Severe mitral stenosis after Duran ring implantation for myxomatous mitral regurgitation.
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Acute Kidney Injury↗
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[Transcatheter percutaneous commissurotomy in rheumatic mitral stenosis].
Percutaneous transcatheter balloon mitral commissurotomy was performed in an 11 year old girl. The atrial septum was perforated and an 8 mm angioplasty balloon was advanced the atrial septal perforation was then dilated to allow passage of 25 mm balloon valvuloplasty catheter across the mitral annulus. Transmitral balloon inflation acutely decreased the end diastolic transmitral gradient (23 mm Hg to 2 mm Hg). Immediate gradient reduction was associated with increases in cardiac output (3.4 to 5.3 L/min). Murmur intensity diminished immediately post-commissurotomy. Balloon commissurotomy did not produced mitral regurgitation. Five weeks later, follow-up catheterization was performed and did not show change in mitral valvular gradient (2 mmHg). Clinical improvement was evident.
Blood Pressure↗
[Electrocardiographic changes in the course of mitral stenosis in relation with the dimensions of mitral valve, the degree of reflux and pulmonary hypertension].
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Electrocardiography↗
Cardiopulmonary exercise testing early after catheter-balloon mitral valvuloplasty in patients with mitral stenosis.
Seven female patients (age 27 to 53 yr) with significant mitral stenosis performed continuous, incremental, maximal treadmill exercise tests the day before and within 3-5 days after catheter-balloon valvuloplasty. Mitral valve area determined by the echo-Doppler method increased from 0.9 +/- 0.3 cm2 to 1.9 +/- 0.7 cm2 (p < 0.02). Mean left atrial pressure was reduced from 24 +/- 8 to 13 +/- 7 mmHg (p < 0.01) and mean pulmonary artery pressure from 36 +/- 13 to 28 +/- 10 mmHg (p < 0.02) with a non-significant increase in cardiac output from 3.6 +/- 1.2 to 4.0 +/- 1.7 l/min. After catheter-balloon valvuloplasty all patients reached a higher maximal workload during exercise, and mean value of oxygen consumption and pulmonary ventilation were significantly lower in submaximal workloads. The calculated ventilatory equivalent for oxygen was significantly reduced in submaximal and in maximal workloads after catheter-balloon valvuloplasty. Peak oxygen consumption and the ventilatory anaerobic threshold were not changed after catheter-balloon valvuloplasty (pre 15.59 +/- 2.72 vs post 16.90 +/- 3.44 and pre 12.10 +/- 2.55 vs post 12.62 +/- 2.71 ml/kg/min, respectively). We concluded that after catheter-balloon valvuloplasty the cost of breathing was reduced and the oxygen consumed was more effectively utilized during exercise. Increases in peak oxygen consumption and in ventilatory anaerobic threshold would require circulatory and metabolic adaptations in response to increased physical activity and were not observed when cardiopulmonary tests were performed early after catheter-balloon valvuloplasty.
Adult↗
Rapid progression of primary cardiac leiomyosarcoma with obstruction of the left ventricular outflow tract and mitral stenosis.
We report a 73-year-old woman with primary cardiac leiomyosarcoma in the left atrium and ventricle. The tumor progressed very rapidly for 2 months after initial clinical evaluation. Obstruction of the left ventricular outflow tract and mitral stenosis were induced by the tumor. Urgent surgical resection was performed because she had cardiogenic shock due to paroxysmal atrial fibrillation. We could not resect the tumor completely because of severe invasion. She refused postoperative chemotherapy and radiotherapy, and died suddenly at home 89 days after surgery. To our knowledge, this is the first observation of mitral stenosis concomitant with obstruction of the left ventricular outflow tract in a patient with primary cardiac leiomyosarcoma.
Aged↗
Floating left atrial mass in a patient with mitral stenosis.
Mobile masses within the left atrial cavity are commonly caused by organized thrombi or left atrial myxoma. The use of transesophageal echocardiography has provided means for differentiation between the 2 conditions. We report a case of a left atrial mass in a female patient who presented with mitral stenosis and atrial fibrillation, and was diagnosed by transthoracic echocardiography (TTE). The mass appeared freely mobile but did not prolapse between the mitral leaflets due to the tightly stenosed valve orifice. In the presence of mitral stenosis, atrial fibrillation and dilated left atrium, the appearance of the mass was in keeping with mobile thrombus. Consequently, the patient was referred for surgical treatment and the mass removed through left atriotomy. Microscopic examination revealed a highly organized thrombus. We conclude that TTE is still a reliable tool in the diagnosis of large mobile atrial thrombi; TEE is needed when differentiation from atrial myxoma is difficult.
Aged↗
[Low molecular weight heparin in pregnancy. Report of three cases with pure mitral stenosis].
Three pregnant women with 5 +/- 1.7 weeks of pregnancy and mitral stenosis are described. Their valve area were < 1.0 cm2. They received medical treatment with little improvement and were included in our valvotomy percutaneous mitral (VPM) program with Inoue technique before their 30th week of pregnancy. Before they were treated with low molecular weight heparin (LMWH), Enoxiparin) as prophylaxis of intracavitary thrombus formation transthoracic and transesophageal echocardiogram demonstrated the absence of thrombus. We used 40 mgs. subcutaneous injection once a day during 16 weeks. Repeated transthoracic and transesophageal echocardiogram during VPM showed no evidence of intracavitary thrombus. Complete blood count and coagulation parameters remained within normal limits. The three cases delivered a healthy products. In conclusion, although this series is small, we show that the LMWH can be used in the first trimester of pregnancy as prophylactic treatment instead of oral anticoagulant treatment.
Adult↗
[A contribution to ergometric tests in the definition of gravity of mitral stenosis. The importance of the behavior of the left ventricular function, not always correlation to hemodynamic alterations above the valve (author's transl)].
An attempt to evaluate the severity of the valvulopathy was performed in 50 patients with pure mitral stenosis, 36 females and 14 males, by a haemodynamic study and by an exercise test. In 76% of the cases, electrocardiographic "ischemic" abnormalities were observed during the exercise test; after the exclusion of patients over 45, and patients with atrial fibrillation and/or digitalis treatment, a high frequency (63,15%) of electrocardiographic ischemic changes with effort is still observed. No correlations between the result of the exercise test either with pulmonary pressure values, or with other haemodynamic data (cardiac index and pulmonary vascular resistances) were demonstrated. The electrocardiographic abnormalities induced by exercise in these patients are discussed; the authors conclude that this behaviour under effort is significant for the importance of the impairment of the left ventricle function in mitral stenosis.
Adult↗
Mitral Stenosis, Sinus Venosus Atrial Septal Defect, and Partial Anomalous Pulmonary Venous Return: Diagnosis by Multiplane Transesophageal Echocardiography.
We describe a 42-year-old man with rheumatic mitral stenosis, sinus venosus atrial septal defect, and anomalous drainage of the right upper pulmonary vein to the superior vena cava. Transthoracic echocardiography (TTE) failed to identify the atrial septal defect and the partial anomalous pulmonary venous return. Transesophageal echocardiography (TEE), using a multiplane probe, was useful in delineating the abnormalities. To our knowledge, this is the first reported patient with rheumatic mitral stenosis and sinus venosus defect. (ECHOCARDIOGRAPHY, Volume 13, November 1996)
Journal Article↗
[Beneficial effect of sildenafil following surgery for mitral stenosis complicated by pre-capillary pulmonary hypertension: report of two cases].
Pulmonary hypertension is a serious disorder, difficult to treat especially in the severe forms. The treatment consists mainly of calcium channel blockers, anti-coagulation, intravenous epoprostenol, inhaled nitric oxide and recent agents as bosentan and sildenafil. Sildenafil, a phosphodiesterase 5 specific inhibitor, has been largely evaluated in primary pulmonary hypertension, and in some cases of secondary pulmonary hypertension including parenchymal and thromboembolic diseases; it has not yet been evaluated in severe pulmonary hypertension with elevated pre-capillary resistance in operated mitral stenosis. We report the cases of two patients operated from mitral valve replacement for severe mitral stenosis with elevated pre-capillary resistance, where oral sildenafil, introduced empirically immediately after the surgical procedure at the dose of 50 mg/d, permitted a significant decrease in pulmonary pressures and resistances, allowing a rapid withdrawal of nitric oxide and reducing therefore hospitalization time in the intensive care unit. We think that this simple treatment, with or without association to nitric oxide, should be generalized to persistent pulmonary hypertension following cardiac surgery.
Capillaries↗
Reassessment of valve area determinations in mitral stenosis by the pressure half-time method: impact of left ventricular stiffness and peak diastolic pressure difference.
Estimation of the orifice area is of major importance in the timing of valve dilation or surgery in patients with mitral stenosis. Determination of the area has traditionally been accomplished at cardiac catheterization by the Gorlin equation. The valve area can also be estimated noninvasively with Doppler echocardiographic measurements of the pressure half-time, which is inversely proportional to the area. This method has gained widespread acceptance, but its accuracy has recently been questioned and factors other than reduction of orifice area appear to modify the pressure half-time. In the present study, the influence of left ventricular stiffness (defined as diastolic pressure rise per milliliter of mitral flow) and peak atrioventricular pressure difference on the pressure half-time was examined both in a hydraulic model and by review of data from 35 patients with mitral stenosis. Left ventricular stiffness less than 0.13 mm Hg/ml was considered normal. In the model study, the orifice area correlated only moderately with inverted pressure half-time (1/PHT) (r = 0.67). By multiple linear regression, inverted pressure half-time was shown to be dependent on valve area, chamber stiffness and peak pressure difference (R = 0.89), area and stiffness being most important (R = 0.85). In the clinical study, an increased ventricular stiffness was found in 22 of the 35 patients. The pressure half-time method overestimated the Gorlin-derived area by an average of 72% in these patients compared with only 10% in 13 patients with normal stiffness (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Early diastolic posterior aortic root slope, a clinical guide to the severity of mitral stenosis.
This report tests the hypothesis that, in early diastole, motion of the anterior left atrial wall corresponds to the motion that can be observed in the contiguous posterior wall of the aortic root. To test this hypothesis, we examined the effects of mitral stenosis, exercise in normals, exercise induced left ventricular ischemia, left ventricular hypertrophy and left ventricular dysfunction on this slope. Each altered early diastolic atrioventricular interaction as predicted and therefore, the early diastolic motion of the anterior left atrial wall does appear to be mirrored by the early diastolic slope of the posterior wall of the aortic root. Consequently, if interpreted in the clinical context, measurement of early diastolic slope of the posterior wall of the aortic root may serve as a useful guide to separate patients with severe from those with mild mitral stenosis.
Aorta↗
Clinical and echocardiographic predictors of left atrial clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis: a prospective study in 200 patients by transesophageal echocardiography.
The objective of this study was to prospectively investigate various clinical and echocardiographic variables to predict the left atrial and left atrial appendage clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis. We studied 200 consecutive patients (112 males and 88 females; mean age 29.6+/-9.6 years). Left atrial clot and spontaneous echo contrast were present in 26 and 53.5% of cases, respectively. There were no significant differences in the mitral valve area, mean transmitral diastolic gradient and left ventricular ejection fraction between patients with and without clot. Patients with clot were older (34.4+/-11.4 vs. 28.2+/-8.5 years, P<0.001), had longer duration of symptoms (41. 4+/-36.0 vs. 28.8+/-22.9 months, P<0.001), more frequent atrial fibrillation and spontaneous echo contrast (69.2 vs. 16.9%, P<0. 00001 and 76.9 vs. 45.3%, P<0.00001, respectively) and larger left atrial area and diameter (41.0+/-12.7 vs. 29.9+/-7.4 cm(2), P<0.00001 and 53.9+/-8.3 vs. 47.6+/-7.4 mm, P<0.0001, respectively) as compared to patients without clot. Similarly patients with spontaneous echo contrast were older (31+/-10.4 vs. 27.8+/-8.3 years, P<0.01), had more frequent atrial fibrillation (48.6 vs. 9.7%, P<0.0001), left atrial clot (37.4 vs. 12.9%, P<0.0001), larger left atrial area and diameter (37.6+/-11.2 vs. 28.1+/-6.7 cm(2), P<0.00001 and 52.2+/-8.3 vs. 45.9+/-6.5 mm, P<0.00001, respectively) and smaller mitral valve area (0.77+/-0.14 vs. 0.84+/-0.13 cm(2), P<0.01) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean transmitral diastolic gradient and left ventricular ejection fraction. On multiple regression and discriminant function analysis, atrial fibrillation and left atrial area were independent predictors of left atrial clot formation. In a subgroup of patients with sinus rhythm, larger left atrial area and presence of spontaneous echo contrast were significantly associated with the presence of clot in left atrium and appendage. We conclude that in patients with severe mitral stenosis, the presence of atrial fibrillation and in the subgroup of the patients with sinus rhythm the presence of large left atrium (> or =40 cm(2)) and spontaneous echo contrast were associated with higher risk of clot formation in the left atrium and might be benefited by prophylactic anticoagulation.
Adolescent↗
[Surgical procedure in complicated mitral stenosis].
The experience with the surgical treatment of complicated forms of mitral stenosis in 110 patients with the III and IV classes of the disease according to the classification of the New York Heart Association was analyzed. Closed mitral commissurotomy was performed in 36 patients, opened commissurotomy--in 33 patients, prosthetics of the mitral valve was made in 41 patients. Closed mitral commissurotomy is believed to be the simplest method of correction of the duct in mild calcinosis and deformity of the mitral valve, and fixed thrombosis of the left auricle. Opened mitral commissurotomy was justified in case of thrombosis of the left auricle and mild calcinosis and deformity of the valve. Substitution of the valve is indicated in cases of massive calcinosis and rough deformity of the valve and subvalvular structures when valve-preserving operations are impossible.
Adult↗
Immediate and long-term effect of mitral balloon valvotomy on severe pulmonary hypertension in patients with mitral stenosis.
The pulmonary vascular hemodynamics were studied in 21 patients with severe mitral stenosis and severe pulmonary hypertension. Hemodynamic data were obtained before and immediately after mitral balloon valvotomy (MBV) and at follow-up 7 to 14 months (mean 12 months) later by repeat catheterization. The mean pulmonary capillary wedge pressure (PCW) decreased from 27 +/- 5 to 15 +/- 4 mm Hg (p < 0.001). The mean mitral valve gradient (MVG) decreased from 18 +/- 4 to 6 +/- 2 mm Hg (p < 0.001). Mitral valve area (MVA) increased from 0.6 +/- 0.1 to 1.5 +/- 0.3 cm2 (p < 0.02). Cardiac index increased from 2.2 +/- 0.3 to 2.6 to 0.5 L/min/m2 (p < 0.02). The pulmonary artery systolic pressure decreased from 65 +/- 13 to 50 +/- 13 mm Hg (p < 0.001), and no significant change was seen in pulmonary vascular resistance (PVR) immediately after MBV from 461 +/- 149 to 401 +/- 227 dynes/sec/cm(-5) (p = 0.02). At follow-up the MVA increased from 1.5 +/- 0.3 to 1.7 +/- 0.3 cm2 (p < 0.02). Cardiac index increased further to 3 +/- 0.4 L/min/m2 (p < 0.02). MVG and PCW pressure remained the same. The pulmonary artery systolic pressure decreased further to 38 +/- 9 mm Hg (p < 0.02). PVR decreased significantly to 212 +/- 99 dynes/sec/cm(-5) (p < 0.02). We concluded that the pulmonary artery pressure decreased without normalizing immediately after MBV and normalized in patients with optimal results from mitral balloon valvotomy 7 to 14 months later. Insignificant change in PVR was seen immediately after MBV and markedly decreased or normalized at late follow-up in patients with optimal result from MBV.
Adolescent↗
Use of continuous-wave Doppler echocardiography to evaluate the hemodynamic importance of atrial systole in patients with mitral stenosis.
Continuous-wave Doppler echocardiography was used to assess the hemodynamic role of left atrial systole and its effect on left ventricular performance in 31 patients with pure mitral stenosis. Seventeen (group I) had severe stenosis, and 14 (group II) had mild-to-moderate stenosis. The contribution of atrial systole to cardiac output was 15% in group I and 24% in group II (p < 0.01). This study shows the effectiveness of using continuous-wave Doppler echocardiography to assess the influence of atrial systole on left ventricular performance in patients with mitral stenosis.
Journal Article↗
Bronchial responsiveness, oscillations of peak flow rate and symptoms in patients with mitral stenosis.
To better characterize airway hyperresponsiveness reported in cardiac patients questionnaire-recorded symptoms, bronchial responsiveness to methacholine (Mch) and to ultrasonically nebulized distilled water (UNDW), diurnal oscillations of peak expiratory flow (PEF) rate were evaluated in 32 patients with moderate mitral stenosis. Twenty patients were responsive to Mch (defined as provocative dose producing a 20% fall in forced expiratory volume in one second (PD20 FEV1) less than 3.2 mg) (geometric mean PD20 FEV1 851 +/- 154 micrograms SE). Only two patients showed a fall in FEV1 greater than 20% after UNDW challenge. Patients responsive to Mch challenge had lower FEV1 as percentage of vital capacity (FEV1/VC) (80 +/- 4.8 vs 83 +/- 3.8%, p less than 0.05), higher coefficient of variation of PEF (CV-PEF) (7.1 +/- 2.8 vs 5 +/- 2.4, p less than 0.05) and higher prevalence of wheeze (70 vs 25%, p less than 0.05) in comparison with patients non-responsive to Mch challenge. CV-PEF was significantly related to FEV1 (r = 0.347, p less than 0.05) and maximal expiratory flow at 50% expired volume (MEF50) (r = 0.405, p less than 0.05). The probability of responding to Mch bronchial challenge increased proportionally with the increase in CV-PEF and the decrease in FEV1, FEV1/VC and MEF50. Airway hyperresponsiveness of patients with mitral stenosis seems to be more similar to that reported in bronchitic than in asthmatic patients.
Adult↗
Comparison between percutaneous balloon valvuloplasty and open commissurotomy for mitral stenosis. A prospective and randomized study.
Eighty patients with tight and pliable mitral stenosis were randomized in a prospective trial comparing percutaneous balloon valvuloplasty and open commissurotomy. Mitral valve area increased significantly in both groups immediately after the procedures. However, a decrease in mitral valve area occurred in both groups at 6, 12 and 24 months during the follow-up. There was no death in either group. Two patients had significant mitral regurgitation after percutaneous balloon valvuloplasty. After 24 months, all patients in the commissurotomy group and 97.4% of the patients in the balloon valvuloplasty group were in New York Heart Association functional class I or II.
Adolescent↗