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PubMed2003

A case of coronary artery fistula with mitral stenosis.

Coronary artery fistulae, being a rare form of congenital anomalies of the coronary arteries, are usually discovered by chance during coronary arteriography. However, these fistulae can cause an important coronary morbidity and mortality leading to angina, syncope, congestive heart failure, myocardial infarction and sudden death. The coincidence of mitral stenosis and congenital artery fistula is rare in the literature. In our case report, a patient with a coronary artery fistula originating from the circumflex, draining to the main pulmonary artery, discovered at cardiac catheterization and coronary angiography done with a prediagnosis of mitral stenosis is presented in the light of the literature.

Arteriovenous Fistula↗

PubMedDate not supplied

Percutaneous transvenous mitral commissurotomy in patients with severe mitral stenosis and acute rheumatic fever.

There is a concern that percutaneous transvenous mitral commissurotomy (PTMC) performed during acute rheumatic fever (ARF) may result in adverse outcomes. We performed a retrospective study at a tertiary care center. Ten patients (ages 8-12 years) with severe symptomatic mitral stenosis and ARF who underwent PTMC (ARF group) were compared with 10 controls with similar mitral valve area (MVA). The procedure was successful in all patients. The median MVA increased from 0.7 to 1.5 cm2 following PTMC in the ARF group and from 0.7 to 1.8 cm2 in the control group [p = not significant (NS)]. The median MVA was 1.2 cm2 in the study group compared to 1.6 cm2 in the control group (p = 0.02) over a mean follow-up of 17.5 +/- 11.7 months. Echocardiographic restenosis occurred in 4 patients (40%) in the ARF group compared to 1 patient (10%) in the control group (p = NS). The improvement in the New York Heart Association functional class was maintained in 8 patients of the ARF group and 9 patients of the control group. PTMC can be performed in children with ARF without an increase in procedural complications. However, the restenosis rates appear to be higher.

Acute Disease↗

PubMed1977

Left atrial thrombosis complicating mitral stenosis: results of surgical treatment.

In 343 patients treated surgically for mitral valve disease, there was thrombosis of the left atrium in 40. Massive atrial thrombosis was present in 32 of them, yet the diagnosis was suspected or established preoperatively in only 12, because of insufficient clinical signs. A transventricular mitral commissurotomy was performed in 32 patients and mitral valve replacement in the remaining 8. Surgical mortality was 23% in the patients with atrial thrombosis compared with 7% in the trombus-free patients: 66% of the deaths were due to cerebral embolism. Systemic embolism occurred in 17% of the patients who had a closed approach initially and in 27% following a planned open procedure. Among the survivors, 65% were asymptomatic or markedly improved; the average follow-up was 42 months. Atrial thrombosis increases the surgical risk because of the high incidence of operative embolism, a complication that is not avoided by the use of open procedures, but that could be prevented by earlier surgical treatment of mitral stenosis, before atrial thrombi develop.

Adult↗

PubMed2004

Evaluation of atrial refractoriness immediately after percutaneous mitral balloon commissurotomy in patients with mitral stenosis and sinus rhythm.

BACKGROUND: Chronic atrial stretch and rheumatic inflammatory activity leads to atrial dilatation and conduction slowing, and this increases the susceptibility to atrial fibrillation (AF). The aim of this study was to examine the effects of changes in the chronic atrial stretch on atrial refractoriness in the early period after percutaneous mitral balloon commissurotomy (PMBC) in patients with mitral stenosis and sinus rhythm. METHODS: Twenty-five patients undergoing PMBC were enrolled in this study. We evaluated the changes in pulmonary arterial pressure (PAP), left atrial (LA) pressure, mean mitral diastolic gradient, and mitral valve area in addition to the changes in atrial effective refractory periods (AERPs), AERP dispersion, and intra-atrial and interatrial conduction times after PMBC. RESULTS: There were significant decreases in mean diastolic gradient, PAP, mean LA pressure, and LA size after PMBC. Accompanying these acute hemodynamic changes after PMBC, AERPs in high right atrium (HRA), distal coronary sinus (DCS), and right posterolateral (RPL) were found to be increased (P <.001), and AERP dispersion, PA(HIS) (an interval between P wave on the surface electrocardiogram and atrial electrogram at the His bundle site), and HRA-DCS intervals were significantly reduced after PMBC (P <.001). It was revealed with linear regression and correlation analysis that only the changes in AERP dispersion were correlated with changes in LA pressure. CONCLUSIONS: Relief of chronic atrial stretch results in an increase in AERPs and decrease in AERP dispersion, suggesting the potential reversibility of the electrophysiological features of chronic atrial dilatation. Our study emphasizes that an acute reduction of chronic atrial stretch in mitral stenosis resulted in favorable effects on atrial electrophysiological characteristics, and our results provide the first detailed insights into the electrophysiological changes after PMBC in patients with sinus rhythm.

Adult↗

PubMed2001

Correlation between quantitative left atrial spontaneous echocardiographic contrast and intact fibrinogen levels in mitral stenosis.

An association between left atrial spontaneous echocardiographic contrast (LASEC) and thromboembolic events has been recognized. However, the appearance of LASEC and the assessment of its intensity are gain dependent. To evaluate the relation between LASEC intensity and coagulation activity, 11 patients with mitral stenosis underwent transesophageal echocardiography with quantitative integrated backscatter assessment of LASEC. Right and left atrial blood samples were evaluated for concentrations of coagulation markers, including intact fibrinogen, fibrinopeptide A, D-dimer, prothrombin fragment 1+2, and thrombin-antithrombin III complex. The patients were found to have significantly higher mean left atrial concentrations compared with right atrial concentrations of thrombin-antithrombin III (28.46 +/- 21.05 versus 3.21 +/- 7.16 ng/mL, respectively; P =.001) and fibrinopeptide A (32.78 +/- 17.54 versus 7.42 +/- 8.27 nmol/L, respectively; P <.001). Intact fibrinogen levels were similar in both atria, and a strong, direct correlation existed between left and right atrial intact fibrinogen levels (r = 0.78, P =.005). Quantitative integrated backscatter of LASEC correlated directly with left atrial fibrinogen level (r = 0.78, P =.013) but not with markers of thrombin generation (thrombin-antithrombin III) or activity (fibrinopeptide A). Our results confirm that patients with mitral stenosis have evidence of a regional hypercoagulable state in the left atrium. However, the intensity of LASEC assessed by quantitative integrated backscatter correlates with both right and left atrial intact fibrinogen level, a systemic marker of coagulation.

Adult↗

PubMed1986

Importance of the "atrial kick" in determining the effective mitral valve orifice area in mitral stenosis.

Atrial fibrillation with a rapid ventricular response in patients with mitral stenosis (MS) is often accompanied by pulmonary congestion and reduced cardiac output owing to a diminished diastolic filling period and the loss of the end-diastolic left ventricular (LV) pressure increment. To test the hypothesis that loss of atrial contraction (atrial kick) also results in a decrease in effective mitral valve orifice area, 6 patients with pure, isolated MS were studied in sinus rhythm during atrial pacing and simultaneous atrioventricular pacing. Atrial pacing at 140 beats/min caused no significant change from baseline in cardiac output or mitral valve area, but there was a decrease in LV end-diastolic volume and ejection fraction as well as an increase in left atrial pressure and mean diastolic gradient. Simultaneous atrioventricular pacing (to eliminate atrial kick) induced a decrease in cardiac output (4.4 +/- 0.9 vs 5.2 +/- 0.8 liters/min at 110 beats/min, 4.2 +/- 0.9 vs 5.1 +/- 0.9 liters/min at 140 beats/min; p less than 0.05) and LV end-diastolic volume (77 +/- 27 vs 93 +/- 29 ml at 110 beats/min, 54 +/- 17 vs 65 +/- 19 ml at 140 beats/min; p less than 0.05), an increase in left atrial pressure (28 +/- 3 vs 20 +/- 5 mm Hg at 110 beats/min, 30 +/- 4 vs 25 +/- 5 mm Hg at 140 beats/min; p less than 0.05), and a decrease in mitral valve area (1.2 +/- 0.4 vs 1.4 +/- 0.5 cm2 at 110 beats/min, 1.2 +/- 0.4 vs 1.4 +/- 0.4 cm2 at 140 beats/min; p less than 0.05). Thus, loss of atrial kick may cause pulmonary congestion and reduced cardiac output in patients with MS, partly because of a decrease in effective mitral valve area.

Adult↗

PubMed2000

Mitral balloon valvotomy for the treatment of mitral stenosis in octogenarians.

OBJECTIVES: To study the safety and benefit of mitral balloon valvotomy (MBV) in patients aged > or =80 years. SETTING: A tertiary cardiac centre DESIGN: A retrospective study of 20 octogenarians (mean age 83, range 80-89 years) in whom percutaneous MBV was performed as a definitive or palliative treatment for severe mitral stenosis. All were in New York Heart Association (NYHA) symptom class III or IV. Fourteen had been judged unfit for cardiac surgery. Hemodynamic data was recorded before and after MBV. Symptomatic outcome was documented at 1 month for all patients. Outcome at 1 year was available for 16 patients. RESULTS: Dilatation of the mitral valve was achieved in all patients without major complications. Mean mitral valve area increased 106% from 0.81 (+/-0.3) to 1.67 (+/- 0.8) cm2, transvalvular gradient decreased from 11.8 (+/- 4.8) to 5.6 (+/-2.9) mm Hg, cardiac output increased from 3.1 (+/- 0.6) to 4.1 (+/- 1.4) l/min (all P<.01). Eight of these 20 patients obtained a valve area > or =1.5 cm2, and 16 obtained an area > or = 1.2 cm2. One month after BMV, all patients were alive, and 16 of the 20 patients were improved by at least one NYHA class. This improvement was sustained in 7 of 16 patients followed up for 1 year. More severe mitral valve degenerative change, determined by echocardiography, was associated with poorer outcome. CONCLUSIONS: In this group of very old and frail patients, MBV was safe and resulted in significant immediate improvement. Sustained symptomatic benefit at 1 year was obtained in those with less extensive leaflet and subvalvular disease. In patients with severe degenerative valve disease on echocardiography, but unacceptable surgical risk, MBV offers short-term palliation.

Activities of Daily Living↗

PubMed1993

Pulmonary hypertension is a contraindication to beta-blockade in patients with severe mitral stenosis.

Intravenous atenolol was given to 31 patients just before balloon mitral valvotomy to assess the hemodynamic efficacy and safety of beta-blockade in mitral stenosis complicated by pulmonary hypertension. Hemodynamic response in patients with pulmonary resistance > 600 dynes.sec.cm-5 (group 2, n = 17) was compared with those (group 1, n = 14) with a resistance below this value. In addition to a higher pulmonary arterial resistance (by design), patients in group 2 had a higher systemic resistance, lower cardiac index, and smaller mitral valve area compared with those in group 1. After atenolol infusion, transmitral gradient and left atrial pressure improved similarly. In spite of the decline in left atrial pressure, pulmonary vascular resistance increased in both groups, more in group 2 (847 +/- 398 dynes.sec.cm-5 to 135 +/- 648 dynes.sec.cm-5) than in group 1 (291 +/- 149 dynes.sec.cm-5 to 363 +/- 200; p < 0.001 for drug effect and p = 0.027 for group effect by two-way analysis of variance). Cardiac index declined similarly from 2.77 +/- 0.51 L/min/m2 to 2.37 +/- 0.37 L/min/m2 in group 1 and from 2.33 +/- 0.58 L/min/m2 to 1.92 +/- 0.54 L/min/m2 in group 2. Systemic pressure tended to decline only in group 2 (mean aortic pressure, 89 +/- 12 mm Hg to 89 +/- 12 mm Hg in group 1 and 90 +/- 9 mm Hg to 83 +/- 12 mm Hg in group 2; p = 0.06 for group effect).(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Antagonists↗

PubMed1987

[Transfemoral valvuloplasty using the balloon catheter in mitral stenosis].

In two female patients (59 and 30 years old) with mitral stenosis, a successful valvuloplasty was carried out with a balloon catheter. After transseptal puncture with determination of the pressure gradient between the left auricle and the left ventricle, the atrial septum was initially dilated with a small balloon and a MediTech balloon catheter with a diameter of 25 mm was pushed forward into the region of the mitral valve via a guide wire. On filling of the balloon, the marked indentation at 3-4 atü hyperbaric pressure initially present could be eliminated. The pressure gradient fell from 8 mm Hg to 2 mm Hg in the first patient and from 12 mm Hg to 3 mm Hg in the second patient. The interventions were without complications. There was a marked clinical improvement with increase of physical exercise tolerance and decrease of dyspnoea in both patients. A mitral valve insufficiency did not occur. The new technique may possibly constitute an alternative to surgical commissurotomy.

Adult↗

PubMed1990

Mitral stenosis in pregnancy: the nursing challenge.

Pregnancy in the patient with mitral stenosis may be complicated by pulmonary congestion/edema, atrial fibrillation, thromboembolic events, and intrauterine growth retardation. Combining both cardiac and obstetric principles with the bio/psycho/social focus of nursing is a challenge in the antepartum intrapartum and postpartum periods.

Cardiac Output↗

PubMed1992

Evaluation of mitral stenosis by cine magnetic resonance imaging.

To evaluate the ability of cine magnetic resonance imaging (cine MRI) in the assessment of mitral stenosis (MS), we studied 20 patients (14 women and 6 men, mean age 60.6 +/- 8.5 years) with rheumatic mitral valve stenosis by using an 0.5 T magnet. Cine MRI showed several signs of MS. Mitral leaflet thickening, reduced diastolic opening, and abnormal valve motion toward the left ventricular outflow tract were all common features. MS was also characterized by an abnormal diastolic transmitral signal from blood. Both left atrial and left ventricular dimensions were similar to those obtained at two-dimensional echocardiography (2-DE) (r = 0.89 and r = 0.86, respectively; p less than 0.001). A significant relationship was also found between the maximum mitral leaflet separation measured by cine MRI in diastole and the mitral valve area as calculated using the pressure half-time method and continuous wave Doppler (r = 0.81; p less than 0.001). These data indicate the improved ability of MRI to detect and assess MS and also suggest that this technique may contribute to the noninvasive assessment of MS.

Aged↗

PubMed1993

Validation of the proximal flow convergence method. Calculation of orifice area in patients with mitral stenosis.

BACKGROUND: It has been proposed recently that measuring the flow convergence region proximal to an orifice by Doppler flow mapping can provide a means of calculating regurgitant flow rate. Although verified in experimental models, this approach is difficult to validate clinically because there is no ideal gold standard for regurgitant flows in patients. However, this method also can be used to derive cardiac output or flow rate proximal to stenotic orifices and therefore to calculate their areas by the continuity equation (area = flow rate/velocity). Applying this method in mitral stenosis would provide a unique way of validating the underlying concept because the predicted areas could be compared with those measured directly by planimetry. METHODS AND RESULTS: We studied 40 patients with mitral stenosis using imaging and Doppler echocardiography. Doppler color flow recordings of mitral inflow were obtained from the apex, and the radius of the proximal flow convergence region was measured at its peak diastolic value from the orifice to the first color alias along the axis of flow. Flow rate was calculated assuming uniform radial flow convergence toward the orifice, modified by a factor that accounted for the inflow funnel angle formed by the mitral leaflets. Mitral valve area was then calculated as peak flow rate divided by peak velocity by continuous-wave Doppler. The calculated areas agreed well with those from three comparative techniques over a range of 0.5 to 2.2 cm2: 1) cross-sectional area by planimetry (y = 1.08x-0.13, r = .91, SEE = 0.21 cm2); 2) area derived from the Doppler pressure half-time (y = 1.02x-0.14, r = .89, SEE = 0.24 cm2); and 3) area calculated by the Gorlin equation in the 26 patients who underwent catheterization (y = 0.89x + 0.08, r = .86, SEE = 0.24 cm2). Agreement with planimetry was similar for 22 patients with mitral regurgitation and 18 without it (P > .6), as well as for 6 in atrial fibrillation (P > .2). CONCLUSIONS: These results validate the proximal flow convergence concept in the clinical setting and also demonstrate that it can be extended to orifice area calculation using the continuity equation.

Atrial Fibrillation↗

PubMed1975

[Pathoanatomical features of isolated congenital mitral stenosis in twins (author's transl)].

The pathoanatomical features of isolated congenital mitral stenosis in female twins are presented. At the age of 7 months one of the infants underwent an emergency mitral valvotomy and died the next day due to mitral insufficiency. A total mitral valvectomy and an implantation of a Björk-Shiley prosthesis were performed on the second child at the age of 27 months. Death occurred 6 months later due to malfunction of the prosthesis caused by a circular fibrous endocardial bulge on both the atrial and ventricular side of the prosthesis. The bulging endocardial fibrosis may have been favored by a local thrombosis, which was found circularly around the bed of the prosthesis after it was removed. Since the child suffered from postoperative serum hepatitis, anticoagulants could not be applied on a regular basis in sufficient doses. The relation of the endocardial fibroelastosis to the congenital valve disease and the implantation of a prosthesis is discussed. The site of the postoperative valve in the first child and the state of the second child after implantation of the mitral valve prosthesis are discussed in detail.

Child, Preschool↗

PubMed1959