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PubMed1978

[Clinical use of the apex carotid diagram in mitral stenosis].

Apex-carotid diagram (ACD) is a new mechanic-cardiographic method, consisting in integration of carotis-sphygmogram and apex-cardiogram in one diagram. In the present work, 121 patients with mitral stenosis were examined. ACD in mitral stenosis is characterized by an extension of the field of ventricle filling (p less than 0.05) and diminished angle alpha' (p less than 0.001). A reliable correlation was established between the values of angle alpha' and the mean pressure in the left ventricle r = -0.88, p less than 0.001 with a standard deviation of +/- mm Hg.

Adolescent↗
PubMed1994

[The accuracy and applicability of different methods in the Doppler technic for the quantification of mitral stenosis].

INTRODUCTION AND OBJECTIVES: We analyse the applicability and accuracy of the various Doppler methods for quantification of mitral stenosis as well as the value of combining measurements. PATIENTS AND METHODS: The study comprised 74 patients with reliable planimetry of mitral orifice. The following Doppler methods were tested: a) pressure half-time; b) color jet width at the mitral valve orifice in the apical long-axis view (short diameter) and its width in the 90 degree rotated view (long diameter), assuming an elliptic mitral orifice; c) proximal isovelocity surface area from the 4-chamber view assuming a hemispheric surface, and d) the continuity equation. The mean value of mitral valve area estimates from all applicable Doppler methods was calculated in each patient. RESULTS: The rates of applicability of each method were, respectively: 85, 97, 97 and 53% (p < 0.01). The correlations--r (SEE)--between each method and planimetry were: 0.86 (0.17 cm2), 0.81 (0.19 cm2), 0.74 (0.21 cm2) and 0.83 (0.18 cm2), respectively. The highest correlation was found with the mean value (r = 0.90; SEE = 0.14 cm2), and only this parameter was selected by stepwise multiple regression analysis (r = 0.93; SEE = 0.12 cm2). CONCLUSIONS: The continuity equation method has the lowest level of obtainable results owing to the high incidence of mitral regurgitation. The mean value of mitral area estimates from all applicable methods in each patient showed the closest correlation with planimetry, thus the performance of these Doppler methods provides improved accuracy in the quantification of mitral stenosis.

Adult↗
PubMed1986

Magnetocardiographic P waves in normal subjects and patients with mitral stenosis.

The P wave of the magnetocardiogram (MCG) was investigated in normal subjects and patients with mitral stenosis to determine its characteristics in normal conditions and left atrial overloading (LAO) and to analyze atrial activation by a magnetic field. In normal subjects, the MCG P wave was negative in left parasternal sites and positive in right lower sternal sites. The current source deduced from the MCG pattern and isomagnetic map was directed inferiorly and to the left through the entire phase of atrial activation, suggesting that in most normal cases the P wave reflects right atrial activity. In patients with mitral stenosis, a negative-positive biphasic P wave was seen more frequently than in normal subjects in left parasternal sites (p less than 0.005). In the late phase of atrial activation, the current source deduced from the isomagnetic map was shifted superiorly and to the left, suggesting an increased leftward force due to LAO. The MCG was similar in sensitivity to the ECG, for diagnosis of LAO, but in a few cases LAO could be detected from the MCG but not the ECG. These findings suggest that the MCG is clinically useful for diagnosis of LAO.

Adult↗
PubMed1991

Application of Doppler color flow imaging to determine valve area in mitral stenosis.

This study was undertaken to examine whether Doppler color flow imaging could accurately estimate the valve area in mitral stenosis. Doppler color flow assessments were performed in both an in vitro model and in 30 patients with mitral stenosis undergoing cardiac catheterization. In the experimental Doppler study using a circuit model, color jet width correlated well with actual orifice diameter (r = 0.99). In the clinical Doppler study, the mitral valve orifice was assumed to be elliptic and the mitral valve area was calculated from the following equation: (pi/4) (a x b), where a = color jet width at the mitral valve orifice in the apical long-axis view (short diameter) and b = the width in the 90 degrees rotated view (long diameter). Mitral valve area was also determined by two-dimensional echocardiography and the pressure half-time method, and the results for all three noninvasive methods were compared with those obtained at cardiac catheterization. By Doppler color flow imaging, mitral valve area could be determined in all patients and there was a significant correlation between the Doppler jet and catheterization estimates of mitral valve area (r = 0.93). Valve area determined by two-dimensional echocardiography correlated well with catheterization measurements in 26 patients (r = 0.84). However, the area could not be determined in 4 (13%) of the 30 patients because of technical problems. Although there was a fair correlation between the valve area determined by the pressure half-time method and catheterization (r = 0.79), this method tended to overestimate valve area in patients with aortic regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Flow Velocity↗
PubMed1982

Effects of nitroglycerin on supine and upright exercise in mitral stenosis.

Resting, supine, and upright exercise hemodynamics were studied in 11 patients with pure or predominant mitral stenosis before and after 0.4 mg sublingual nitroglycerin. Resting mean pulmonary wedge pressure was reduced from 27 +/- 1.6 to 21 +/- 1.6 mm Hg (p less than 0.001), while mean cardiac index (2.98 +/- 0.40 vs 2.68 +/- 0.30 cc/min/m2; NS) and mean heart rate (82 +/- 4.4 vs 87 +/- 6.7 bpm; NS) were unchanged after nitroglycerin. Resting mean left ventricular end-diastolic pressure dropped from 11 +/- 1.7 to 8 +/- 1.1 mm Hg (p less than 0.02) after nitroglycerin, while stroke index (37 +/- 5.1 vs 32 +/- 3.8 mm Hg; NS) was unchanged. Left ventricular systolic pressure fell from 122 +/- 6.0 to 111 +/- 3.1 mm HG (p less than 0.001) after nitroglycerin. At peak supine exercise similar qualitative changes were observed. Mean pulmonary wedge pressure was lower after nitroglycerin (43 +/- 2.3 vs 36 +/- 2.1 mm Hg; p less than 0.02), while cardiac index (3.62 +/- 0.39 vs 3.4 +/- 0.26 cc/min/m2; NS) and heart rate (116 +/- 7.1 vs 113 +/- 4.6 bpm; NS) were not different. Left ventricular end-diastolic pressure (13 +/- 1.4 vs 10 +/- 1.3; NS) was slightly but not significantly reduced by nitroglycerin. Left ventricular stroke index (34 +/- 3.4 vs 31 +/- 2.2 mm Hg; NS) was unchanged by nitroglycerin. Left ventricular systolic pressure (137 +/- 7.3 vs 127 +/- 6.1 mm Hg; p less than 0.02) was reduced 10 mm Hg at peak supine exercise after nitroglycerin. During upright exercise, peak heart rate (160 +/- 8.1 vs 160 +/- 8.0 bpm; NS) and peak systolic blood pressure (117 +/- 5.7 vs 112 +/- 2.8 mm Hg; NS) were not changed with nitroglycerin. Exercise duration was improved after nitroglycerin (5.02 +/- 0.62 vs 5.66 +/- 0.65 minutes; p less than 0.02). Thus sublingual nitroglycerin lowers mean pulmonary wedge pressure to reduce pulmonary congestive symptoms, improves supine exercise hemodynamics, and may enhance treadmill exercise duration in some patients with pure or predominant mitral stenosis.

Adolescent↗
PubMed1987

Holter monitoring in patients with mitral stenosis and sinus rhythm.

To determine the type and frequency of supraventricular arrhythmias in patients with mitral stenosis and sinus rhythm we studied 63 such patients, mean (sd) age 48.8 (8.2) years, by 24 hour ambulatory ECG monitoring. Thirty-five patients (55.6%) had supraventricular tachyarrhythmias. Twenty-five (39.7%) had paroxysmal atrial tachycardia, 14 (22.2%) atrial fibrillation, 8 (12.7%) multifocal atrial tachycardia and 5 atrial flutter. Ninety-five per cent (101) of episodes were asymptomatic and 96% non-sustained. Supraventricular premature beats occurred in 59 patients with couplets and triplets in 40 (63.5%) and 28 (44.4%), respectively. Frequent supraventricular premature beats, couplets, triplets and episodes of paroxysmal arrhythmias were commoner in patients greater than 50 years. Ectopic atrial rhythms with varying P wave morphology occurred in 12 patients (19%). Nine patients (14.3%) had suffered systemic embolic episodes. We conclude that supraventricular ectopic and tachyarrhythmias occur frequently in patients with mitral stenosis and sinus rhythm and that most paroxysms are non-sustained and asymptomatic.

Adult↗
PubMed1994

Noninvasive predictors of systemic embolism in mitral stenosis. An echocardiographic and clinical study of 500 patients.

Few predictors of systemic embolism in patients with mitral stenosis have been identified by noninvasive methods. This study used the most powerful noninvasive diagnostic tool, transthoracic echocardiography, as well as other noninvasive clinical information to look for predictors. Five hundred consecutive patients with a mitral valve area of 2 cm2 or less were studied. They were divided into two groups: group 1 consisted of 143 patients with a history of systemic embolism and group 2 consisted of 357 patients with no history of systemic embolism. Using a stepwise logistic regression on a random subsample of 400 patients, 4 independent predictors were found: the presence of atrial fibrillation (p = 0.003, relative risk [RR] = 2.3, 95% CI = 1.3, 4.2), the absence of significant tricuspid regurgitation (p = 0.008, RR = 2.5, 95% CI = 1.3, 4.9), the absence of aortic regurgitation (p = 0.022, RR = 2.2, 95% CI = 1.1, 4.2), and the presence of left atrial smoky echoes (p = 0.039, RR = 1.7, 95% CI = 1.1, 3.0). When the above model, together with significant interaction terms, was applied to the remaining 100 patients, both the Hosmer-Lemeshow and Brown goodness-of-fit statistics were not significant (p = 0.888 and p = 0.248, respectively), indicating that the fit was adequate and the model was validated. Thus, important noninvasive predictors of systemic embolism in patients with mitral stenosis can easily be obtained. Subgroups of patients with high risk of systemic embolism can be identified. This may refine our therapeutic strategies to prevent the catastrophe of systemic embolism.

Adolescent↗
PubMed1993

Hemodynamic effects of a beta adrenergic blocking agent-atenolol in patients with severe mitral stenosis.

The hemodynamic effects of atenolol, a cardioselective adrenergic blocking drug, were studied in 10 patients with clinically severe mitral stenosis during cardiac catheterization to evaluate the severity of disease before cardiac surgery. At 5 minutes after intravenous injection of 0.1 mg/kg of atenolol, there were significant reductions of heart rate, cardiac index, pulmonary pressure, pulmonary capillary wedge pressure and mitral valve gradient. The right and left ventricular filling pressures were increased slightly. The pulmonary and systemic vascular resistance did not change after atenolol. The PR interval although prolonged significantly was still within normal range. No serious side effects occurred during the post-catheterization 24 hour observation period except for one patient who developed slow ventricular rate (48/min) during the study. The hemodynamic effects of atenolol observed in this study appear to benefit the patients with mitral stenosis by reduction of pulmonary pressure, pulmonary capillary wedge pressure and mitral valve gradient. These hemodynamic changes may, therefore, lead to improvement of pulmonary congestive symptoms.

Adolescent↗
PubMed1992

The role of percutaneous transvenous balloon mitral valvuloplasty in the treatment of patients with symptomatic mitral stenosis.

Since its introduction in 1984, percutaneous transvenous mitral balloon valvuloplasty (PTMV) has emerged as an effective technique in the treatment of selected patients with severe mitral stenosis. The most important factors determining the haemodynamic and clinical outcome after PTMV are the anatomic and pathological features of the mitral valve apparatus. In patients with pliable, non-calcified valves, immediate success rates of well over 90% are achieved. Short-term follow-up studies of such patients after PTMV demonstrate a low rate of valve restenosis, with the vast majority of patients remaining much improved clinically. Less favourable immediate and short-term results are observed in patients who have non-pliable, calcified valves. Major acute complications of PTMV include thromboembolic events and the production of severe mitral regurgitation. It appears that, as a result of increased operator experience, better patient selection and refinements in the technique of PTMV, the rates of these acute complications are now very low. Follow-up studies will be needed to assess the long-term efficacy of the procedure. The first publications on this field are encouraging.

Calcinosis↗
PubMed1999

Aberrant infrarenal inferior vena cava as a hindrance to percutaneous transvenous mitral valvuloplasty in a patient with mitral stenosis: case report.

Cardiac catheterization and percutaneous transvenous mitral commissurotomy using the Inoue technique were attempted in a 44-year-old woman with mitral stenosis. The pulmonary arterial wedge pressure was 25 mmHg, mean transmitral diastolic pressure gradient 20.3 mmHg, cardiac index 1.80 L/min/m2, and mitral valve area 0.70 cm2. After the diagnostic catheterization, the guide wire for the transseptal procedure was checked in the middle of the inferior vena cava (IVC). A 7-French end-holed Bermann catheter was then used to detect the course of the IVC. It was found that the IVC coursed along the left border of the 4th and 5th lumbar vertebrae, to the left of the abdominal aorta. At the upper border of the third lumbar vertebra, the IVC returned to the right side of the vertebra. In consideration of the inability to pass the Brockenbrough needle through the detoured infrarenal IVC and the risk of rupturing the vessel, the transseptal procedure and attempted percutaneous transvenous mitral commissurotomy were aborted. Therefore, the patient underwent open mitral commissurotomy instead.

Adult↗
PubMed1989

Use of pulmonary capillary wedge pressure to assess severity of mitral stenosis: is true left atrial pressure needed in this condition?

There is disagreement concerning the use of the pulmonary capillary wedge pressure (in place of left atrial pressure) in assessing the presence and severity of mitral valve disease. This study was done to assess the accuracy and reliability of an oximetrically confirmed pulmonary capillary wedge pressure in measuring the transvalvular pressure gradient and valve area in patients with mitral stenosis. In 10 patients with mitral stenosis (1 man and 9 women; mean age +/- SD 47 +/- 7 years), pulmonary capillary wedge pressure was measured through an 8F Goodale-Lubin catheter with its wedge position confirmed by oximetry (oxygen saturation greater than or equal to 95%). In addition, a transseptal left atrial pressure was measured through a Brockenbrough catheter and left ventricular pressure was measured through a pigtail catheter. The mean and phasic left atrial and pulmonary capillary wedge pressures were similar (mean left atrial pressure 18 +/- 6 mm Hg; mean pulmonary capillary wedge pressure 18 +/- 8 mm Hg; p = NS). When the pulmonary capillary wedge pressure was used without adjustment for time delay, the transvalvular pressure gradient (9.8 +/- 3.3 mm Hg) and valve area (1.5 +/- 0.5 cm2) were significantly different (p less than 0.05) from the values obtained with use of left atrial pressure (7.2 +/- 2.9 mm Hg and 1.7 +/- 0.6 cm2, respectively). In contrast, when the pulmonary capillary wedge pressure was adjusted for the time delay through the pulmonary vasculature, the difference in gradients averaged only 1.7 mm Hg and the mitral valve areas were similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial Function↗
PubMed1977

[Anatomical and functional evaluation before and after the operative treatment of mitral stenosis via echocardiography].

A confrontation was made of the echocardiographic data and the operation findings in 33 patients with "pure" mitral stenosis confirmed by catheterization and intraoperation. A significant correlation was found between the decelerated movement rate of the diastolic part of the anterior mitral cusp (E--F) and the mitral stenosis degree. The not negligible diagnostic value upon the position of the posterior mitral cusp during diastole is stressed--forward of the horizontal, passing through point C of the mitral closing, as well as upon the size of the left ventricle. The correlation between the valvular calcinosis, established by the echocardiogram and that, established at the operation proved to be poor.

Adult↗
PubMed1993

[Surgical treatment for mitral valve defects with preponderance of mitral stenosis and high pulmonary vascular resistance. Clinical and hemodynamic observations 6 months after valve replacement].

10 patients with isolated or predominant mitral stenosis (mean mitral valve area 0.9 cm) and high preoperative values of pulmonary vascular resistance (mean 7.2 Wood units) were chosen for further hemodynamic postoperation evaluation. The patients had normal function of the aortic valve and no significant stenosis of coronary arteries. Hemodynamic evaluation was done by floating Swan-Ganz catheter preoperatively at rest and 6 months after mitral valve replacement at rest and during bicycle cycloergometer test in the supine position. Significant improvement in NYHA class was noted. Preoperatively 6 patients were in NYHA III class, 4 in NYHA IV class. After mitral valve replacement 4 patients were in class III and 6 in class II. Before mitral valve replacement only 3 patients were able to perform 25 Watt test. After surgery all except one performed at least 25 W. There was a significant decrease of pulmonary vascular resistance from 7.2 +/- 2.2 preoperatively to 3.1 +/- 1.9 Wood units at rest after the operation. Post operation during exercise pulmonary vascular resistance attained 4.2 +/- 1.9 Wood units. These changes were due to a fall in mean pulmonary artery pressure 49 +/- 13 at rest preoperatively to 25 +/- 6 mm Hg (rest) and 43 +/- 14 mm Hg (23 W) postoperatively and a rise in stroke volume index from 24 +/- 7 ml (m2) beat preoperatively to 32 +/- 9 at rest and 33 +/- 6 (25 W) postoperatively. Despite clinical and hemodynamic improvement there was no full recovery of pulmonary hemodynamics.

Adult↗
PubMed1994

Angle of incidence does not affect accuracy of mitral stenosis area calculation by pressure half-time: application to Doppler transesophageal echocardiography.

Continuous wave Doppler transesophageal echocardiography (TEE) may allow the estimation of stenotic mitral valve area. Intuitively the posterolateral position of the transducer appears to limit the application of TEE for this purpose because of the excessive angle of incidence to mitral valve inflow. However, algebraic equations can be used to predict that the angle of incidence should not affect mitral valve area derived by using pressure half-time. To test the validity of this prediction and the potential application of Doppler TEE to estimate mitral valve area, 28 patients (21 women, 7 men) with a mean age of 59 +/- 14 years with mitral stenosis were studied by continuous wave transthoracic echocardiography (TTE) and TEE guided color flow Doppler. TTE was performed from the apical four-chamber (TEE-0) and a modified parasternal four-chamber (TTE-MAL) plane as a means of intentionally increasing the angle of incidence. TEE was done by using the horizontal (TEE-HAX) and vertical (TEE-VAX) planes. Mitral valve area was calculated by pressure half-time method. Mean mitral valve area did not differ (p = not significant [NS]) between TTE-0 (1.26 +/- 0.84 cm2), TTE-MAL (1.37 +/- 0.94 cm2), TEE-HAX (1.39 +/- 0.92 cm2), and TEE-VAX (1.35 +/- 0.89 cm2). The estimated mean angle of incidence during TTE-MAL was 45 +/- 12 degrees (range 21 to 68 degrees). Six (21%) of 28 and 9 (32%) of 28 patients had an underestimation of transmitral peak velocities with TEE from the horizontal or vertical planes, respectively. However, excellent correlations were found between mitral valve area derived by using TEE-0 versus TTE-MAL (r = 0.97; SEE = 0.25 cm2; intercept = 0.02 cm2; slope = 1.08; and p = 0.0001), TEE-HAX (r = 0.91; SEE = 0.39 cm2; intercept = 0.14 cm2; slope = 1.00; and p = 0.0001) and TEE-VAX (r = 0.92; SEE = 0.36 cm2; intercept = 0.13 cm2; slope = 0.97; and p = 0.0001). These results are directly applicable to Doppler TEE in the determination of mitral stenosis area by pressure half-time, whereby 21% to 32% of patients using the horizontal or vertical transesophageal planes may have a significant angle of incidence leading to underestimation of transmitral valve velocities. Future studies comparing Doppler TEE with cardiac catheterization are of interest. However, the present study suggests that Doppler TEE will play an important role in the hemodynamic assessment of the severity of mitral valve stenosis.

Aged↗
PubMed1995

Long term effects of atenolol in patients of mitral stenosis & normal sinus rhythm.

We studied the effect of atenolol 100 mg/day in 50 symptomatic patients of mitral stenosis and normal sinus rhythm, in a placebo controlled study. Atenolol caused significant bradycardia as compared to placebo (vitamin C; P < 0.001) without any adverse effects. It also increased exercise capacity significantly as compared to placebo (P < 0.001). All the patients were followed up to the period of 9 months and no adverse effects were seen. We conclude that beta adrenergic blocking drugs like atenolol can be used as the only treatment for patients with mitral stenosis without congestive heart failure and in sinus rhythm, for long-term symptomatic relief.

Adolescent↗
PubMedDate not supplied

Behavioral disturbance, embolism, and mitral stenosis.

The hypothesized equivalence of behavioral disturbances (BD) and embolic (E) events in predicting subsequent events in mitral stenosis patients was tested by a retrospective comparison of clinical courses. Behavioral disturbances, presenting in twenty patients, were followed by 9.6 BD, 13.8 E, and 5.3 fatal events per 100 patient years. Embolic events, presenting in thirty-three patients, were followed by 1.9 BD, 8.4 E, and 3.4 fatal events per 100 patient years. Forty-six patients presenting with neither event subsequently had 2.7 BD, 7.3 E, and 3.6 fatal events per 100 patient years. It is concluded that a behavioral disturbance in the setting of mitral stenosis is a predictive of an embolic event as is an embolic event itself.

Adolescent↗
PubMed2004

Cor-triatriatum sinister presenting in the adult as mitral stenosis: an analysis of factors which may be relevant in late presentation.

BACKGROUND: Cor-triatriatum sinister is a rare congenital heart defect resulting from the division of the left atrium by a fibro-muscular membrane. It is usual for patients to present in infancy and early childhood, although some cases remain undetected until adult life. As a consequence of trans-membrane flow obstruction, the clinical features often mimic mitral stenosis. At present, the reasons for late presentation are poorly understood. METHODS: A complete review of all cases of cor-triatriatum sinister published in the English literature from 1966 to date as mitral stenosis was performed. Statistical analysis was carried out to determine associations between measurements reflecting the communicating membrane fenestration area, the presence of several clinical variables and patient age at initial presentation. RESULTS: Both pulmonary capillary wedge pressure and mean pressure gradient were significantly higher in younger adults. In addition, the incidence of atrial fibrillation and mitral regurgitation was found to rise with advancing age. CONCLUSIONS: Cor-triatriatum sinister remains an uncommon form of congenital heart disease although it is being diagnosed with increasing frequency in adults due to improvements in diagnostic imaging. This diagnosis should be considered in all patients presenting with signs or symptoms of mitral stenosis.

Adult↗