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PubMedDate not supplied

Mitral stenosis: I. Anatomical, physiological, and clinical considerations.

Because of the dramatic decline in the incidence of acute rheumatic fever in the United States and much of the developed world over the past 70 years, mitral stenosis, once a common valvular problem, is now distinctly uncommon in many countries. Nevertheless, because mitral stenosis maintains a high prevalence in developing countries and among emigrants from those countries to the United States, continued awareness of the condition is warranted. Furthermore, failure to recognize mitral stenosis not only precludes many effective therapies but in so doing may result in serious complications.

Adolescent↗
PubMed2003

Electrocardiographic diagnosis of left atrial enlargement in patients with mitral stenosis: the value of the P-wave area.

OBJECTIVE: To investigate the value of the P-wave area in diagnosing left atrial enlargement in patients with mitral stenosis. METHODS: We measured the P-wave area from lead II of a standard 12-lead ECG in 136 consecutive patients with mitral stenosis. We also measured the left atrial diameter with two-dimensional echocardiography. RESULTS: Left atrial enlargement was identified in 120 (88.2%) patients. There was an excellent correlation between P-wave area and left atrial diameter in these patients (r = 0.739, p = 0.001). A P-wave area of > or = 4 ms x mv had an 85.8% sensitivity and 93.7% specificity for left atrial enlargement. There was also a smaller but significant correlation between left atrial diameter and the total P-wave duration (r = 0.635, p < 0.01) or P-wave amplitude (r = 0.683, p < 0.01) in these patients. However, the P-wave area had a better overall sensitivity than the P-wave duration (43.3%) or amplitude (10.8%) in diagnosing left atrial enlargement. CONCLUSIONS: Left atrium enlargement can be estimated by P-wave area measured from ECG lead II in patients with mitral stenosis. A P-wave area 24 ms x mv serves as a new criterion of left atrial enlargement.

Adolescent↗
PubMed1989

[A case of cardiac myxoma associated with long-term lasting symptoms of mitral stenosis].

We reported a case of 70-year-old woman whose left atrial myxoma was resected. She had been suffered from low cardiac output due to mitral stenosis for 15 years or more. Resection of the myxoma corrected mitral stenosis completely. Cardiac output and pulmonary wedge pressure, however, were not improved following the operation. Postoperative echo- and angiocardiography revealed marked early closure of the mitral valve. These findings indicate that left ventricular compliance should be reduced if inflow stenosis continued for a long period and it is difficult to improve depressed ventricular function even if mitral stenosis is completely removed.

Aged↗
PubMed1995

Beta adrenergic blockade does not improve effort tolerance in patients with mitral stenosis in sinus rhythm.

OBJECTIVES: This study was designed to assess the effects of beta-blockade on cardiopulmonary exercise performance in symptomatic patients with tight mitral stenosis in sinus rhythm. BACKGROUND: The role of beta-blockers in these patients has been controversial and assessment of effort tolerance using treadmill exercise time has produced conflicting results. METHODS: Nineteen patients with isolated symptomatic (New York Heart Association class II or III) mitral stenosis received a beta-blocker (acebutalol or atenolol) or matching placebo for one week each in a randomized double-blind crossover fashion. Exercise on a treadmill with real time gas exchange analysis was performed six times over 4 weeks in each patient. The test was further repeated once within a week of percutaneous mitral valvotomy. RESULTS: Heart rate at rest and during peak exercise was significantly lower with beta-blockade compared to control state or placebo treatment. Mean peak oxygen consumption did not differ significantly between treatment groups. When patients were arbitrarily classified into those with (group I, heart rate < or = 130.min-1) and those without (group II, heart rate > or = 131.min-1) adequate beta-blockade, there was a significant difference in peak VO2. The peak VO2 for group I: 14.0 +/- 3.2 vs 17.5 +/- 4.0 ml.min-1.kg-1; peak VO2 for group II: 17.2 +/- 2.4 vs 18.0 +/- 2.4 ml.min-1.kg-1 (beta-blockade vs control state respectively). Treadmill exercise time did not differ between treatment groups. The slope of minute ventilation (MV) and carbon dioxide (CO2) excretion, and instantaneous carbon dioxide ventilatory equivalent (MV/VCO2) was unchanged with beta-blocker therapy indicating no improvement in ventilatory performance. CONCLUSIONS: Beta-blocker therapy in tight mitral stenosis appears to have no beneficial effect on aerobic capacity, nor does it improve ventilatory performance. Adequate beta-blockade may adversely effect peak oxygen consumption.

Acebutolol↗
PubMed1988

[Percutaneous transluminal valvuloplasty of mitral stenosis. Apropos of 17 cases].

Percutaneous mitral commissurotomy using balloon catheters was attempted in 17 patients (16 of whom were women) with rheumatic mitral valve stenosis. The patients' age ranged from 15 to 34 years (men 21 years). Functionally, 15 of the patients were in stage III of the New York Heart Association classification, and 2 were in stage II. Sinus rhythm was present in all cases. Slight mitral regurgitation was noted in 2 cases, associated with mild aortic disease in one of them; 3 other patients presented with slight aortic regurgitation. In all 17 cases the mitral stenosis was tight, uncalcified, with flexible valves and little or no alteration of the subvalvular system. One single balloon catheter was used in 11 patients and 2 balloon catheters were introduced simultaneously in the remaining 6 patients. The new therapeutic method was successful in all patients. Following valvuloplasty, the mean transmitral gradient was reduced from 25 +/- 3 to 11 +/- 2 mmHg (P less than 0.001), the mean capillary pressure fell from 26.8 +/- 7.1 to 13.5 +/- 3.7 mmHg (P less than 0.001) and the cardiac index increased from 3.3 +/- 1 to 4.2 +/- 1.2 l/min/m2 (P less than 0.001). The mitral valve area, measured by two-dimensional echocardiography, increased from 1.0 +/- 02 to 2.1 +/- 0.3 cm2 (P less than 0.001). The mitral valve regurgitation observed in 2 patients before valvuloplasty was aggravated, although still moderate, in one of them and remained stable in the other.

Adolescent↗
PubMed1995

Transesophageal echocardiographic assessment of reversal of systolic pulmonary venous flow in mitral stenosis.

Transesophageal echocardiography and diagnostic cardiac catheterization were performed in 36 patients with symptomatic mitral stenosis to assess the incidence and significance of systolic flow reversal in the pulmonary veins. Mitral regurgitation was graded by contrast ventriculography, and left atrial pressure was directly measured after transseptal puncture. Pulmonary venous flow was recorded with transesophageal Doppler imaging from the left upper pulmonary vein. Early systolic flow reversal was identified in 11 patients (31%) and began an average of 58 +/- 13 ms after QRS onset. This pattern correlated strongly with the presence of atrial fibrillation or flutter. Late systolic flow reversal was identified in 8 patients (22%), beginning an average of 245 +/- 46 ms after the QRS complex. These patients had higher left atrial V-wave pressure (36 +/- 10 vs 29 +/- 8 mm Hg; p < 0.05) and V-wave peak-X-descent trough (18 +/- 7 vs 11 +/- 5 mm Hg; p < 0.01) than patients without systolic flow reversal. Neither pattern of pulmonary venous flow reversal was related to the severity of angiographic mitral regurgitation. Systolic reversal of pulmonary venous flow is not specific for angiographically severe mitral regurgitation in patients with mitral stenosis. Similar limitations to pulmonary venous flow analysis likely apply to other patient groups with elevated left atrial pressure and poor left atrial compliance.

Adult↗
PubMed1983

M-mode and two-dimensional echocardiographic correlation with findings at catheterization and surgery in patients with mitral stenosis.

Thirty-two consecutive patients referred to our institution for evaluation of rheumatic mitral stenosis were studied with M-mode echocardiography (M-mode E), two dimensional echocardiography (2DE), and cardiac catheterization. Twenty-three of these patients underwent mitral valve surgery, 11 requiring mitral valve replacement, and 12 requiring open mitral commissurotomy. Clinical and noninvasive parameters were assessed in order to predict catheterization-determined mitral valve areas as calculated by the Gorlin formula, and to predict the choice of operation in patients selected for surgery. For the prediction of valvular area, 2DE planimetry correlated highly (r = 0.89, p less than 0.01) with Gorlin formula results. The presence or absence of pericardial effusion, the anterior-posterior valve leaflet separation (M-mode E), and the left atrium-aortic index (2DE) correlated poorly with the degree of mitral stenosis as determined by the Gorlin formula. The most useful predictors of type of mitral surgery were age over 50 years, 2DE valve classification, the presence or absence of calcium at fluoroscopy, and degree of anterior leaflet-septal separation (M-mode E).

Age Factors↗
PubMed1998

What does the left atrial v wave signify during balloon commissurotomy of mitral stenosis?

Left atrial v-wave amplitude has been associated with the presence and severity of chronic mitral regurgitation (MR) but it has not been evaluated for the detection of acute MR. We evaluated the left atrial v-wave amplitude of 205 consecutive patients with mitral stenosis immediately before and after stepwise, incremental balloon mitral commissurotomy to determine predictors of large v waves at baseline and an increase in v-wave amplitude after balloon commissurotomy. The sensitivity and specificity of an increase in v-wave amplitude for detecting worsening and severe MR were determined. A large v wave was present in 44% of patients before balloon commissurotomy and was predicted by age, mean left atrial pressure, mean transmitral gradient, mean pulmonary artery pressure, and angiographic severity of MR. There was a strong inverse correlation between v-wave amplitude and calculated left atrial compliance (r = -0.92). An increase in v-wave amplitude after balloon commissurotomy was associated with an increasing probability of worsening or severe MR. This indicator had a sensitivity, specificity, and positive and negative predictive values of 35%, 91%, 64%, 75%, respectively, for detecting any increase in MR. For the detection of severe MR, the sensitivity was 79%, specificity 89%, positive predictive value 42%, and negative predictive value 98%. Thus, left atrial v-wave amplitude reflects left atrial compliance and severity of mitral stenosis before balloon commissurotomy. An increase in v-wave amplitude is an insensitive but very specific indicator of worsening or severe MR during stepwise, incremental balloon mitral commissurotomy.

Atrial Function, Left↗
PubMed1993

Suspension of the papillary muscles during valve replacement for mitral stenosis.

Of 94 patients who underwent intravalvular mitral valve replacement with CarboMedics bileaflet mechanical prosthesis, 10 presented with heavily calcified stenotic valves. After total excision of the mitral valve in these patients, both papillary muscles were reconnected to the annulus with Goretex sutures. Repeat cardiac catheterization was completed in six of these 10 patients two to 24 months after surgery. Global and segmental left ventricular function was estimated using the MEDIS program (Thorax Centrum, Rotterdam) for analysis of left ventricular function. In five of the six patients re-examined, the ejection fraction was improved, the global ejection fraction increasing from 54% +/- 6% to 63% +/- 10%. We conclude, even though the number of followed patients is extremely small, that mitral valve replacement with suspension of the papillary muscles is surgically feasible and has beneficial effects on the contractility of the left ventricle in patients with mitral stenosis.

Follow-Up Studies↗
PubMed1986

Actuarial analysis of reoperation in patients undergoing open mitral commissurotomy for mitral stenosis.

Reoperation is one of the most seriously problematical events in postoperative follow-up of patients undergoing open mitral commissurotomy (OMC) for mitral stenosis. In 217 patients with pure mitral stenosis, even when associated with severe subvalvular changes, the actuarial rate of freedom from reoperation was 94% 12 years after OMC. In contrast, in 85 patients with MS combined with regurgitation, the rate was 66%. In postoperative management of patients undergoing OMC, it is mandatory to know preoperative anatomical findings of the stenosed mitral valve.

Actuarial Analysis↗
PubMed1994

Accurate measurement of the transmitral gradient in patients with mitral stenosis: a simultaneous catheterization and Doppler echocardiographic study.

OBJECTIVES: This study compared the accuracy of Doppler echocardiography with that of conventional cardiac catheterization in the measurement of transmitral gradients in patients with mitral stenosis. BACKGROUND: Simultaneous measurement of left atrial and left ventricular pressures is the most accurate method for determination of the mean mitral valve gradient in patients with mitral stenosis. Because of the inherent risks of transseptal catheterization, pulmonary capillary wedge pressure has been used in many invasive laboratories for determination of the mean mitral valve gradient. Recent studies have observed significant errors when pulmonary capillary wedge pressure was used for these measurements. Doppler echocardiography provides a noninvasive alternative for measurement of the transmitral gradient, but its relative accuracy has remained unclear. METHODS: Seventeen patients with mitral stenosis who underwent transseptal cardiac catheterization had simultaneous measurement of 1) transmitral gradient by direct left atrial and left ventricular pressures, 2) transmitral gradient by pulmonary capillary wedge and left ventricular pressures, and 3) transmitral gradient by Doppler echocardiography. RESULTS: Transmitral gradient measured by pulmonary capillary wedge and left ventricular pressures significantly overestimated the gradient obtained by direct measurement of left atrial pressure, with a mean (+/- SD) difference of 3.3 +/- 3.5 mm Hg (or 53%). Correcting the pulmonary capillary wedge pressure for the phase shift resulted in better correlation, but a consistent overestimation still remained, with a mean difference of 2.5 +/- 2.9 mm Hg (or 43%). The best correlation with the smallest variability was comparison of the Doppler-derived mean gradient with the gradient from direct measurement of left atrial and left ventricular pressures, with a mean difference of 0.2 +/- 1.2 mm Hg. CONCLUSIONS: Compared with the transmitral gradient obtained by direct measurement of left atrial and left ventricular pressures, the Doppler-derived gradient is more accurate than that obtained by conventional cardiac catheterization and should be considered the reference standard.

Adult↗
PubMed1979

Hemodynamic effects of phentolamine in mitral stenosis and congestive cardiomyopahty.

Nine patients with alcoholic cardiomyopathy and 8 patients with mitral stenosis were studied by right and left heart catheterization. Hemodynamic observations were made during control period and during the infusion of phentolamine at a rate of 0.3 mg per minute. The patients with the cardiomyopathy responded to phentolamine with a significant decline in the left ventricular filling pressure, pulmonary artery mean pressure, peripheral resistance, and arteriovenous oxygen difference. There was a significant increase in the cardiac index. The patients with mitral stenosis did not show any hemodynamic improvement after phentolamine infusion.

Cardiac Output↗
PubMed1991

Clinical study of left atrial compliance and left atrial volume in mitral stenosis.

We studied left atrial compliance and left atrial volume in 21 patients with mitral stenosis showing a normal sinus rhythm. 1) A significant (p less than 0.001) negative linear correlation of r = 0.72 was found between the mitral valve area (MVA) and left atrial mean pressure (LAm). 2) A significant (p less than 0.005) positive linear correlation of r = 0.60 was found between MVA and left atrial compliance (delta V/delta P). 3) A significant (p less than 0.001) hyperbolic correlation of r = 0.73 was found between LAm and delta V/delta P. 4) A significant (p less than 0.001) hyperbolic correlation of r = 0.65 was found between left atrial specific compliance (delta V/delta P/LAVmax. LAVmax: left atrial maximum volume) and left atrial mean volume. 5) These findings led to the conclusion that in patients with mitral stenosis showing a normal sinus rhythm, left atrial compliance was decreased in patients whose left atrial volume was increased, and the decrease of left atrial compliance was related to narrowing of the mitral valve area and elevation of the left atrial pressure.

Adult↗
PubMed1993

Left ventricular apical approach for the surgical treatment of congenital mitral stenosis.

From June 1987 to October 1991, 12 patients with congenital mitral valve stenosis underwent surgical correction. Their ages ranged from 2 to 74 months. Nine patients were less than 22 months of age. Five patients were in New York Heart Association functional class IV, and seven patients were in class III. In nine, parachute-type mitral stenosis was clearly definite. In three, a complex congenital valvular and subvalvular stenosis was found. Associated anomalies were present in every patient; five had undergone previous operations. Correction of the mitral stenosis was done through an apical left ventriculotomy. The removal of the mitral obstruction starts from below; the papillary muscle was split and the chordae were divided or fenestrated. The commissurotomies were performed from the ventricular aspect of the mitral valve. Associated anomalies were corrected simultaneously. The operative mortality rate was zero. There was one late death, which was unrelated to cardiovascular status. The echocardiographic serial postoperative studies (up to 52 months) showed no significant residual mitral stenosis and normal global and regional function of the left ventricle in all but one patient.

Cardiac Surgical Procedures↗
PubMed1990

Alfentanil for urgent caesarean section in a patient with severe mitral stenosis and pulmonary hypertension.

We present the case of a parturient with severe mitral stenosis and pulmonary hypertension who received general anaesthesia using alfentanil for urgent Caesarean section. Alfentanil promoted haemodynamic stability and allowed immediate postoperative extubation. Epidural morphine provided postoperative analgesia. This combination permitted early ambulation and prevention of thromboembolism. A disadvantage of this technique, neonatal respiratory depression, was promptly reversed with a single dose of naloxone. The anaesthetic management of mitral stenosis in pregnancy is discussed and the neonatal pharmacokinetics of maternally administered alfentanil are presented.

Adult↗
PubMed1991

Systemic and pulmonary flow in mitral stenosis: evidence for a bronchial vein shunt.

We measured pulmonary and systemic flows in 22 patients with mitral stenosis and in 7 controls. In patients with mitral stenosis, pulmonary flow index averaged 2.33 +/- 0.41 l/min/m2 and systemic flow index averaged 2.15 +/- 0.60 l/min/m2, p = 0.045. There was a strong correlation between the difference in pulmonary and systemic flow indexes and the difference in mean left and right atrial pressure (r = 0.749, p = 0.00008). After a successful dilatation in 17 patients, there was a significant drop in the difference between pulmonary and systemic flow indexes (0.26 +/- 0.41 vs. 0.07 +/- 0.37 l/min/m2, p = 0.048). We conclude that chronic elevation of left atrial pressure leads to a left to right shunt probably through bronchial veins.

Bronchi↗