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A 66-year-old female with known mitral stenosis presented with symptoms of progressive pulmonary congestion. Concomitantly, subvalvular left ventricular outflow obstruction was suspected clinically and both lesions were confirmed at cardiac catheterization. At operation, marked septal hypertrophy and rheumatic mitral stenosis were observed, the mitral valve was replaced, and a septal myomectomy was performed.
The present study examined the utility of the stepwise balloon dilatation technique in 41 patients with significant calcific mitral stenosis undergoing percutaneous transvenous mitral commissurotomy (PTMC). Thirty-five patients (85.4%) had a successful procedure; one patient developed cardiac tamponade and underwent mitral valve replacement. The mitral valve area increased from 0.9 +/- 0.2 cm2 to 1.7 +/- 0.3 cm2 following PTMC. Increase in mitral regurgitation (MR) was seen in 11 patients (26.8%). All patients showed improvement in functional class of > or =1 level following PTMC, which was sustained in 34 patients at follow-up. At a mean follow-up period of 20 +/- 12 months (range 3-51 months) in 35 patients, 26 patients (74.3%) were in New York Heart Association (NYHA) functional Class I, 8 patients (22.9%) were in NYHA Class II, and 1 patient (2.8%) was in NYHA Class III. The cumulative 4-year cardiac event-free survival rate was 81.8%. However, patients with grade 4+ calcification had only 50% event-free survival rate. At follow-up, an increased incidence of cardiac events was seen in female patients as compared with male patients (83.3% versus 16.7%). Restenosis was seen in 3 patients (8.6%). One patient underwent repeat PTMC 37 months after the initial procedure. There was no incidence of death or mitral valve replacement at follow-up. We conclude that the stepwise balloon dilatation technique can be safely and effectively applied for patients with significant calcific mitral stenosis to achieve an optimal mitral valve area with low incidence of significant increase in MR. Favorable long-term benefits also accrue in the form of improved functional status and low incidence of repeat procedures (repeat PTMC or mitral valve replacement). The majority of patients (74.3%) were in NYHA functional class I without medication. Patients with grade 4+ calcification show less benefit from PTMC and may be considered for mitral valve replacement. Cardiac events occur more frequently in female patients than in male patients during follow-up.
To compare the single rubber-nylon balloon and double polyethylene balloon techniques, 94 patients with rheumatic mitral stenosis underwent percutaneous transseptal balloon mitral valvuloplasty between November 1985 and September 1988. The single balloon technique was used in 73 patients and the double balloon technique was used in 21. The two groups were similar in age, weight, severity of the lesion, and cardiac functional status. The mean mitral valve diastolic gradient decreased from 17.9 +/- 6.5 to 2.9 +/- 3.1 mm Hg (p less than 0.001), 18.5 +/- 6.7 to 5.8 +/- 3.1 mm Hg (p less than 0.001), and 18.1 +/- 5.9 to 3.2 +/- 3.7 mm Hg (p less than 0.001) in the single balloon group, double balloon group, and the entire series, respectively. The final mitral diastolic gradient in the single balloon group was lower than in the double balloon group (p less than 0.05). Complications in the single balloon group were lower than in the double balloon group. Additional advantages of single over double balloon technique were easier maneuverability and higher success rate. The initial and long-term follow-up results confirmed the earlier impressions that percutaneous transseptal balloon mitral valvuloplasty is an effective and safe nonsurgical method of treatment for rheumatic mitral stenosis, and the single rubber-nylon balloon technique is at least as effective as, if not superior to, the double polyethylene balloon technique.
Eight patients with mixed mitral stenosis and regurgitation underwent hemodynamic and angiographic study prior to mitral valve replacement. The stenotic orifice of the mitral valve was calculated employing the total left ventricular stroke volume by cineangiography as the numerator of the Gorlin Formula. Excellent agreement with the measured orifice of the mitral valve was obtained using a value of 37.9 (0.85 X 44.5) for the constant in the Gorlin formula as recommended by Cohen and Gorlin. Recalculation of this constant independently by our data yielded a value that was almost identical. Regurgitant flows and orifice sizes were calculated for each patient using the same constant as for calculation of the stenotic orifices.
To assess left ventricular shape and contraction pattern under the condition of the narrowed mitral orifice, 41 patients with mitral stenosis were studied by cross-sectional and M-mode echocardiography. Abnormal left ventricular configuration and asynergy were observed in 23 patients (56%). The change in configuration persisted during the cardiac cycle and was mainly due to a straightening and abnormal motion of the interventricular septum. Furthermore, hypokinesis or akinesis of the posterior left ventricular wall contributed to the change of left ventricular shape. Consequently the left ventricular shape became from circular to half moon- or pear-like configuration. Of these 23 patients, 19 had a severe degree of subvalvular lesion, whereas such a lesion was noted in only 6 of the 18 patients with normal left ventricular shape and contraction pattern. It is considered that a rigid mitral complex immobilizes the posterior wall of the left ventricle in patients with mitral stenosis. In addition, tricuspid regurgitation, which was frequently observed in our patients, may play an important role in abnormal septal motion. This study showed that abnormal left ventricular shape and asynergy in the posterior wall are not rare in patients with mitral stenosis and are due to a rigid mitral complex and associated tricuspid regurgitation.
BACKGROUND AND AIM OF THE STUDY: Although depressed left ventricular ejection fraction is present in a considerable proportion of subjects with pure mitral stenosis (MS), its mechanisms are not clearly identified. The purpose of this study was to identify determinants of depressed ejection fraction in young patients with isolated mitral stenosis in sinus rhythm. METHODS: We retrospectively analyzed 320 records of patients with MS (mitral valve area < or = 2.0 cm2) who underwent invasive diagnostic procedure in our center. Of these 39 subjects aged 20-40 years with isolated MS in sinus rhythm were selected for the final analysis. RESULTS: An ejection fraction not exceeding 50% was found in 12 patients (group A). When comparing group A to the remainder (group B), group A patients had lower left ventricular end-diastolic volume indices (60.5 +/- 21.6 ml/m2 vs. 76.1 +/- 16.1 ml/m2, p = 0.02) and stroke volume indices (28.0 +/- 10.4 vs. 47.9 +/- 12.0, p < 0.001). No significant differences between the groups in patients' age, end-systolic volume index, mitral valve area, mean transmitral gradient, left-sided cardiac pressures, pulmonary wedge pressure, systemic vascular resistance, and cardiac output were found. Indices of left ventricular isovolumic contraction and relaxation as well as end-systolic indices of left ventricular function were also comparable. Group A had significantly higher pulmonary vascular resistance, pulmonary artery pressures, and higher heart rate. An approximate index of left ventricular compliance was significantly lower in group A with similar left ventricular minimal and end-diastolic pressures. CONCLUSIONS: Depressed ejection fraction in pure mitral stenosis with preserved sinus rhythm seems attributable to left ventricular underfilling that appears to be precipitated by other factors in addition to a narrowed mitral orifice, e.g. decreased passive left ventricular compliance and/or altered interventricular interactions.
The influence of aortic regurgitation on the Doppler assessment of pressure half-time (T1/2) and on the derived calculation of the mitral-valve area has not yet been adequately evaluated in patients with mitral stenosis and associated aortic regurgitation. Therefore this study was undertaken to verify the accuracy of the T1/2 method for the noninvasive estimation of mitral-valve area in patients with mitral stenosis and associated aortic regurgitation. Data were obtained from 31 selected patients who underwent cardiac catheterization within 24 h of the noninvasive examination. From the Doppler velocity curve, T1/2 was calculated as the interval between the peak transmitral velocity and velocity/ square root of 2. Mitral-valve area was measured from the T1/2 with a computerized system using the equation: 220/T1/2, in cm2. Calculation of the mitral-valve area at catheterization was derived applying the modified Gorlin formula. Mean mitral-valve area, as determined at catheterization, ranged from 0.5 to 2.8 cm2 (1.3 +/- 0.6). Mean mitral-valve area, as calculated by continuous-wave Doppler, ranged from 0.7 to 2.7 cm2 (1.5 +/- 0.6). Linear-regression analysis of data revealed a good correlation between Gorlin and Doppler measurements of the mitral-valve area (r = 0.90, SEE = 0.28 cm2, P less than 0.001, y = 1.0x + 0.2). Doppler showed a systematic overestimate of the mitral-valve area (26%) in patients with mitral stenosis and aortic regurgitation as compared to the Gorlin formula. The overestimate of continuous-wave Doppler was even greater (39%) in a subgroup of patients with 2+ or 3+ angiographic aortic regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)
To investigate the feasibility of percutaneous transvenous balloon dilatation of the mitral valve in patients with combined aortic and mitral stenosis, 12 patients were studied by echocardiography and catheterization before and after mitral valvuloplasty. Aortic stenosis was defined from prevalvuloplasty catheterization study as a transaortic pressure gradient of more than 25 mm Hg. All 12 patients underwent transvenous balloon mitral valvuloplasty successfully. Immediately after the procedure, all patients experienced improvement in clinical symptoms and in hemodynamic variables. Mitral valve areas were significantly increased from 0.78 +/- 0.18 to 1.73 +/- 0.21 cm2 (P < 0.0001) by planimetry method. Cardiac output was significantly increased from 3.6 +/- 0.1 to 4.2 +/- 0.5 L/min (P = 0.01). Mean transaortic flow rate increased 33% (from 198 +/- 68 to 254 +/- 41 mL/s, P = 0.002). Mean pressure gradient across the aortic valve after mitral valvuloplasty was not significantly increased, from 34 +/- 7 to 37 +/- 13 mm Hg. Aortic valve areas, derived from the Gorlin formula, were significantly increased from 0.57 +/- 0.12 to 0.73 +/- 0.14 cm2 (P = 0.006) after mitral valvuloplasty. However, continuity equation-derived aortic valve area was independent of increasing flow rate after mitral valvuloplasty from 1.29 +/- 0.35 to 1.30 +/- 0.29 cm2. During follow-up with a mean of twenty four +/- fourteen months, 8 patients were in New York Heart association functional class I, 3 in class II, and 1 in class IV who received pericardiotomy owing to constrictive pericarditis without aortic valve replacement. In conclusion, mitral valvuloplasty alone may be safe and effective in alleviating symptoms in mitral stenosis patients with transaortic pressure gradient > 25 mm Hg. Continuity equation-derived aortic valve areas seem to be flow independent in evaluation of aortic stenosis and are important for decision making.
Three patients with rheumatic mitral stenosis were treated with percutaneous mitral valvotomy. A Brockenbrough catheter was advanced transseptally into the left atrium and then into the left ventricle over a long guide wire. An angle wire loop retriever was advanced through a 10 Fr straight catheter via the femoral artery into the left ventricle. The retriever was used to catch the flexible end of the long guide wire. This end of the long guide wire was then drawn out of the right femoral artery by the retriever through the straight catheter. The straight catheter was left in the descending aorta; the Brockenbrough catheter was removed and a 7 Fr balloon catheter was introduced percutaneously over the long guide wire through the femoral vein. This balloon catheter was used for interatrial septal dilatation and right femoral venous dilatation. In two patients this catheter was replaced over the long guide wire with a 9 Fr Schneider-Medintag Grüntzig catheter (3 X 12 mm diameter when inflated) and in the other by a Mansfield (18 mm diameter when inflated). The procedure was well tolerated in these three patients and there were no complications. Haemodynamic function improved, there was appreciable decrease in dyspnoea, and exercise tolerance was increased. This procedure has several advantages: the balloon is more easily positioned through the mitral valve; the stability of the balloon during inflation is improved by traction at both ends of the long guide wire; and there is the option of rapidly exchanging one balloon for a larger one over the long guide wire. This technique seems to be less arrhythmogenic and results in less blood loss because manual compression of the femoral vessels after the procedure is easier.
BACKGROUND: To examine whether an extremely enlarged left atrium (giant left atrium) obstructs the venous return from the inferior vena cava (IVC), the velocity of IVC flow was measured at its junction with the right atrium (IVC orifice) in patients with mitral stenosis by use of color and pulsed-wave Doppler echocardiography from a right parasternal longitudinal plane. METHODS AND RESULTS: The maximum dimension of the IVC orifice by two-dimensional echocardiography and the maximum IVC orifice flow velocity by pulsed-wave Doppler echocardiography were measured in 74 patients with mitral stenosis and atrial fibrillation (mean age, 59 years). The control population consisted of 16 subjects with atrial fibrillation alone (mean age, 61 years). Flow velocities in the superior vena cava and hepatic vein were also obtained by pulsed-wave Doppler echocardiography from the supraclavicular and subcostal views, respectively. Fifty-one mitral stenosis patients without severe tricuspid regurgitation were divided into two groups according to the left atrial dimension (LAD), which was measured by the standard left parasternal long-axis view (group A: n = 33, LAD less than 65 mm; group B: n = 18, LAD greater than or equal to 65 mm). Peak inspiratory and expiratory velocities of IVC orifice flow in diastole averaged over three consecutive inspirations in group B (mean +/- SD, 93.4 +/- 32.0 and 47.6 +/- 19.8 cm/sec) were significantly greater (p less than 0.01) than in the control subjects (67.9 +/- 12.8 and 34.5 +/- 7.0 cm/sec) and in group A (70.2 +/- 18.4 and 38.1 +/- 11.5 cm/sec, respectively). However, there were no significant differences in superior vena caval and hepatic vein flow velocities among the three groups. The maximum IVC orifice dimension in group B (11.4 +/- 4.4 mm) was significantly smaller than in the control subjects (20.1 +/- 2.1 mm) and in group A (18.6 +/- 5.4 mm) because of displacement of the atrial septum into the right atrium. There were significant negative correlations between the IVC orifice dimension and the peak IVC orifice flow velocity (r = -0.62, SEE = 0.33 cm/sec, n = 67, y = e(-0.01x + 3.6), p less than 0.01) as well as the left atrial dimension (r = -0.71, SEE = 0.32 mm, n = 67, y = e(-0.02x + 3.8), p less than 0.01) in these 51 patients and control subjects. In the remaining 23 patients with severe tricuspid regurgitation, the peak inspiratory IVC orifice velocity (n = 9, 88.6 +/- 30.0 cm/sec) was significantly greater (p less than 0.05) and the IVC orifice dimension (23.8 +/- 9.7 mm) significantly smaller (p less than 0.05) in patients with a giant left atrium than in those without (n = 14, 69.9 +/- 15.3 cm/sec and 30.5 +/- 9.6 mm, respectively); in the latter, the IVC orifice dimension was significantly (p less than 0.05) greater than in the controls. CONCLUSIONS: A giant left atrium in patients with mitral stenosis obstructs venous return at the IVC orifice by marked displacement of the atrial septum toward the right atrium.
OBJECTIVE: To study the incidence of spontaneous echo contrast in left atrium of Indian patients with rheumatic mitral stenosis in normal sinus rhythm and to define its relations. SUBJECTS: Transthoracic and multiplane transoesophageal echocardiographic studies were performed in 89 consecutive patients with rheumatic mitral stenosis who were in normal sinus rhythm. RESULTS: Spontaneous echo contrast in the left atrium was seen in 57.3% of patients on multiplane transoesophageal echocardiography and in only 5.6% on transthoracic echocardiography. The mean mitral valve area was 1.07 (SD 0.33) cm2 and 1.32 (0.45) cm2 (P = 0.004), mean left atrial size was 4.27 (0.67) cm and 3.91 (0.5) cm (P = 0.029), mean diastolic pressure gradient was 12.64 (5.69) mm Hg and 10 (5.5) mm Hg (P = 0.049), and absence of mitral regurgitation was seen in 45% and 23% of patients respectively (P = 0.1). Among patients with spontaneous echo contrast, 31% had either left atrial/appendage thrombus or a history of embolism, upsilon 0% in patients without spontaneous echo contrast (P < 0.0001). CONCLUSIONS: There is a high incidence of spontaneous echo contrast in the left atrium in Indian patients with rheumatic mitral stenosis in normal sinus rhythm on multiplane transoesophageal echocardiography. These patients are likely to embolise or form thrombi in the left atrium. The presence of spontaneous echo contrast is also associated with significantly smaller mitral valve area, larger left atrium, and higher mean diastolic mitral pressure gradient.
The authors present an analysis of the late results of closed mitral commissurotomy in 364 patients (maximum terms of observation--17 years). Main causes of recurrent mitral stenosis were recognized: activation of a rheumatic process (50%), nonspecific scarring processes (27%), inadequate commissurotomies (11.1%) and others (11.1%). The routine antirheumatic therapy (bicillin+salicylates) was found to be ineffective in prophylaxis against mitral restenoses. Recurrent mitral stenosis proved to occur more frequently in patients operated upon in young age (under 30).
BACKGROUND AND AIM OF THE STUDY: The non-invasive evaluation of mitral valve area is often used in the assessment of patients with mitral stenosis. The pressure half-time method is commonly used to calculate valve area, but is inaccurate in many clinical scenarios. We sought to quantify the effects of changing cardiac output on the accuracy of mitral valve area determination. METHODS: Thirteen patients with mitral stenosis underwent routine stress echocardiography with resting and peak exercise results compared. A previously described and clinically validated mathematical model of the cardiovascular system was used to validate the clinical results. Seven different loading conditions for each of four different stenotic valve areas were modeled. RESULTS: In patients, with increasing cardiac output, pressure half-time decreased (-30.6+/-35.3 ms/l/min) and calculated valve area increased by 0.25+/-0.30 cm2/l/min. By continuity, it appeared that approximately half of this increase was due to actual valve orifice stretching, the remainder reflecting fundamental changes in the relationship between half-time and valve area. Mathematical modeling resulted in similar changes in pressure half-time and calculated valve area (0.06 to 0.12 cm2/l/min, p = 0.20 versus clinical results). CONCLUSION: Changes in cardiac output result in predictable changes in pressure half-time, and should be considered when performing serial examinations in patients with mitral stenosis.
Although the haemodynamic response during submaximal supine exercise in mitral stenosis has been well described, the determinants of peak oxygen uptake during maximal upright exercise are poorly characterized and may differ in sinus rhythm and atrial fibrillation. Seventy patients with isolated mitral stenosis underwent Doppler-echocardiography and bicycle exercise with respiratory gas analysis. Forty-two patients were in sinus rhythm (Group I) and 28 in atrial fibrillation (Group II). Peak oxygen uptake was 21.3 +/- 5.6 ml.min-1.kg-1 in group I and 18.1 +/- 5.1 ml.min-1.kg-1 in group II (P < 0.05). There was no significant correlation between indices of exercise tolerance (exercise duration, ventilatory threshold, peak oxygen uptake, indexed peak oxygen uptake, peak oxygen pulse) and valve area or gradient in either group. Indexed peak oxygen uptake was not correlated to delta oxygen pulse but was linearly related (r = 0.43) to delta heart rate (delta heart rate = peak heart rate/rest heart rate) in Group I but not in Group II. Thus, in patients with mitral stenosis, no correlation was found between the mitral valve area or the gradient at rest and maximal upright exercise tolerance, suggesting that peripheral adaptation and, in sinus rhythm, chronotropic reserve, are important compensatory mechanisms.
Echocardiographic and cardiac catheterization findings were compared in 61 patients with mitral stenosis without other significant lesions in an attempt to determine the clinical usefulness of echocardiography in the assessment of such patients. There was a poor correlation between the E-F slope on the echocardiogram and the calculated mitral valve area (r = 0.51). A review of reported data relating the E-F slope to mitral valve area indicated that echocardiographic assessment of mitral valve area had low sensitivity and specificity. The amplitude of excursion of the anterior leaflet did not differ significantly in patients undergoing valvotomy and those undergoind valve replacement. The data obtained suggest that while the echocardiogram is a reliable method of diagnosing mitral stenosis, the E-F slope is an unreliable index of the severity of the lesion.
BACKGROUND: Association of valvular heart disease and lipid profile might be important as in the case of aortic stenosis. However, it has not been so far considered in detail the probable association of other valvular diseases, particularly of mitral stenosis (MS) with lipid profile. In our study, we aimed to search possible association of echocardiographic mitral valve score, evaluated according to Wilkins score, with lipid parameters in a group of patients with mitral stenosis, who were referred for possible percutaneous balloon valvuloplasty. MATERIAL AND METHOD: We retrospectively reviewed 401 patients (316 female, 85 male), who were referred as possible candidates for PMBV, with moderate to severe MS of predominantly rheumatic origin. Mitral valve was evaluated according to Wilkins score by an experienced author as indicated. RESULTS: Mean age of all patients was 36.6+/-11.3 years, and was not different in both genders. Mean mitral valve area was 1+/-0.1 mm2. Considering all patients, total Wilkins score was significantly, but mildly correlated with ratio of total/HDL cholesterol ratio (r=0.174, p=0.02). Presence of more than one recurrent attack of rheumatic fever, narrow mitral valve area, high total/HDL cholesterol and being male were independent predictors of poor echocardiographic Wilkins score (>8). CONCLUSION: We think that Wilkins echocardiographic score of mitral stenosis, particularly of leaflet thickening, might well be associated with serum lipids, probably as the same extent does aortic stenosis.
BACKGROUND: The purpose of this study was to prospectively evaluate a large group of consecutive, non-anticoagulated patients with severe rheumatic mitral stenosis and to analyze the left atrial appendage function in relation to left atrial appendage clot and spontaneous echo contrast formation. METHODS AND RESULTS: We prospectively studied left atrial appendage function in 200 consecutive patients with severe mitral stenosis who underwent transesophageal echocardiography and correlated it with spontaneous echo contrast and left atrial appendage clot. The mean age was 30.2 +/- 9.4 years. Fifty-five (27.5%) patients were in atrial fibrillation. Left atrial appendage clot was present in 50 (25%) patients and 113 (56.5%) had spontaneous echo contrast. The older age, increased duration of symptoms, atrial fibrillation, spontaneous echo contrast, larger left atrium, depressed left atrial appendage function and type II and III left atrial appendage flow patterns correlated significantly (p<0.05) with the left atrial appendage clot. Left atrial appendage ejection fraction was significantly less in patients with clot (21.8 +/- 12.8% v. 39.1 +/- 13.2%, p<0.0001) and in those with spontaneous echo contrast (30.3 +/- 16.2 % v. 40.3 +/- 11.8%, p<0.001). Left atrial appendage filling (18.0 +/- 11.7 v. 27.6 +/- 11.8 cm/s, p <0.0001) and emptying velocities (15.4 +/- 7.0 v. 21.5 +/- 9.6 cm/s, p<0.001) and filling (1.4 +/- 1.0 v. 2.5 +/- 1.4 cm, p<0.0001) and emptying (1.5 +/- 1.2 v. 2.1 +/- 1.2 cm, p <0.05) velocity time integrals were also significantly lower in patients with clot as compared to those without clot. On multivariate regression analysis, atrial fibrillation (odds ratio 6.68, 95% CI 1.85-24.19, p=0.003) and left atrial appendage ejection fraction (odds ratio 1.06, 95% CI 1.00 - 1.11, p=0.04) were the only two independent predictors of clot formation. Incidence of clot was 62.59% in patients with left atrial appendage ejection fraction < or = 25% as compared to 10.4% in those having left atrial appendage ejection fraction >25%. Similarly patients with spontaneous echo contrasthadlower filling (21.7 +/- 11.5 v. 29.4 +/- 12.7 cm/s, p<0.0001) and emptying (17.0 +/- 8.1 v. 23.9 +/- 10.9 cm/s, p<0.0001) velocities, as well as filling (1.9 +/- 1.3 v. 2.7 +/- 1.3 cm, p<0.01) and emptying (1.7 +/- 1.0 v. 2.3 +/- 1.4 cm, p<0.01) velocity time integrals as compared to patients without spontaneous echo contrast. In a subgroup of the patients with normal sinus rhythm, the left atrial appendage ejection fraction was significantly less in patients with clot compared to those without clot (31.2 +/- 13.2 v. 41.3 +/- 11.5 %, p<0.01). CONCLUSIONS: In the patients with severe mitral stenosis, besides atrial fibrillation, a subgroup of patients in normal sinus rhythm with depressed left atrial appendage function (left atrial appendage ejection fraction < or = 25%) had a higher risk of clot formation in left atrial appendage and these patients should be routinely anticoagulated for prevention of clot formation.
Three years after valve replacement for Monckeberg type aortic stenosis, a tight and poorly tolerated tight mitral stenosis is observed, secondary to massive calcifications of the ring extending to the valves. The diagnosis is made with Doppler sonography and hemodynamic examination. Excision of the calcifications is particularly difficult. An early death occurs. Calcifications of the mitral ring extending to the valves, either isolated or mainly associated with a calcified aortic stenosis, may be complicated by mitral stenosis. The latter, usually moderate, may be tight and require surgical treatment, of severe prognosis.