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PubMed1986

The haemodynamic effects of amrinone in patients with mitral stenosis and pulmonary hypertension.

The aim of this study was to investigate the haemodynamic effects of amrinone in patients with pulmonary hypertension and impaired right ventricular function. Twelve patients with mitral stenosis (NYHA classification III and IV) took part in the study. The haemodynamic measurements were performed in the steady state under anaesthesia prior to surgery. The patients received a bolus injection of 1.5 mg kg-1 amrinone; haemodynamic measurements were taken at 3, 5, 10, 15, 20 and 30 min. Amrinone increased cardiac index by approximately 30%, heart rate rose from on average 76 to 82 beats per minute. Whereas pulmonary capillary pressure did not change significantly, mean pulmonary artery pressure fell clearly from 33 to 28 mmHg. A decrease in the elevated pulmonary vascular resistance of about 40% was calculated. The higher the initial value for resistance in the pulmonary circulatory system, the more marked was the reduction (r = 0.96). The study shows that amrinone induces a vasodilation in the pulmonary circulatory system. A reduction in ventricular afterload is of great significance particularly for the therapy of right heart insufficiency. Amrinone therefore appears to be a suitable substance with its observed vasodilating and its well known positive inotropic effects for the treatment of right heart failure in cases of pulmonary hypertension.

Adult↗
PubMed1996

Exercise performance after PTMC in mitral stenosis: the relation with hemodynamics, ventilatory response and skeletal muscle function.

We examined the contribution of hemodynamics, ventilatory response and skeletal muscle function to the exercise performance after percutaneous transvenous mitral commissurotomy (PTMC). Nine patients with mitral stenosis (MS) underwent symptom-limited maximal ergometer exercise before, at 1 week and 3 months after PTMC. At 3 months after PTMC four patients (group 1) revealed an improved exercise performance (peak oxygen uptake (VO2) 747 +/- 145 to 1,039 +/- 175 ml/min; p < 0.01), and five patients (group 2) showed an unchanged exercise performance. Exercise performance in group 1 already increased at 1 week after PTMC. Peak cardiac output (Q) in group 1 increased (4.9 +/- 0.7 to 6.9 +/- 1.0 L/min, p < 0.05) at 3 months after PTMC. The slope of the minute ventilation (VE)-carbon dioxide production (VCO2) relation during exercise decreased at 1 week after PTMC (40.2 +/- 4.2 to 30.5 +/- 3.8, p < 0.05), and decreased slope of VE-VCO2 remained at 3 months after PTMC. However in group 2 these parameters did not change. There was a significant correlation between percent change of peak VO2 and percent change of peak Q from before to 3 months after PTMC (r = 0.84, p < 0.01). However there were no differences in reduction of mean pulmonary artery pressure, pulmonary vascular resistance and maximum isometric force (MIF) of left quadriceps between two groups. These findings suggest that the increased Q and improved excessive ventilation were important for increase in exercise performance in patients with MS after PTMC.

Exercise Test↗
PubMed2003

Prediction of atrial fibrillation in patients with severe mitral stenosis--role of atrial contribution to ventricular filling.

OBJECTIVE: Atrial contribution to ventricular filling was studied to assess its role in predicting the future development of atrial fibrillation (AF) in patients with severe mitral stenosis (MS) and sinus rhythm. DESIGN: Two hundred and eight patients with severe MS and sinus rhythm were followed up for 1 year. Baseline data were compared between group I (who developed AF at follow-up) and group II (who maintained sinus rhythm). Left atrial size, severity of MS, velocity time integral (VTI) of mitral valve flow and VTI due to atrial systole (A-VTI) were noted. Percentage contribution of A-VTI to the total VTI (A-%) was calculated. Sensitivity and specificity of A-% to predict the onset of AF was obtained. RESULTS: Left atrial size, severity of MS and total VTI were similar in the two groups. Group I patients were older (31.1 +/- 9.1 and 18.4 +/- 6.5 years, respectively, p < 0.03) with smaller A-VTI (5.3 +/- 2.2 and 6.7 +/- 3.4 cm, respectively, p < 0.01) and A-% (8.9 +/- 1.8 and 11.2 +/- 2.7, respectively, p < 0.003). A-% of <9% (mean value of A-VTI in group I) had high sensitivity (84%, positive predictive value 76%) and specificity (80%, negative predictive value 87%) to predict the development of AF. CONCLUSION: Atrial contribution to ventricular filling is reduced in patients prone to develop AF (due to inefficient left atrial contraction, much before its dilatation). It can be used for early identification of patients likely to develop AF with high sensitivity and specificity. It is simple, easily available, cost-effective and will guide earlier intervention and more frequent follow-up. There is a preclinical loss in atrial pump function much before the eventual onset of AF.

Adolescent↗
PubMed1999

Regression of large atrial thrombi and coronary neovascularizations with conventional anticoagulation in mitral stenosis--a case report.

The authors report a case of angiographically documented multiple coronary neovascularizations originating from the left circumflex artery (LCX) and coursing toward multiple thrombi located in the left atrium in a patient with severe mitral stenosis. The thrombi as well as the neovascularizations underwent near-complete resolution with 4 weeks' anticoagulation therapy with warfarin maintaining an international normalization ratio of 3.5. Percutaneous mitral balloon valvuloplasty was performed successfully without complications.

Anticoagulants↗
PubMed2003

Pulmonary venous flow in pure mitral stenosis and sinus rhythm--does pulmonary hypertension alter pulmonary venous flow velocity?

Pulmonary venous flow (PVF) is influenced by changes in left atrial (LA) pressure and function in various diseases. In mitral stenosis (MS), there is an alteration of LA hemodynamic due to the impaired ventricular filling caused by the stenotic valve and elevation of LA pressure. Although a variety of altered patterns of PVF have been described in MS, the potential influence of pulmonary hypertension, which is frequently associated with MS and has an adverse effect on the functional status and the prognosis of MS, on the PVF pattern is not clearly defined. The aim of this study is to determine the effects of pulmonary hypertension on PVF in patients with MS. Thirty-eight consecutive patients with pure MS and sinus rhythm (30 females, mean age 40 years old) underwent transthoracic and transesophageal echocardiography. Right heart and transseptal catheterization was also performed to measure pulmonary artery systolic pressure (PASP), pulmonary artery diastolic pressure (PADP), pulmonary capillary wedge pressure (PCWP), and left atrial pressure (LAP). The subjects were divided into two groups: group 1 (n = 25)included subjects with PASP < 50 mmHg, group 2(n = 13)included subjects with PASP 50 mmHg. LA size, mitral valve area (MVA), mean mitral gradient (MG), LAP, PASP, PADP, PCWP, and the peak velocity of PV systolic (PVFS), diastolic (PVFD) and atrial reversal flow (PVFAr) were also measured and compared between the two groups. There was no significant difference in age, heart rate, MVA, and LA size between the two groups. LAP, PASP, PADP, PCWP, and MG were significantly higher in group 2. However, PVFS and PVFAr were significantly lower in group2 (46.6 +/- 15.8 vs 29.9 +/- 12.8 cm/sec, P < 0.005; 22.1 +/- 6.8 vs 17.3 +/- 5.9 cm/sec, P < 0.05). There was no significant difference of PVFD between the two groups. PVFS had negative correlation to LAP, MG, PASP, PADP, and PCWP. PVFAr had negative correlation with PASP, PADP, and PCWP. There was no significant correlation between PVFAr and MVA. LA size and LAP. In conclusion, in patients with pure MS and sinus rhythm, PVF, especially PVFAr, is influenced by the presence of pulmonary hypertension.

Adult↗
PubMed2000

Infection of left atrial thrombus associated with mitral stenosis: A case report.

We describe the first reported case of an infected left atrial thrombus. The case of the 65-year-old male patient in this report was associated with mitral stenosis and involved Escherichia coli, and was treated successfully with surgical resection of the infected thrombus. This case suggests that such infection should be considered as a possible complication of intracardiac thrombus when bacteremia is present.

Aged↗
PubMed1985

[Genesis of protodiastolic extra heart sound in mitral stenosis: a phono-, apex-, echo- and cineangiographic study].

To clarify the genesis of a protodiastolic extra heart sound (S3') which was occasionally recorded at about the beginning of a diastolic rumble in mitral stenosis (MS), phono-, apex- and echocardiography were performed for 33 patients with MS, and left ventricular (LV) cineangiography was performed for eight of them. The patients were classified as S3'(+) and S3'(-) groups, according to whether they had S3'. Results were as follows: The S3' was synchronous with the rapid filling (RF) wave of the apexcardiogram (ACG). Its amplitude was proportional to the size of the RF wave. The RF wave was significantly sharper in the S3'(+) group as compared with that of the S3'(-) group. The S3' always appeared after onset of dispersion of dots in the velocity pattern of blood flow at the mitral valve orifice according to pulsed Doppler echocardiography. There was no significant difference between the S3'(+) and S3'(-) groups in the region of the mitral valve orifice according to two-dimensional echocardiography, and at the peak rate of change of the LV dimension during diastole as determined by M-mode echocardiography. The peak rate of change of the long-axis dimension of the LV during diastole as determined by cineangiography was significantly greater in the S3'(+) group than in the S3'(-) group. However, there was no significant difference between the two groups regarding the peak rate of change in the short-axis dimension of the LV during diastole as determined by cineangiography. The amplitude of the early diastolic dip of the interventricular septum (IVS) was significantly greater in the S3'(+) group as compared with that of the S3'(-) group. The amplitude of the S3' and the size of the RF wave correlated positively with the amplitude of the early diastolic dip of the IVS in pts with atrial fibrillation. Fractional shortening of the LV ascertained by M-mode echocardiography was significantly greater in the S3'(+) group than in the S3'(-) group. The end-systolic dimension of the LV tended to be less in the former than in the latter group. In conclusion, the S3' in MS was considered to be a third heart sound. Expansion along the long-axis of the LV and its sudden change in early diastole may account for the genesis of the S3', and this expansion may be accentuated by restoring force and active diastolic suction of the LV, and by velocity, direction and spread toward the cardiac apex of the stenotic mitral jet flow.

Adult↗
PubMed2000

Predictors of left atrial spontaneous echo contrast and thrombi in patients with mitral stenosis and atrial fibrillation.

The purpose of this study was to investigate the independent factors associated with the presence of left atrial (LA) spontaneous echo contrast (SEC) and thromboembolic events in patients with mitral stenosis (MS) in chronic atrial fibrillation (AF). Factors independently associated with LASEC, thrombi, and embolic events have been mainly investigated in patients with nonvalvular AF or inhomogeneous populations with rheumatic heart disease. Transesophageal and transthoracic echo studies were performed in 129 patients with MS in chronic AF. Previous embolic events were documented in 45 patients, 20 of them within 6 months, and 65 patients were receiving long-term anticoagulation. The intensity of LASEC and mitral regurgitation, the presence of thrombi and active LA appendage flow (peak velocities > or = 20 cm/s), and LA volume as well as other conventional echo-Doppler determinations were investigated in every patient. The prevalences of significant LASEC (degrees 3+ and 4+), thrombus, active LA appendage flow, and significant mitral regurgitation (>2+) were: 52% (67 patients), 29.5% (38 patients), 32% (41 patients), and 36% (47 patients), respectively. Multivariate analysis showed that decreasing mitral regurgitation severity, absence of active LA appendage flow, and mitral valve area were the independent correlates of LASEC (odds ratio [OR] 3.7, 5.4, and 0.17, respectively; all p <0.02). Active LA appendage flow and anticoagulant therapy were associated negatively, whereas the severity of LASEC was associated positively with the finding of LA thrombus (OR 9.6, 3.9, and 1.6, respectively; all p <0.05). The intensity of LASEC and previous anticoagulant therapy (OR 1.74 and 4.5, respectively; p <0.005) were the independent covariates of thrombi and/or recent embolic events. In conclusion, the severity of mitral regurgitation and lack of active LA appendage flow were, respectively, the strongest independent correlates of significant LASEC and thrombus in patients with MS in chronic AF. LASEC remains the cardiac factor most strongly associated with thrombus and/or recent embolic events in these patients.

Atrial Appendage↗
PubMed2005

Percutaneous transluminal mitral valvuloplasty reduces circulating soluble CD40 ligand in rheumatic mitral stenosis.

BACKGROUND: Recent data suggest that the pathogenesis of vascular inflammation and thrombosis involves CD40 ligand (CD40L), which is mostly derived from platelets. Previous studies have demonstrated that platelet activation occurs in peripheral blood of patients with rheumatic mitral stenosis (MS). However, in patients with MS, the plasma level of soluble CD40L has never been investigated. METHODS AND RESULTS: Seventeen patients with symptomatic MS undergoing percutaneous transluminal mitral valvuloplasty were studied (group 1, 11 patients in permanent atrial fibrillation and 6 patients in sinus rhythm). Solid-phase, sandwich enzyme-linked immunosorbent assay determined the plasma levels of soluble CD40L in the femoral vein and artery, and right and left atria before valvuloplasty, and those in the peripheral venous blood obtained 10 min after valvuloplasty, and at the 4-week follow-up after valvuloplasty. The Doppler pressure half-time method was used to calculate the mitral valve area. Additionally, plasma concentrations of soluble CD40L in the peripheral venous blood obtained from 17 control patients were measured (including nine healthy volunteers in sinus rhythm [group 2] and eight patients in permanent lone atrial fibrillation [group 3]). Plasma levels of soluble CD40L were significantly elevated in group 1 patients (437.6 +/- 370.2 pg/mL) [mean +/- SD] compared with group 2 (203.8 +/- 218.0 pg/mL) and group 3 patients (173.5 +/- 105.0 pg/mL) [p < 0.05]. The area of mitral valve increased significantly after valvuloplasty (1.10 +/- 0.20 cm(2) vs 1.47 +/- 0.29 cm(2), p < 0.0001). The mean left atrial pressure fell significantly and immediately after valvuloplasty (22.8 +/- 4.9 mm Hg vs 17.6 +/- 5.5 mm Hg, p = 0.0004). The peripheral venous plasma levels of soluble CD40L obtained before valvuloplasty significantly fell after valvuloplasty (before, 437.6 +/- 370.2 pg/mL; vs 10 min after, 215.4 +/- 113.9 pg/mL; vs 4 weeks after, 217.5 +/- 111.9 pg/mL; p < 0.02). CONCLUSIONS: Patients with moderate-to-severe MS had higher venous plasma levels of soluble CD40L than healthy volunteers or patients with lone atrial fibrillation. Additionally, the elevated venous plasma levels of soluble CD40L fell significantly following valvuloplasty.

Adult↗
PubMed1991

[Transesophageal echocardiographic study on systolic flow pattern of the pulmonary vein in patients with mitral stenosis and atrial fibrillation].

To determine the clinical significance and effect of cycle length on systolic backward (C) and forward (S) flow patterns of the pulmonary vein, we performed transesophageal and transthoracic echocardiography in patients with atrial fibrillation (Af). Study population consisted of 10 patients with mitral stenosis and sinus rhythm (MS-SR), 15 with MS and Af (MS-Af), 15 with mitral valve replacement and Af (MVR-Af), 10 with Af without organic heart disease (lone-Af) and 15 normal subjects. Various parameters, including peak velocities of C and S waves, closing amplitude of anterior mitral valve echogram during end-diastole, amplitude of the mitral annulus and interatrial septal motion during systole and left atrial pressure during the mitral closing period or end-diastole, were measured in each group. Results were as follows: 1. C wave was observed in all Af groups and six of 10 patients with MS-SR. Particularly, peak velocity of the C wave in MS-Af group was increased significantly compared with those of every other group. 2. Peak velocity of S wave in all Af groups, particularly in MS- and MVR-Af groups, decreased significantly compared with that of the normal group. 3. There were significant negative correlations between preceding R-R interval and peak velocity of the C wave or closing amplitude of anterior mitral valve echogram or left atrial pressure during end-diastole in MS-Af group. 4. There were significant positive correlations between preceding R-R interval and peak velocity of the S wave or amplitude of the mitral annulus or interatrial septal motion during systole in MS-Af group. 5. Peak velocities of the C and S waves had no correlations to preceding R-R interval in lone-Af group. We concluded that the C and S waves of pulmonary venous flow velocity pattern in MS-Af are affected by cycle length, and that the former is influenced by left atrial pressure and/or pliability of the mitral valve during the mitral closing period, and the latter by the grade of left atrial dilatation and/or preceding left atrial emptying.

Adult↗
PubMed2001

[Mitral stenosis evaluated with three-dimensional echocardiography].

The authors evaluated the possibilities of three-dimensional echocardiography in the assessment of the severity of mitral valve stenosis. In 45 patients, the Doppler pressure half-time method was compared with two three-dimensional echocardiographic methods in the measurement of mitral valve orifice: anyplane echocardiography and surface rendering. There was significant relation between them: r = 0.74 and r = 0.70, both p < 0.0001. In addition, mitral valve stenosis was also quantified by two new indices, such as the doming volume of the mitral apparatus and mitral valve volume. Subgroup analysis revealed relation between atrial fibrillation and decreasing doming volume as well as significantly higher mitral valve volume in patients with critical stenosis. Associated valve abnormalities did not influence the mitral orifice measurement neither by Doppler method nor three-dimensional echocardiography. In conclusion, three-dimensional echocardiography allows reliable assessment of mitral stenosis and moreover provides new quantitative indices, which can be clinically important in the assessment of three-dimensional geometry of the mitral apparatus.

Adolescent↗
PubMed1984

Mitral stenosis associated with valvular tophi.

Chronic tophaceous gout has become less common since the introduction of allopurinol and probenecid. Cardiac tophi have rarely been reported. In this article, we report a case of severe mitral stenosis in which valvular tophi played a major role in the pathogenesis. The case was well substantiated by echocardiography, surgical pathology, and chemical analysis.

Aged↗
PubMed1989

Mean frontal QRS axis and pulmonary artery pressures in rheumatic mitral stenosis.

The relationship between the mean frontal QRS axis calculated from the scalar 12 lead ECG, and the pulmonary artery (PA) pressures obtained by cardiac catheterisation in 64 cases of isolated rheumatic mitral stenosis (MS), was analysed. An overall trend of rightward axis shift with increasing PA pressures was observed; the best correlation was seen with systolic PA pressures (r = 0.51). It was possible to recognise 3 categories of patients: (1) With an axis of 70 degrees and below, systolic PA pressures were below 70 mm Hg in 82.4% of cases and below 80 mm Hg in 94% of cases; diastolic pressures were below 40 mm Hg in 88.2%; mean PA pressures were below 50 mm Hg in 88.2% cases. (2) With an axis of 71 degrees to 100 degrees, systolic PA pressures ranged from 30 to 120 mm Hg, diastolic PA pressures from 12 to 60 mm Hg and mean PA pressures from 19 to 80 mm Hg. (3) With an axis of above 100 degrees, systolic PA pressures were over 70 mm Hg in 95.5% of cases, diastolic PA pressures more than 30 mm Hg in 90.9%, and mean PA pressures more than 45 mm Hg in 90.9% cases. It was therefore possible to predict, with reasonable accuracy, the range of PA pressures in patients with isolated MS, except in those cases with an axis between 71 and 100 degrees.

Adolescent↗
PubMed2000

[Study of spontaneous echo contrast in patients with rheumatic mitral stenosis by transesophageal echocardiography].

Spontaneous echo contrast (SEC) is common in the areas of slow blood flow. This study was conducted to examine the correlation of SEC and left atrial appendage function, atrial fibrillation (Af) and thrombus in patients with rheumatic mitral stenosis. The transthoracic and multiplane transesophageal echocardiograms were performed on 117 patients(mean age 42.22 +/- 10.79 years). Left atrial size, left atrial appendage area, mitral valve area, left atrial appendage flow peak emphatic velocity and full velocity were measured. The presence of SEC and thrombus in the left atrium and appendage was noted. The results showed that among the patients, 57 had normal sinus rhythm, 60 had Af; 19 had thrombus, 98 had no thrombus; 71 had SEC and 46 had no SEC. Compared with the patients without SEC, the patients with SEC showed greater incidence of thrombus (28.76% vs 0, P < 0.05), higher rate of Af (69.01% vs 23.91%, P < 0.05), larger LAD (46.93 +/- 0.85 mm vs. 41.76 +/- 1.05 mm, P < 0.05), larger LAA area (8.06 +/- 0.32 cm2 vs 6.92 +/- 0.31 cm2, P < 0.05), smaller MVA area (1.07 +/- 0.23 cm2 vs 1.32 +/- 0.35 cm2, P < 0.05), lower LAA flow peak emphatic velocity (0.17 +/- 0.01 m/s vs 0.32 +/- 0.02 m/s, P < 0.05), and lower LAA full velocity (0.18 +/- 0.01 m/s vs 0.31 +/- 0.03 m/s, P < 0.05). These findings indicate that the presence of SEC is associated with significantly greater incidence of thrombus, higher rate of Af, larger LAD and LAA area, smaller MVA area, lower LAA flow peak emphatic velocity and full velocity. Atrial fibrillation, the diameter of left atrium and the area of mitral valve are independent predictors of SEC. SEC is significantly associated with LAA function and thrombus formation.

Adolescent↗
PubMed2000

Incidence of spontaneous echocontrast in left atrium in mitral stenosis detected by transoesophageal echo cardiography and related factors.

The incidence of left atrial (LA) spontaneous echo contrast (SEC) and the clinical and echocardiographic variables related to it were prospectively evaluated in a series of 60 patients with mitral stenosis (MS) undergoing transoesophageal echocardiography (TEE) with a 5 MHz multiplane transducer. LA-SEC was found in 39 patients (65%) employing TEE. Statistical analysis showed a significant relationship between the presence of SEC and MS without mitral regurgitation (MR) (P < 0.05), MS with < or = MR grade II (P < 0.05), atrial fibrillation (P < 0.001) and increased left atrial dimension (P < 0.05). Age, sex, mitral valve area and ejection fraction did not show any positive association (P > 0.05). Thus, it is concluded that LA-SEC is a common finding observed in approximately 65% of MS patients undergoing TEE and associated with conditions favouring stasis of left atrial blood.

Adolescent↗
PubMed2000

Role of activated protein C resistance in left atrial thrombogenesis in patients with mitral stenosis.

Activated protein C resistance (APC-R) is the most common inherited cause of clinically apparent venous thromboembolism. Previous data indicate that left atrial thrombus (LAT) formation is a common complication in mitral stenosis (MS) and a hypercoagulable state exists in these patients. The aim of this study was to invastigate the association between APC-R and LAT formation in patients with MS. Seventy-seven consecutive patients with rheumatic MS were included in this study. Transesophageal echocardiography was performed on all patients to assess the presence of any thrombus or spontaneous echo contrast (LASEC) in the left atrial cavity or appendage. Thirty four of the patients had LAT and 43 did not. Prevelance of APC-R was smiliar between the two groups of patients with and without LAT (23% vs 16%, p=0.425). LAT(+) patients had higher incidence of atrial fibrillation (AF, 74% vs 51%, p=0.046) and LASEC (71% vs 19%, p<0.001) compared to LAT(-) patients. On multivariate regression analysis, only the presence of LASEC achieved statistical significance as an independent risk factor for LAT formation (p=0.0001, odds ratio=9.589, 95% confidence interval [CI] =3.143-29.251). Because onunivariate analysis both LASEC and AF were associated with LAT, we also compared the prevelance of APC-R in the subgroups of patients who have these risk factors with and without LAT. There was a correlation between the presence of APC-R and LAT in the AF(+) subgroup of MS patients (p=0.033, odds ratio=8.167, 95% CI=1.001-72.812). However, the presence of APC-R was not associated with the increased risk of LAT in LASEC(+) patients (p=0.217, odds ratio=1.200, 95% CI=1.003-1.435). Although the presence of APC-R itself is not an independent risk factor for LAT formation in MS, it may increase the risk of LAT when present in combination with AF (as an additional risk factor) in these patients.

Activated Protein C Resistance↗
PubMed1975

Left ventricular end-diastolic volume in advanced ischemic heart disease; comparison between healthy subjects and patients with mitral stenosis.

The left ventricular end-diastolic volume (EDV), end-systolic volume (ESV) and systolic ejection fraction (SV/EDV) were determined in 6 healthy subjects, 21 patients with ischemic heart disease and 8 patients with mitral stenosis by the left ventricular 133Xe washout technique. Cardiac and stroke indexes as well as left ventricular work and stroke work indexes do not differ in all three groups. A significantly higher EDV and ESV together with a low SV/EDV suggested impaired left ventricular function in patients with ischemic heart disease.

Adult↗