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PubMed1985

Hemodynamic evaluation of stenotic cardiac valves: I. Effect of ventriculography and atropine on mitral stenosis.

Mitral area is the parameter used for quantitating mitral stenosis (MS) severity. When mitral gradient (MG) is low and reduction of mitral valve area (MVA) might be critical, interventions presumably increasing mitral valve flow (MVF), such as stress or atrial pacing, have been carried out. The purpose of this study was to analyze in 28 patients the combined effect of left ventriculography (LVG) and intravenous atropine (ATR) in the hemodynamic evaluation of MS. The rationale for combining these two interventions is to add up the ATR-positive chronotropic effect to the LVG potentiation of cardiac output. The LVG plus ATR markedly accelerated heart rate (from 80 +/- 14 to 104 +/- 18 bts/min, P less than 0.001), mildly increased cardiac index (from 2.6 +/- 0.6 to 2.9 +/- 0.6 1/min/m2, P less than 0.05), and importantly increased MVF (from 136 +/- 30 to 172 +/- 46 ml/bt, P less than 0.001). Pulmonary wedge pressure increased (from 14 +/- 5 to 21 +/- 5 mmHg, P less than 0.001) because of an important increment of MG (from 12 +/- 6 to 18 +/- 7 mmHg, P less than 0.001). None of six cases with mild MS (MVA greater than 1.5 cm2) and nine of ten cases with severe MS (MVA less than or equal to 1.0 cm2) had MG after LVG plus ATR greater than 12 mmHg. The remaining case with severe MS and the two cases (out of 12) with moderate MS having MG after LVG plus ATR less than or equal to 12 mmHg had, at surgical evaluation, noncritically reduced MVA. This study shows that LVG plus ATR is a valid and easy intervention for increasing MVF during cardiac catheterization. It also allows the reclassification of patients with low baseline MG and reduced MVA into two subgroups: Cases with critically reduced MVA at surgery achieve a postintervention MG greater than 12 mmHg and those cases with noncritically reduced MVA achieve a postintervention MG less than or equal to 12 mmHg.

Adult↗
PubMed1975

Treadmill exercise test in aortic stenosis and mitral stenosis.

The incidence of positive submaximal treadmill exercise tests was evaluated in patients with mitral stenosis and aortic stenosis, no electrocardiographic evidence of left ventricular hypertrophy, and normal coronary arteries on angiography. Seven of 19 patients (37 percent) with aortic stenosis (53 to 80 mm Hg gradient across the aortic valve) had greater than or equal to 1.0 mm of ischemic S-T segment depression during or after a submaximal treadmill test. Three of 15 patients (20 percent) with mitral stenosis (11 to 22 mm Hg mean gradient across the mitral valve) had greater than or equal to 1.0 mm of ischemic S-T segment depression during or after a submaximal treadmill exercise test. Patients with significant valvular disease, no electrocardiographic evidence of left ventricular hypertrophy, and normal coronary arteries may have a positive submaximal treadmill exercise test due to an unfavorable balance between myocardial oxygen supply and myocardial oxygen demand.

Adult↗
PubMed2003

Clinical and haemodynamic profiles of young, middle aged, and elderly patients with mitral stenosis undergoing mitral balloon valvotomy.

OBJECTIVE: To compare the clinical characteristics, haemodynamic findings, and symptomatic outcome in four age groups of patients in the UK undergoing percutaneous mitral balloon valvotomy. DESIGN: A review of patients with mitral stenosis treated by balloon dilatation. SETTING: Western General Hospital, Edinburgh, a cardiac referral centre. RESULTS: Of 405 patients who had mitral balloon valvotomy, 19 were aged under 40 years, 101 aged 40-54, 173 aged 55-69, and 112 were 70 years old or more. Medical co-morbidity and Parsonnet score for risk at surgery increased notably with age. Older patients had greater symptomatic limitation and a more severe degree of mitral stenosis, with more valve degenerative change. The incidence of atrial fibrillation, mitral reflux, left ventricular impairment, coronary artery disease, and aortic valve disease increased progressively with age. Before balloon dilatation the right ventricular systolic and left atrial pressures were similar in all age groups, but younger patients had a higher transmitral gradient and cardiac output. After balloon dilatation the younger patients achieved a greater increase in valve area. Complications of balloon valvotomy were more common in the older patients. At five years after balloon dilatation the percentages of patients in each age group who were in New York Heart Association classes I and II were 87%, 63%, 36%, and 19%, respectively. Mortality at five years was 0%, 5%, 31%, and 59%. CONCLUSIONS: Percutaneous balloon valvotomy gives a good haemodynamic and symptomatic result in patients under 55. In older patients improvement is often less pronounced and less sustained, but the procedure is a well tolerated palliative treatment for those unsuitable for surgery.

Adolescent↗
PubMed2001

Assessment of left atrial appendage filling pattern by using intravenous administration of microbubbles: comparison between mitral stenosis and mitral regurgitation.

Mitral stenosis (MS) and mitral regurgitation (MR) are the most frequent conditions that cause a dilation and dysfunction of the left atrial appendage (LAA). Despite similarly dilated LAA in patients with MS and MR, the incidence of LAA thrombi and the risk of thromboembolism is different between these patients. The purpose of this study was to characterize the filling pattern of LAA by using intravenous administration of perfluorocarbon-exposed dextrose albumin (PESDA) during transesophageal echocardiographic examination in patients with MS and MR. Twenty-four patients with moderate to severe MS, 12 patients with severe MR, and a control group including 30 patients with conditions other than mitral valve disease underwent transesophageal echocardiographic examination with an intravenous bolus injection of PESDA. LAA emptying and filling velocities and maximal and minimal areas of LAA and LAA ejection fraction were measured. Digital gray-scale intensity (GSI) of the left atrial (LA) and LAA cavity after PESDA injection was measured by off-line analysis. Compared with control patients, patients with MS or MR had larger maximal and minimal areas of LAA and reduced LAA ejection fraction. LAA peak emptying flow velocity was significantly lower in patients with MS compared with those of MR or control patients. LAA peak filling velocity was significantly lower in patients with MS compared with that of control patients. However, there was no significant difference of LAA peak filling velocity between the patients with MS and MR. There was no significant difference of GSI ratio of LAA and LA between patients with MR and control patients; however, GSI ratio of LAA and LA was significantly lower in patients with MS compared with that of MR. The incidence of LAA spontaneous echo contrast and LAA thrombi in patients with MS was significantly higher than that of the patients with MR and control subjects (P <.005). Despite similarly dilated LAA area and depressed contractile function of LAA in patients with MS and MR compared with control patients, profoundly impaired LAA filling with resultant flow stasis was demonstrated by contrast echocardiography in patients with MS. These findings may explain the higher incidence of LAA spontaneous echo contrast and thrombus in patients with MS.

Aged↗
PubMed1990

The reproducibility of continuous wave Doppler measurements in the assessment of mitral stenosis or mitral prosthetic function: the relative contributions of heart rate, respiration, observer variability and their clinical relevance.

The reproducibility of continuous wave Doppler echocardiographic measurements of transmitral diastolic flow velocity were studied in terms of bias and random error in 40 patients with either mitral stenosis or a Björk-Shiley mitral valve prosthesis. Twenty-seven patients were in sinus rhythm; 13 patients had atrial fibrillation. Intra- and interobserver differences in bias were small for the Doppler parameters studied i.e. early peak velocity (0.6% vs 3.6%), mean diastolic velocity (1.1% vs 8.6%), mean temporal velocity (2.3% vs 14.5%) and pressure half-time (2.7% vs 4.8%). The overall random error of the measurements (in terms of twice the standard deviation) was estimated separately in patients in sinus rhythm and atrial fibrillation: early peak velocity 5.6% and 9.2%, respectively, mean diastolic velocity 9.4% and 22%, mean temporal velocity 8.6% and 19% and pressure half-time 34% and 46%. The relative contributions to the overall random error of observer variation, heart rate dependency and respiratory variation were also studied. Heart rate dependency was demonstrated for both the mean diastolic velocity and the pressure half-time. Respiratory variation was found in the early peak velocity. From the results of this study the number of measurements to reduce the random error of the final average could be determined. Our results indicate that for the measurements in which a respiratory effect is present it is advisable to average the measurements taken over complete respiratory cycles.

Blood Flow Velocity↗
PubMed2004

Prevalence and fate of severe pulmonary hypertension in 559 consecutive patients with severe rheumatic mitral stenosis undergoing mitral balloon valvotomy.

BACKGROUND AND AIM OF THE STUDY: The prevalence of severe pulmonary hypertension (PH) in patients with severe mitral stenosis (MS) remains unknown, and the long-term effect of mitral balloon valvotomy (MBV) in large numbers of these patients is not well characterized. METHODS: Details from the prospective MBV database at the authors' institution relating to 559 consecutive patients who had successful MBV were analyzed. Patients were allocated to three groups on the basis of their pulmonary artery systolic pressure (PASP) at cardiac catheterization immediately before MBV: group A (n = 345) had PASP <50 mmHg; group B (n = 183) had PASP 50-79 mmHg; and group C (n = 31) had PASP > or =80 mmHg. Patients were evaluated clinically and echocardiographically at six months after MBV, and annually thereafter for up to 13 years. RESULTS: No mortality was encountered after MBV. Immediately after MBV, the mean PASP was 38.5+/-6.8 mmHg in group A (mild PH), 59.0+/-7.7 mmHg in group B (moderately severe PH), and 97.8+/-17.0 mmHg in group C (severe PH). At follow up (ca. 4 years), Doppler-monitored PASP fell to normal, and was similar in groups A, B and C (29+/-8, 31+/-9, and 29+/-5 mmHg, respectively; p = NS). CONCLUSION: MBV was shown to be safe and effective in treating patients with MS and severe PH. The latter condition regressed to normal levels over 6-12 months after successful MBV.

Adult↗
PubMed2005

Mitral stenosis after mitral valve repair using the duran flexible annuloplasty ring for degenerative mitral regurgitation.

The case is presented of a 47-year-old woman who had undergone mitral valve repair using the Duran annuloplasty ring four years earlier, and who was diagnosed with mitral stenosis owing to fibrous tissue overgrowth. In this patient, dense whitish fibrous tissue covered the annuloplasty ring and extended onto both leaflets of the mitral valve, narrowing its orifice and rendering the leaflets stiff and immobile. The pannus covering the mitral valve could not be stripped off without damaging the leaflets, making mitral valve replacement necessary. Mitral valve replacement with a St. Jude Medical mechanical heart valve prosthesis was successfully performed, and no major perioperative complications were encountered.

Female↗
PubMed1998

A prospective echocardiographic study of the effects of balloon mitral commissurotomy on pre-existing mitral regurgitation in patients with mitral stenosis.

Mitral regurgitation which is more than mild in severity is usually regarded as a relative contraindication to balloon mitral commissurotomy (BMC) because it is commonly believed that it may be worsened by the procedure. The aim of this study was to investigate the effects of BMC on pre-existing mitral regurgitation. Transthoracic and biplane transoesophageal echocardiography (TTE, TEE) combined with colour flow mapping (CFM) were performed prospectively on 50 consecutive patients immediately before and within 24 h after Inoue BMC. Before BMC, mitral regurgitation (MR) was diagnosed by TEE and left ventriculography in 36 and 13 patients respectively. Angiographic MR was mild in all 13 cases. The precise origins of MR jets were carefully sought by scanning in multiple TTE and TEE views. The maximal area of colour flow MR jets detected by TEE was measured by planimetry. After BMC mean mitral valve area increased from 1.0 +/- 0.3 to 1.7 +/- 0.8 cm2, p < 0.0001, mean left atrial pressure and volume decreased from 23.7 +/- 5.6 mm Hg to 21.6 +/- 7.5 ml, p = 0.039, and from 105 +/- 56 to 90 +/- 46 ml, p = 0.002, respectively. MR jets as assessed by TEE CFM disappeared in 12 patients, in all of whom MR had been undetected by angiography. MR jets remained within 20% of their original sizes in 16 (44%) patients and more than doubled in only 3 patients. However, the latter had only mild angiographic MR after BMC. BMC created new MR jets, distinct from pre-existing ones, in 27 (75%) patients. Their aetiologies were commissural splitting in 24, leaflet tears in 2 and chordal rupture in 1 case. New MR jets were co-existent with old jets in 17 (47%) cases and in 10 (28%) cases old jets were replaced by new jets. The severity of angiographic MR was unchanged in 21 (58%) of the 36 patients; new jets, all originating from one or both commissures, were found in 13 (65%) patients on TEE. Angiographic MR increased by 1 grade in 11 (33%) patients; new jets were detected in 9 patients, 8 from the commissures and 1 due to chordal rupture; in only 1 of the 11 patients did the increase in MR appear to be due to a worsening of a pre-existing jet. Angiographic MR increased by 2 grades in 3 (8%) patients; new jets appeared in all 3, arising from the commissures in 2 and from a leaflet tear in 1 case. One patient with a leaflet tear sustained an increase of 3 grades in angiographic MR. The final degree of angiographic MR was nil in 13, mild in 15, moderate in 6 and severe in 2 patients. Leaflet tears were responsible for both cases of severe MR. BMC does not appear to affect pre-existing mitral regurgitation adversely in almost all patients. It may abolish trivial jets but in most cases it creates new jets alongside the old ones. Leaflet tears are responsible for severe mitral regurgitation after BMC and this is independent of pre-existing regurgitant jets.

Blood Flow Velocity↗
PubMed1979

[Echocardiographic determination of the severity of mitral stenosis by the mitral valve closure index (author's transl)].

In 34 patients with mitral stenosis or combined mitral valve disease class II, III or IV (NYHA), the mitral valve closure index (MVCI, Shiu et al. 1977), based on the rate of diastolic apposition of the anterior and posterior mitral leaflet echos, and the diastolic closure rate (EF-slope) were determined and compared with hemodynamic data such as mean left atrial pressure (PLA), mean diastolic pressure gradient across the stenotic valve (DP) and mitral valve orifice area (Q), calculated by the Gorlin formula. MVCI and EF-slope correlated more favorably with DP (MVCIr = -0.71, EF-sloper = -0.53) than with Q and PLA. The results were not different in patients with sinus rhythm or atrial fibrillation. Using MVCI or EF-slope thie discrimination between severe and moderate or between moderate and light mitral stenosis was uncertain. Nevertheless, MVCI below 30 was associated with light, above 50 with severe mitral stenosis. In spite of the relationship between MVCI or EF-slope and the severity of mitral stenosis, in the individual case an exact quantification of mitral stenosis is not possible due to the great variability of echocardiographic data. For the assessment of the severity of mitral stenosis the mitral valve closure index is not superior to the EF-slope.

Adult↗
PubMed1993

Comparison of results of percutaneous balloon valvuloplasty in patients with mild and moderate mitral stenosis to those with severe mitral stenosis. The North American Inoue Balloon Investigators.

Most reported studies of percutaneous balloon valvuloplasty in adults with acquired mitral stenosis have used patients with severely stenosed valves. The risks and benefits of valvuloplasty were examined in a multicenter registry of patients to determine whether balloon valvuloplasty can effectively dilate less severely obstructed valves, and to clarify the role of this procedure in symptomatic patients with mild and moderate mitral stenosis. The study groups were derived from the North American Inoue Balloon Valvuloplasty Registry. Full hemodynamic data were available in 264 patients; 45 (17%) with mild or moderate mitral stenosis (mitral valve area > or = 1.3 cm2) were compared with the remaining 219 with severe mitral stenosis (valve area < 1.3 cm2). Percutaneous balloon valvuloplasty was performed using the anterograde transseptal technique with an Inoue balloon. The mean age of patients with mild and moderate mitral stenosis was 53 +/- 13 years, and all were symptomatic with a mean New York Heart Association functional class of 2.9 +/- 0.7. Balloon valvuloplasty resulted in an increase in calculated mitral valve area from 1.4 +/- 0.1 to 2.3 +/- 0.7 cm2 (p < 0.05), and a final valve area > or = 1.9 cm2 was achieved in 37 patients (82%). There were no procedural deaths, but complications included right atrial perforation, transient ischemic attack and emergency surgery for severe mitral regurgitation. One-year follow-up evaluation revealed symptomatic improvement in most patients (mean New York Heart Association class 1.4 +/- 0.6; p < 0.0001). However, 2 patients needed repeat valvuloplasty for restenosis, and 5 had mitral valve replacements.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2000

[Improvement in inspiratory muscle function in patients with mitral stenosis after percutaneous mitral valvuloplasty. Preliminary communication].

BACKGROUND: It has been proved that there is an inspiratory muscle dysfunction in mitral stenosis; Although its causes still remain unknown. AIM: To evaluate the effect of percutaneous balloon mitral valvuloplasty (PMV) on inspiratory muscle performance (IMP) in patients with mitral stenosis (mitral area < 1.5 cm2). PATIENTS AND METHODS: We studied IMP in 8 patients (35 +/- 10 years) before and 3 months after successful PMV. Inspiratory muscle strength was studied by measuring maximal statistical inspiratory mouth pressure (MIP). Endurance was evaluated using a two minute incremental threshold loading test in order to obtain the maximal sustainable inspiratory pressure (SIP), with the maximal sustainable load (MSL) the patients could sustain for 2 minutes. RESULTS: Mitral valvuloplasty increased mean cardiac index from 3.1 +/- 0.3 to 4.15 +/- 0.3 l/min/m2 (p < 0.01), and significantly decreased mean pulmonary and capillary pressures. The MIP value(118 +/- 6 cmH2O), similar to that of normal group, increased to 137 +/- 7 cmH2O (p < 0.01). SIP and maximal sustainable load were 52 +/- 3 cmH2O and 294 +/- 29 g respectively, lower than normal subjects (p < 0.05). They increased after PMV to 80 +/- 3 cmH2O and 463 +/- 26 g respectively (p < 0.001). CONCLUSIONS: PMV improved inspiratory muscle function in patients with severe mitral stenosis, probably secondary to a decrease work of breath and improvement of ventricular function.

Case-Control Studies↗