Combined Mitral Stenosis Research Articles

Which Phenotypes Should We Include in the Hypoplastic Left Heart Syndrome?

The recent special issue of the World Journal for Pediatric and Congenital Heart Surgery devoted to hypoplastic left heart syndrome, and its related anomalies, contained significant information of great clinical relevance. Very little attention, however, was devoted to the integrity of ventricular septum as providing a criterion to distinguish between the phenotypes to be included within the syndrome, as opposed to the related anomalies. In this commentary, we summarize the evidence in support of the notion that the phenotypes to be included within the syndrome can be interpreted on the basis of an acquired disease of fetal life. We suggest that it is the integrity of the ventricular septum that provided the major criterion for the distinction between the lesions making up the syndrome and the related anomalies. The subsets of lesions to be included within the syndrome can then be recognized in terms of the time, subsequent to the closure of the embryonic interventricular communication, at which the left ventricle ceased its growth relative to the remainder of the cardiac components. On this basis, it is possible to recognize the combinations of aortic and mitral atresia, mitral stenosis with aortic atresia, combined mitral and aortic stenosis, and hypoplasia of the left ventricle with commensurate hypoplasia of the aortic and mitral valves; the latter combination now recognized as the hypoplastic left heart complex.

Lithotripsy-Assisted Transcatheter Mitral Valve Replacement for Severe Mitral Annular and Valve Calcification.

Transcatheter mitral valve replacement (TMVR) is evolving; however, limitations include severe calcification of the mitral valve leaflets and mitral annular calcification (MAC), which may be associated with incomplete valve expansion. Shockwave intravascular lithotripsy (IVL)-assisted percutaneous mitral valvuloplasty to treat calcific mitral stenosis has been reported. We describe the first human use of IVL-assisted transseptal TMVR with the Intrepid valve to treat a severely calcified mitral valve in a patient with severe stenosis and regurgitation. An 83-year-old man with rheumatic heart disease and severe MAC (MAC score, 10; calcium volume score, 7756 cm3) presented with combined mitral stenosis and regurgitation (valve area, 1.5 cm2; 3+ mitral regurgitation [MR]) and medically refractory heart failure symptoms and was enrolled into the APOLLO (Transcatheter Mitral Valve Replacement With the Medtronic Intrepid TMVR System in Patients With Severe Symptomatic Mitral Regurgitation) trial of Intrepid valve TMVR. Transseptal implantation of a 48-mm Intrepid valve was facilitated by Shockwave IVL delivered via two 8.0 × 60-mm M5+ balloons placed across the mitral annulus before implantation. Cerebral embolic protection during IVL and valve implant was provided by a Sentinel device and left subclavian balloon occlusion. Despite initial postimplant valve frame deformation and moderate central MR, postdilation achieved valve frame expansion and reduced MR. Echocardiography and computed tomography performed before hospital discharge and at 30 days show progressive valve frame expansion in the anteroposterior dimension, increased valve area, and resolution of MR. Intravascular lithotripsy of severe MAC before self-expanding TMVR may enhance annular compliance, mitigate fibroelastic recoil, and minimize TMVR valve frame deformation. Although promising, further study is required before IVL is considered a routine adjunct for TMVR in severe MAC.

Prevalence of Significant Tricuspid Regurgitation in Patients Planned for Mitral Valve Surgery in a Tertiary Center of Nepal

Background Tricuspid regurgitation is frequently present in patients with mitral valve disease and most of this tricuspid regurgitation present are significant.
 Objective To find out the prevalence of tricuspid regurgitation in adult patients present in our hospital who are planned for isolated mitral valve surgery for mitral stenosis, mitral regurgitation or both. Patients with moderate and severe tricuspid regurgitation were considered as significant.
 Method This was the retrospective cross-sectional study performed at Shahid Gangalal National Heart Center of Nepal. All cardiac surgical patients scheduled for isolated mitral valve surgery during the 3 years’ period from 2017 to 2020 were enrolled in the study and presence or absence of significant tricuspid regurgitation were recorded and analysed.
 Result Out of total patients 65% (663) of the cases with mitral valve pathology had significant tricuspid regurgitation. Out of the total mitral stenosis cases 70% were associated with significant tricuspid regurgitation, 62.6% of the cases of mitral regurgitation had significant tricuspid regurgitation and 64.8% of patients with combined mitral stenosis and regurgitation were associated with significant tricuspid regurgitation.
 Conclusion Significant tricuspid regurgitation is present in most of the cases with isolated mitral valve pathology. So routine tricuspid valve evaluation and repair if needed during mitral valve surgeries is recommended.

Transcatheter Mitral Valve Replacement in High-Surgical Risk Patients: A Single-Center Experience and Outcome.

Background Re-operative mitral valve (MV) replacement is a high-risk procedure, therefore, transcatheter MV replacement (TMVR) is a promising therapeutic option. Aim In this study, we aimed to evaluate the feasibility and safety of TMVR in patients with high surgical risk with degenerated mitral bioprostheses (TMViV), failed surgical rings (TMViR), and mitral annular calcification (TMViMAC). Methods This is a retrospective cohort study that enrolled patients with high surgical risk who underwent TMVR from February 2017 to September 2020. The TMVR procedure was performed using Edwards SAPIEN-3 valves through the transseptal approach. Results Sixty-four patients aged 62.7 ± 16.1 years with an STS score of 9.2 ± 3.7% underwent TMVR [35 (55%) TMViV, 16 (25%) TMViR, and 13 (20%) TMViMAC]. Mitral stenosis was more frequent in TMViV, mitral regurgitation was more frequent in TMViR, and combined mitral stenosis and regurgitation were more frequent in TMViMAC (P < 0.05). The MV gradient was 14.3 ± 5.3 mmHg and the MV area was 1.5±0.6 cm2. The 29 mm valve was frequently used in TMViV and TMViMAC, while the 23 mm valve was frequently used in TMViR (P=0.003∗). The procedural and fluoroscopy times were 58.7 ± 8.9 and 41.1 ± 8.2 minutes, respectively. Technical success was reported in 62 (98.4%) patients; 1 TMViR patient experienced valve embolization and salvage surgery, and 1 TMViMAC patient experienced slight valve malposition. At 3 months, 2 (3.1%) patients showed valve thrombosis (treated with anticoagulation), and 1 (1.6%) patient developed a paravalvular leak (underwent surgical MV replacement). At 6 months, 3 (4.7%) patients showed valve degeneration (underwent surgical MV replacement). Throughout follow-up, no patient exhibited mortality. Conclusions TMVR is a feasible and safe approach in patients with high surgical risk. TMViV and TMViR are reasonable as the first treatment approaches, and TMViMAC seems encouraging.

Transcatheter Implantation of Interatrial Shunt Devices to Lower Left Atrial Pressure in Heart Failure.

Patients with heart failure with preserved ejection fraction (HFpEF) constitutes a considerable sized population like that of subjects with heart failure with reduced ejection fraction. The symptoms include exercise induced dyspnoea and fatigue besides an increased mortality rate when compared to the general population. There is limited evidence of benefit from pharmacological therapy. A main pathophysiological mechanism is a left ventricular filling pressure that might be near to normal during resting conditions but increases during exercise leading to pulmonary congestion. Based on observations like the apparent lesser symptomatology in patients with combined mitral valve stenosis and atrial septal defect (Lutembacher syndrome) when compared to patients with isolated mitral valve stenosis, several Inter-Atrial Shunt Devices (IASD) have been developed with the intent to unload the pressure in the left atrium by creating a shunt into the right atrium. Smaller studies have found that the IASDs reduce the left ventricular filling pressure during exercise and increase the functional status of patients both subjectively and objectively with reported low rates of complications. These devices are undergoing further investigations and might prove to be a new paradigm in the treatment of patients with HFpEF.

Mitral valve replacement in infants and younger children

Data on mitral valve replacement (MVR) in young children is still limited. Our objective was to evaluate MVR in children below 5 years and identify factors affecting the outcomes. This retrospective study included 29 patients who had MVR from 2002 to 2020. We grouped the patients into two groups according to their age: age ≤ 24 months (n = 18) and > 24 months (n = 11). Primary cardiac diagnoses were Shone complex (n = 7; 24%), isolated congenital mitral valve abnormality (n = 11; 38%), and complete atrioventricular septal defect (n = 3; 10%). The median age was 19 month (25th–75th percentile: 11–32) and 59% were females (n = 17). The hemodynamic lesions were mitral regurgitation in 66%, mitral stenosis in 10%, and combined mitral stenosis and regurgitation in 24% of the patients. St. Jude mitral valve was the most common valve implanted (n = 19, 66%), followed by CarboMedics in 21% of the patients (n = 6). The mitral valve was implanted in the supra-annular position in 6 cases (21%). Preoperative and operative data were comparable between both groups. There was no association between valve size and position with postoperative heart block (P > 0.99, for both). The median follow-up duration was 19.4 months (8.6–102.5). Nine patients had mitral valve reoperation, six had MVR, and three had clot removal from the mitral valve. There was no effect for age group on reoperation (SHR 0.89 (95% CI 0.27–2.87), P = 0.84). Valve size significantly affected reoperation (SHR 0.39 (95% CI 0.18–0.87), P = 0.02). The supra-annular position was associated with an increased risk of reoperation (SHR 3.1 (95% CI 1.003–9.4), P = 0.049). There was no difference in survival according to the age (Log-rank P = 0.57) or valve size (Log-rank P = 0.66). Mitral valve replacement in children is associated with low morbidity and mortality. The risk of reoperation could be affected by the valve size and position rather than the age.

Pathologic Characteristics of 119 Archived Specimens Showing the Phenotypic Features of Hypoplastic Left Heart Syndrome

To assess the phenotypic variations found among hearts diagnosed at autopsy with hypoplastic left heart syndrome, with attention to implications related to this syndrome as an acquired disease of fetal life, rather than being the consequence of abnormal embryogenesis. We assessed 119 specimens, from 2 archives, diagnosed initially as representing hypoplastic left heart syndrome. Among the 119 specimens, the majority of which had been entered into the archives prior to the availability of surgical treatment for the syndrome, 36 (30%) had the combination of mitral and aortic atresia, 26 (22%) had mitral and aortic stenosis, and 57 (48%) had mitral stenosis combined with aortic atresia. Of the hearts with combined atresia, 92% (33 specimens) had slit-like left ventricles, compared to 12% (3 specimens) of hearts with stenosis of both aortic and mitral valves, and 2 hearts (4%) with mitral stenosis and aortic atresia (P < 0.001). Hypoplasia of the left atrial appendage was present in half (18 specimens, 51%) of those with combined atresia, as opposed to just 18% (10 specimens) of mitral stenosis combined with aortic atresia (P = 0.001). Small left ventricles with valves deemed proportional in size were found in 11 (42%) of those with combined mitral and aortic stenosis. Fibroelastosis was significantly more common in the hearts with mitral stenosis compared to those with mitral atresia (76% vs 11%, P < 0.001). The ascending aorta was significantly smaller in the hearts with aortic atresia. The variability in the morphologic findings support the notion that the lesions seen represent acquired disease occurring subsequent to closure of the embryonic interventricular communication, rather than representing abnormal embryogenesis.

Romatizmal Mitral Kapak Hastalığı Ülkemizde Güncelliğini Koruyor mu? Romatizmal Kökenli Mitral Kapak Replasmanı Erken ve Uzun Dönem Sonuçlarımız

Introduction: The purpose of this study was to present early and long-term results of mitral valve replacement in the treatment of rheumatic mitral valve disease, encountered frequently as an etiology in our clinic. Patients and Methods: All patients undergoing mitral valve replacement in our clinic between July 2008 and December 2017 were retrospectively reviewed. Patients with rheumatic mitral stenosis and/or regurgitation were included in the study. Primary outcome of interest was early mortality rates, long-term survival rates, and independent predictors of long-term survival. Results: In total, 88 patients were included in the study. Early mortality was observed in 4 (4.5%) patients. Concomitant arrhythmia surgery was performed in 19 (21.6%) patients with preoperative atrial fibrillation, and 11 of the 19 (12.5%) patients showed sinus rhythm after the operation. Overall 5-year survival rate was 77.9%. When compared to the valve pathologies, 5-year survival rates was 72.6% in patient group with isolated mitral stenosis, 81.8% in patient group with isolated mitral regurgitation, and 86.7%, in patient group with combined mitral stenosis and regurgitation. There was no statistically significant difference among the groups (p= 0.63). The existence of preoperative chronic renal failure (HR, 33.4; 95% CI, 4.1-272.3; p= 0.001) and cardiopulmonary bypass time (HR, 1.05; 95% CI, 1.02-1.08; p< 0.001) were independent predictors of long-term survival. Conclusion: Rheumatic mitral valve disease remains a problem in our country due to rural and border migration. Valve replacement is an optimal choice and produces satisfactory results in terms of prevention of recurrence and provision of effective valve orifice area. In addition, it is necessary to take precautions in the presence of preoperative chronic renal failure and to avoid prolonged cardiopulmonary bypass periods during the operation to ensure long term survival.

Invited Commentary

In the 1960s, Kay and colleagues [1Kay J.H. Egerton W.S. Zubiate P. The surgical treatment of mitral insufficiency and combined mitral stenosis and insufficiency with use of the heart-lung machine.Surgery. 1961; 50: 67-74PubMed Google Scholar] and Reed and colleagues [2Reed G.E. Tice D.A. Clauss R.H. Asymmetric exaggerated mitral annuloplasty: repair of mitral insufficiency with hemodynamic predictability.J Thorac Cardiovasc Surg. 1965; 49: 752-761PubMed Google Scholar] described methods to reduce the posterior annulus by plicating the annulus at the commissures. Anchoring sutures were placed on the anterior side of the annulus at the commissure, with considerably larger bites on the posterior annulus, which decreased the length of the posterior annulus. By contrast, annuloplasty is used to support or reduce in size the posterior portion of the mitral annulus and to provide a stable foundation for appropriate alignment of the leaflets. Some surgeons use the Kay suture plication technique only if abnormalities are localized solely at the commissures, which are not the majority of cases. Also, Kay and colleagues demonstrated good results with mitral repair for patients with ischemic mitral insufficiency, but no analyses were performed to examine the impact of confounding variables. Some studies demonstrated that complications after mitral valve repair, including annuloplasty, were affected by patients' preexisting comorbidities [3Grossi E.A. Goldberg J.D. LaPietra A. et al.Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications.J Thorac Cardiovasc Surg. 2001; 122: 1107-1124Abstract Full Text Full Text PDF PubMed Scopus (279) Google Scholar]. Sawazaki and colleagues [4Sawazaki M. Tomari S. Izawa N. Zaikokuji K. Tateishi N. Imaeda Y. Interrupted commissural band annuloplasty for degenerative mitral valve disease.Ann Thorac Surg. 2014; 97: 558-562Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar] modified the original Kay technique in order to avoid posterior annuloplasty to prevent hemolysis and prevent mitral stenosis secondary to pannus formation. The article by Sawazaki and colleagues [4Sawazaki M. Tomari S. Izawa N. Zaikokuji K. Tateishi N. Imaeda Y. Interrupted commissural band annuloplasty for degenerative mitral valve disease.Ann Thorac Surg. 2014; 97: 558-562Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar] reports a series of 63 patients with bilateral commissural band annuloplasty compared with 58 patients with a Cosgrove band, looking at the incidence of mitral stenosis and hemolysis that seems to favor the former technique. The incidence of these complications is generally low, and the attempt at improving the technique of Kay and colleagues does not seem to address prime considerations in the occidental setting of mitral valve repair. Definitive conclusions regarding the use of this technique can be derived only after a larger comparative study and by including numerous precisions on types of lesions, patients' preoperative characteristics, and associated procedures. Finally, on the basis of long-term studies, mitral valve repair at 10 years is durable, meaning that is carries better survival than do mechanical valves [4Sawazaki M. Tomari S. Izawa N. Zaikokuji K. Tateishi N. Imaeda Y. Interrupted commissural band annuloplasty for degenerative mitral valve disease.Ann Thorac Surg. 2014; 97: 558-562Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 5DiBardino D.J. ElBardissi A.W. McClure R.S. Razo-Vasquez O.A. Kelly N.E. Cohn L.H. Four decades of experience with mitral valve repair: analysis of differential indications, technical evolution, and long-term outcome.J Thorac Cardiovasc Surg. 2010; 139 (discussion 83–74): 76-83Abstract Full Text Full Text PDF PubMed Scopus (102) Google Scholar]. Also, repair offers a better preservation of heart function, lower risk of thromboembolic events, and infection, and it does not require the use of anticoagulation. In the near future, the technique presented in this article could be added to the available methods of performing mitral repair. Interrupted Commissural Band Annuloplasty for Degenerative Mitral Valve DiseaseThe Annals of Thoracic SurgeryVol. 97Issue 2PreviewMitral annuloplasty is useful for treating degenerative mitral valve disease. Although the incidence of complications is low, prosthetic ring-related complications can occur. Hemolysis and mitral stenosis are serious complications requiring reoperation. Limited use of prosthetic material could decrease the risk for complications. Commissural annuloplasty has been reported by Kay and Reed; their techniques involve suture plication. To prevent dehiscence, we selected short bands and compared the echocardiographic changes between this method and the Cosgrove ring. Full-Text PDF

English

INTRODUCTION: Acute rheumatic fever is an auto-immune response to bacterial infection with group A streptococcus (GAS). Despite the dramatic nature of the acute episode, acute rheumatic fever leaves no lasting damage to the brain, joints or skin. Recurrences of acute rheumatic fever may cause further valve damage, leading to steady worsening of rheumatic heart disease. AIMS AND OBJECTIVE: To study prevalence of acute rheumatic fever and rheumatic heart disease as detected by 2D ECHOCARDIOGRAPHY in patients 05 years to 40 years of age attending OPD and IPD of medicine and pediatrics department Rama Medical College, Kanpur. MATERIAL AND METHODS: The present study was conducted on patients of 05 to 40 years of age. All patients were examined clinically and relevant investigations including 2D ECHOCARDIOGRAPHY was done in all patients. RESULTS: A total of 734 patients belonging to age group 05 to 40 years & attending the OPD & IPD of Medicine & pediatrics Department of Rama Medical College, Kanpur, were studied, Out of 734 patients, 42 patients (5.72%) had findings of RF & RHD on 2D ECHO. RF were present in 10 patients (1.36%), RHD in 28 patients (3.81%), and 04 patients (0.54%) had evidence of both RF & RHD, 38.09% had findings of RF & RHD, were >25 years of age, Out of 42 patients 61.90% were females & 38.09% were males, RF & RHD occurred more frequently (57.14%) in rural population as compared to urban population (42.86%). Among the Jones Minor Criteria, the most common manifestation (57.14%) was Arthralgia followed by Fever (50%). ESR was raised in 28.57%, CRP was elevated in 28.57% and PR-interval prolongation was seen in 14.28%.Clinically 04 patients had evidence of carditis. All these patients also had ECHO findings suggesting carditis. Other than that ECHO also identified 10 more patients with carditis. Mitral valve was most commonly involved. Isolated mitral stenosis was present in 25% of patients, isolated mitral regurgitation in 18.75% of patients, while combined mitral valve stenosis & regurgitation was present in 37.50% of patients. Multi valvular lesions were present in 18.25% of patients. CONCLUSION: Our study shows prevalence of RF to be 19.07 per 1000 patients and prevalence of RHD to be 43.59 per 1000 patients, there is higher sensitivity and positive predictive value of 2D ECHO in detecting RF and RHD. Maximum number of patients of RF and RHD belong to the >25 years age group, followed by 20-25 years, 15-20 years and 05-10 years with prevalence is higher in females than male, Polyarthritis was the most common manifestation among the Jones major criteria seen in 35.71% patients.2D ECHO had a sensitivity and positive predictive value of 100% in identifying carditis as compared to clinical methods of detecting carditis with sensitivity of 28.57%.

Addressing the hemodynamic dilemma of combined mitral and aortic stenosis

Accurate assessment of valvular hemodynamics is essential in the decision-making process when referring a patient for cardiac surgery who has suspected coexistent aortic and mitral valve disease. Often times, one valvular lesion is worse than the other, and the question of "prophylactically" replacing the less severe valve at the time of surgery is controversial. In these situations and because of uncertainty regarding noninvasive assessment, hemodynamic evaluation in the cardiac catheterization laboratory provides critical information in guiding therapy.

Snare-assisted anterograde balloon mitral and aortic valvotomy using Inoue balloon catheter

We performed concurrent antegrade mitral and aortic valvotomy using Inoue dilatation catheter in 3 cases of combined rheumatic mitral and aortic stenosis. Following mitral valvotomy by standard procedure, aortic valve was crossed with the help of a floatation catheter. Stiff long length guide wire was fixed in descending aorta using a snare. Inoue catheter was threaded over the wire across the aortic valve and aortic valvotomy completed. Mitral valve area increased from mean 1 cm2 to 2 cm2; aortic gradient dropped from mean of 97 mm to 36 mm. Concurrent anterograde balloon mitral and aortic valvotomy may be effective and safe.

Current Status of Surgery for Rheumatic Carditis in Children

Background The incidence of rheumatic heart disease (RHD) has increased recently in the western United States. We reviewed our 18-year surgical experience with RHD in children to examine current surgical techniques and results. Methods From 1985 until 2003, 596 children (<21 years) with rheumatic fever were seen at Primary Children's Medical Center. Rheumatic carditis was diagnosed in 366 patients (61.4%). Twenty-six with carditis (26/366, 7.1%) required operation for rheumatic valve disease including 8 for mitral regurgitation, 7 for mitral and aortic regurgitation, 4 for aortic regurgitation, 4 for mitral regurgitation and stenosis, 2 for combined mitral stenosis and regurgitation with aortic insufficiency, and 1 for mitral and tricuspid regurgitation. Results Mean age at operation was 13.5 ± 4 years. Three patients required operation during the acute phase of rheumatic fever (< 6 weeks), 2 during the subacute phase (< 6 months), and 21 during the chronic phase after the episode of rheumatic fever (6.7 ± 3 years). Mitral valve repair was possible in 19 of 22 patients who required mitral operation. Aortic valve repair was possible in 4 patients whereas replacement was necessary in 9, including 2 Ross procedures. No operative deaths were recorded and 2 late deaths occurred at 4.6 and 10 years. Actuarial survival was 94% at 5 years and 78% at 10 years. Six patients required reoperation; actuarial freedom from reoperation was 78% at 5 years, 65% at 10 years, and 49% at 15 years. All survivors are in New York Heart Association class I or II. Conclusions Children with RHD in the United States uncommonly require valve operation. Mitral repair with a technique that allows annular growth is possible in most children with good long-term functional results. Long-term surveillance of children with RHD is necessary because of the possible need for late valve operation.

Recurrent Mitral Stenosis: Problems of Management

Abbreviation: TEE 5 transesophageal echocardiography A 44-year-old woman was evaluated for the primary complaint of the sensation of rapid and irregular beating of the heart, which was intensified by exertion. This sensation had been apparent for approximately 2 months and was associated with increased fatigability. Her previous history disclosed that elsewhere, 21 years previously, she had undergone aortic valve replacement combined with mitral valvotomy, but the records of this event were unavailable. She had never previously noted a rapid or irregular heart rhythm, and the remainder of the history and review of systems was completely negative. Three weeks previously, her referring physician had initiated regular oral treatment with digoxin and warfarin. On examination, the BP was 130/80 mm Hg, and the pulse rate was estimated at 85 beats/min and irregular. Physical findings included a displaced apical impulse to 1 cm lateral to the midclavicular line. An accentuated first heart sound and a soft mitral opening snap were audible. Opening and closing sounds were compatible with a mechanical aortic prosthetic valve. There was a grade 2/6 apical pansystolic murmur together with a grade 2/6 mid diastolic rumbling murmur consistent with combined mitral stenosis and regurgitation. A grade 3/6 early systolic ejection murmur was noted at the base together with a soft, high-pitched (blowing) diastolic decrescendo murmur (grade 1/6) heard maximally at the mid-left sternal border and consistent with aortic regurgitation. The lungs were clear to auscultation, and the findings of the remainder of the examination were normal. The ECG disclosed atrial fibrillation with a ventricular response rate of 75 beats/min; ST-T abnormalities were consistent with the effect of digitalis. An echocardiogram disclosed an enlarged left atrium (diameter, 4.8 cm). The mitral valve was thickened and stenotic, with a valve area estimated by both direct planimetric measurement and Doppler echocardiographic assessment to be approximately 1.1 cm 2 . Mild-to-moderate mitral regurgitation was demonstrated. A mechanical prosthetic valve in the aortic position was visualized, and peak systolic gradient of 47 mm Hg across this structure was derived by Doppler echocardiographic assessment. Mild regurgitation was noted across this orifice. The left ventricular size and systolic motion were normal. There was mild-to-moderate tricuspid regurgitation, from which the right ventricular systolic pressure was estimated to be in the range of 30 to 40 mm Hg. Chest radiography disclosed a cardiac silhouette indicative of left atrial enlargement, but the lung fields were clear. A mechanical prosthetic aortic valve was present together with evidence of a previous sternotomy.

Left atrial and ventricular ball thrombi complicating rheumatic heart disease with combined mitral and aortic stenosis.

A 42-year-old woman with chronic mitral stenosis was admitted for progressive dyspnea, palpitation, and weakness of lower extremities. Echocardiography revealed rheumatic, thickened, and stenotic mitral and aortic valves, and two free-floating ball thrombi were detected in the left atrium and ventricle, respectively. She died suddenly the next day, probably due to mitral or aortic outflow obstruction by the ball thrombi. We believe that the occurrence of free-floating ball thrombi in both the left atrium and left ventricle concomitantly has never been reported.

Predictors of left atrial thrombus and spontaneous echo contrast in rheumatic valve disease before and after mitral valve replacement

In this study we aimed to analyze, with reference to mitral regurgitation (MR), the incidence and predictors of left atrial (LA) thrombus and spontaneous echo contrast in patients with rheumatic valve disease before and after mitral valve replacement. The incidence of LA thrombus is known to be less in patients with MR. The impact of mitral valve replacement on this beneficial effect has not been studied in detail. The study included 169 consecutive patients (59 men and 110 women, average age 40 ± 13 years) with rheumatic mitral valve disease who underwent transesophageal echocardiographic examination 1 to 3 days before and within 7 days (mean 4.0 ± 1.3) after mitral valve replacement using mechanical prostheses in a single institution. The preoperative incidence of echocardiographic LA spontaneous echo contrast (SEC) was 1.1%, 30%, and 54%, and the incidence of thrombus was 1.1%, 13%, and 17% in the groups with MR, combined mitral stenosis + MR, and isolated mitral stenosis, respectively. In the MR group, SEC and thrombus incidence increased significantly after surgery. The independent predictors for postoperative thrombus development were atrial fibrillation, postoperative SEC, and preoperative thrombus. Thrombus recurred after surgery in 64% of 14 patients who had surgical thrombectomy. The presence of postoperative MR was associated with decreased risk of postoperative SEC and thrombus development. The interaction between MR and SEC and thrombus both before and after surgery provides further support for the protective effect of MR against LA thrombus formation.

Versatility of Inoue balloon catheter

Inoue rubber nylon single balloon catheter is being used worldwide for performing balloon mitral valvuloplasty (BMV). The popularity of Inoue balloon is attributed to its self-positioning configuration, size-adjustability, rapid inflation-deflation sequence and the ease of performance. We report its use in performing various non-mitral interventions. Its utility in treating patients with mitral stenosis and combined mitral and tricuspid stenosis is well established. Seventeen patients with valvular pulmonic stenosis (age 32±16 years; 11 males and 6 females) achieved significant reduction of peak systolic gradient (PSG) from 125±28 to 32±16 mmHg ( P<0.005). Four patients with inferior vena-cava obstruction (age 20–48 years; 3 males and 1 female) derived symptomatic benefit following successful dilatation. Inoue balloon was used to create percutaneous pericardial window in four cases (age 43–68 years; 2 males and 2 females) of recurrent pericardial collection secondary to carcinoma lung/breast, thus alleviating the symptoms of tamponade. One patient each with coarctation of aorta (32 years, male), discrete subaortic membrane (16 years, female), and critical valvular aortic stenosis (13 years, male) derived immediate hemodynamic improvement with Inoue balloon dilatation. No major complications were encountered. We conclude that Inoue balloon can be used to successfully manage various stenotic lesions.

Percutaneous double-valve balloon valvotomy for multivalve stenosis: Immediate results and intermediate-term follow-up

Ten patients each with combined mitral and tricuspid stenosis (group 1) and with combined mitral and aortic stenosis (group 2) underwent double-valve balloon valvotomy as a single staged procedure. The aortic valve was dilated by the Mansfield balloon technique, whereas the mitral and tricuspid valves were dilated with either the Mansfield or Inoue balloon. The mitral valve area increased from 0.78 ± 0.21 cm 2 to 2.05 ± 0.56 cm 2 ( p < 0.0005) in group 1 and from 0.75 ± 0.20 cm 2 to 2.1 ± 0.59 cm 2 ( p < 0.05) in group 2. The tricuspid valve area increased from 1.11 ± 0.41 cm 2 to 2.52 ± 0.69 cm 2 ( p < 0.0005). In group 2, the transaortic gradient decreased from 93.56 ± 17.7 mm Hg to 28.56 ± 7.8 mm Hg ( p < 0.0005) and the valve area increased from 0.37 ± 0.05 cm 2 to 1.03 ± 0.25 cm 2 ( p < 0.005). The excellent symptomatic and hemodynamic results were sustained at 30.3 ± 9.8 months of follow-up in group 1 and at 23.5 ± 9.1 months in group 2. Double-valve balloon valvotomy is feasible and safe and provides excellent immediate and intermediate-term follow-up results in selected patients with multivalve disease. A longer follow-up in a larger number of cases is needed to define further the role of this therapy. (Am Heart J 1997;133:64-70.)

Effects of increasing flow rate on aortic stenotic indices: evidence from percutaneous transvenous balloon dilatation of the mitral valve in patients with combined aortic and mitral stenosis.

To investigate the effects of transvalvar flow rate on aortic valve resistance and valve area after percutaneous transvenous balloon dilatation of the mitral valve in a homogeneous group of patients with rheumatic heart disease. Retrospective analysis of 12 patients with combined aortic and mitral stenosis who had undergone balloon dilatation of the mitral valve over a period of 9 years. Tertiary referral centre. Twelve (8 women, 4 men; mean (SD) age 37 (9) of 227 consecutive patients with critical mitral stenosis undergoing transvenous balloon dilation of the mitral valve in the centre also had aortic stenosis, defined as a transaortic pressure gradient of more than 25 mm Hg measured at a catheterisation study before valvuloplasty. Echocardiographic variables (mitral valve area measured by the pressure half-time method and planimetry, and the aortic valve area derived from the continuity equation) and haemodynamic measurements (cardiac output, left ventricular mean systolic pressure, aortic mean pressure, transaortic valve pressure gradient, mitral valve and aortic valve areas derived from the Gorlin formula, and aortic valve resistance) were assessed before and after transvenous balloon dilatation of the mitral valve. Follow up catheterisation to measure haemodynamic variables was performed one week after mitral valvuloplasty. Mean transaortic flow rate increased 33% after mitral valvuloplasty (from 198 (68) to 254 (41) ml/s, P = 0.002). Aortic valve areas derived from the Gorlin formula were significantly increased from 0.57 (0.12) to 0.73 (0.14) cm2 (P = 0.006) after mitral valvuloplasty. However, aortic valve area and valve resistance derived from the continuity equation were independent of the increase in flow rate after mitral valvuloplasty (from 1.29 (0.35) to 1.30 (0.29) cm2 and from 317 (65) to 259 (75) dyn.s.cm-5, both P = NS). The Gorlin-derived aortic valve area tends to be flow-dependent, and continuity equation-derived aortic valve area and catheterisation-derived valve resistance seem to be less flow-dependent. In patients with combined mitral and aortic stenosis, these flow-independent indices are important for decision-making.

The importance of clinical examination for the diagnosis of innocent heart murmur in adolescents

To determine the prevalence of innocent murmur among adolescents, and to evaluate the clinical features in comparison with echocardiogram (two-dimensional, M-mode, Doppler, and color-Doppler) in the assessment of heart murmurs. The study was carried out from March to December, 1992, and involved high school students coming from families of the medium and low-medium social classes. Considering the total of 1400 students registered in a public school, 536 adolescents aging from 10 to 20 years were admitted in this study. Twenty seven students with heart murmur were submitted to Echocardiography in order to find any cardiac lesions. Among 536 adolescents, 171 (32%) had some kind of heart murmur. On the basis of the clinical diagnosis, 160 (29.9%) patients were classified as having innocent murmur and 11 (2.1%) as having "pathologic murmur". Out of 27 students submitted to echocardiography, 20 of them with clinical diagnosis of innocent murmur showed normal results. Among seven students with clinical diagnosis of "pathologic murmur", the echocardiography recognized cardiac lesions in two (small ventricular septal defect and rheumatic heart disease: combined mitral incompetence and stenosis, and aortic incompetence). From the data obtained, the prevalence of innocent murmur among adolescents was 29.9% on the basis of clinical diagnosis. It is suggested that careful clinical examination by physicians skilled in cardiac examination is the recommended method for the diagnosis of innocent murmur (sensitivity of 100% and specificity of 80%).