent coronary artery disease; and (3) mitral stenosis therapy has undergone a reorientation with the introduction of percutaneous mitral balloon valvotomy, which has proven to be safe, cost-effective, and to provide short- and long-term improvements in symptomatic and hemodynamic status in selected patients.

Catheterization↗
PubMed1987

Comparison of two-dimensional and Doppler echocardiography and intracardiac hemodynamics for quantification of mitral stenosis.

Forty-three patients with mitral stenosis (MS) were studied to assess the relation of catheter-derived pressure gradient half-time (P 1/2), mitral valve areas (calculated by the Gorlin formula and 2-dimensional echocardiography [2-D echo]) to mitral valve areas derived from Doppler pressure half-time (T 1/2) in order to establish an accurate line-drawing method in nonlinear velocity tracings and to revalidate the use of the empiric constant of 220 ms as the T 1/2 that predicts a 1.0-cm2 mitral valve area. Mitral valve area could be quantified by 2-D echo in 39 of 43 patients and by Doppler in 31 of 34 patients, for a success rate of 91%. A reliable technique for measuring Doppler T 1/2 in nonlinear Doppler velocity tracings was a "mid-diastolic" line-drawing method, validated with the "anatomic" mitral valve area by 2-D echo (r = 0.89) and with the "hemodynamic" mitral valve area by the Gorlin formula (in pure MS without regurgitation) (r = 0.95). By both Doppler T 1/2 and hemodynamic P 1/2, the use of 220 ms to predict a mitral valve area of 1.0 cm2 was validated. Each T 1/2 and P 1/2 had an exponential inverse relation to the mitral valve area by the Gorlin formula in pure MS. Doppler and 2-D echocardiographic quantification of MS are complementary. Reliable measurement of T 1/2 in nonlinear velocity tracings is achieved by a mid-diastolic line-drawing method and use of the equation 220 ms/T 1/2 = mitral valve area accurately quantifies MS.

Adult↗