Gorlin Mitral Valve Area Research Articles

Accuracy of three-dimensional echocardiographic measurements of mitral valve orifice area using transthoracic free-hand scanning

Although three-dimensional (3D) echocardiography has been used to measure mitral valve areas (MVA) in mitral stanosis from both transescphageal (TEE) and transthoracic (TTE) approaches, the accuracy of these techniques has not been compared. Accordingly, we compared the accuracy of mitral valve area measurements obtained with a 3D volumetric free-hand (FH) TEE approach to those acquired with a 3D TEE approach using invasive Gorlin mitral valve area as the gold standard. Methods: 19 patients (49±18 yrs) with mitral stenosis were studied with TEE and free-hand TEE prior to valvuIoplasfy. During TEE, 2D images were acquired every 3 ° over 180 ° (SONOS 5500). Freehand images were obtained in 80 planes gated to respiration and heart rate using magnetic tracking, and processed on Omniview (TomTec). Direct 3D mitral valve area measurements reconstructed from TEE and free-hand TEE were compared to invasive Gorlin mitral valve area. Results: Both 3D techniques, free*hand TEE and TEE, were in good agreement with invasive data (Bland-AItmann and correlation, figure). Conclusions. Mitral valve orifice area measurements obtained with free-hand TEE scanning are as accurate as those obtained with 3D TEE, with the advantages of being noninvasive and suitable for serial measurements.

Balloon mitral valvuloplasty: comparison of haemodynamic and echocardiographic assessment of mitral stenosis at different heart rates in the catheterisation laboratory

Aims: To compare echo-Doppler, Gorlin equation and haemodynamic methods of measuring mitral valve stenosis during right ventricular pacing-induced tachycardia before and after Inoue balloon mitral valvuloplasty to determine which method gave the most consistent results. Methods and results: Measurements were made before and after valvuloplasty at: baseline heart rates, paced at 115 and then 145 beats/min. Mitral valve area by echo-Doppler was 1.1(±0.1) cm 2 (mean±S.E.) before and 1.8(±0.2) cm 2 after valvuloplasty; and by Gorlin equation: 0.9(±0.1) cm 2 before and 1.5(±0.1) cm 2 after. Echo-Doppler measurements were heart rate dependent but those by Gorlin measurements were not. At baseline, cardiac index was 2.08(±0.2) l min −1, left atrial pressure 23.3(±7.9) mmHg and mean mitral diastolic gradient 16.9(±9.9) mmHg. After valvuloplasty, cardiac index was 2.31(±0.1) l min −1, left atrial pressure fell to 19.2(±5.6) mmHg and mean diastolic gradient was reduced to 8.5(±1.8) mmHg. Conclusions: The Gorlin mitral valve area appeared to be the most heart rate independent indicator of success following valvuloplasty.

Percutaneous balloon mitral commissurotomy during pregnancy.

OBJECTIVE: To evaluate the effectiveness and safety of percutaneous balloon mitral commissurotomy for the treatment of pregnant women with severe mitral stenosis over a period of six years. DESIGN: Analysis...

Comparison of the usefulness of doppler pressure half-time in mitral stenosis in patients

Doppler pressure half-time is a reliable method for estimating mitral valve area when net left atrial and ventricular compliance remain stable. The accuracy of Doppler pressure half-time in estimating mitral valve area in older patients is unknown. We studied 80 patients (65 women and 15 men, aged 56 ± 14 years) with cardiac catheterization and echocardiography. Mitral valve area was calculated using the Gorlin formula and by the Doppler pressure half-time method. Patients were stratified into those aged < 65 years (n = 57), and those aged ≥65 years (n = 23). The discordance between pressure half-time and Gorlin-derived mitral valve area was assessed and related to multiple clinical, echocardiographic, and hemodynamic variables. The difference between pressure half-time and Gorlin-derived mitral valve area was greater in the older than in the younger patient (0.34 ± 0.30 vs 0.15 ± 0.27 cm 2, p = 0.009) but the older group had smaller mitral valve areas by the Gorlin method (0.72 ± 0.18 vs 0.89 ± 0.32 cm 2, p = 0.02) and lower cardiac output. The difference between pressure half-time and Gorlin remained greater in the group of older patients (0.32 ± 0.30 vs 0.19 ± 0.22 cm 2, p = 0.04), even when the analysis was restricted to patients with similar mitral valve area (< 1 cm 2 by the Gorlin method). Using multivariate analysis, age ≥65 years remained the only significant predictor of the discrepancy between pressure half-time and Gorlin mitral valve area. Thus, when compared with Gorlin-derived mitral valve area, pressure half-time overestimated valve area in older patients, and this technique for estimating mitral valve area should be used with caution in patients ≥65 years of age.

Successful percutaneous double balloon valvuloplasty for congenital mitral stenosis

A 19-month-old infant had an isolated severe ‘typical’ congenital mitral stenosis with dysplastic valves and two symmetric papillary muscles. He underwent successful double balloon mitral valvuloplasty via the right femoral vein. Left atrium pressure decreased from 30 to 20 mmHg and end diastolic mitral gradient from 12 to 0 mmHg. Cardiac index increased from 4.4 to 6.3 l/min per m 2. Gorlin's mitral valve area increased from 1 to 1.7 cm 2/m 2 and Doppler mitral valve area from 0.9 to 2.2 cm 2/m 2. At 16 months follow-up, the infant showed sustained clinical improvement.

Results of percutaneous double-balloon mitral commissurotomy in one medical center in Tunisia

Percutaneous balloon mitral commissurotomy was attempted in Tunisia, where rheumatic fever is still endemic, in 463 consecutive patients with severe rheumatic mitral valve stenosis. Their mean age ±SD was 33 ± 12 years (range 8 to 68), 324 patients (70%) were women, and 327 (71%) were in sinus rhythm. Valvotomy was technically successful in 454 patients (98%). The mean mitral valve gradient decreased from 20 ± 7 to 6 ± 4 mm Hg, mean left atrial pressure decreased from 27 ± 8 to 15 ± 6 mm Hg, cardiac index increased from 3.0 ± 0.7 to 3.6 ± 0.8 L/min/m 2, and Gorlin mitral valve area, from 0.97 ± 0.19 to 2.2 ± 0.4 cm 2 (all p < 0.001). Two-dimensional echocardiographic mitral valve area increased from 1.03 ±0.18 to 2.15 ± 0.36 cm 2 (p < 0.00001). A final valve area of ≥1.5 cm 2 was achieved in 98% of patients. Multivariate analysis identified a pre-mitral valve area <0.8 cm 2 and an echocardiographic score (echo score) ≥12 as the strongest predictors of residual stenosis (final mitral valve area <1.5 cm 2). Major procedural complications included mortality (0.4%), tamponade (0.7%), thromboembolism (2.0%), severe mitral regurgitation (4.6%), significant (pulmonary to systemic flow ratio ≥1.5) interatrial shunt (4.8%). Four hundred thirty patients were followed up between 6 and 82 months (mean 37 ± 22): 95% were in functional class I to II without reintervention, and 7 patients died (1.6%); restenosis (echocardiographic mitral valve area <1.5 cm 2) occurred in 10.4% of patients. The 3-year Kaplan-Meier freedom from restenosis was 92%, and from reintervention 93%. Because fluoroscopic calcium and postprocedure mitral valve area <-1.8 cm 2 were the independent predictors of restenosis, patients with calcified valves should be selected for this procedure on a case-to-case basis.

Results of percutaneous balloon mitral valvotomy in young adults

The results of percutaneous balloon mitral valvotomy (PBMV) were evaluated in 235 young patients (mean age 29 ± 11 years) with symptomatic rheumatic mitral stenosis, and the single-balloon Inoue technique was compared with the double-balloon Mansfield technique. PBMV was associated with a significant increase in Gorlin mitral valve area (0.78 ± 0.23 to 1.61 ± 0.64 cm 2; p < 0.001), and improvement in New York Heart Association functional class (2.78 ± 0.59 to 1.28 ± 0.58; p < 0.001). Mitral regurgitation increased significantly (0.4 ± 0.6 to 1.3 ± 1.0; p < 0.001), but was significant (≥3+) only in 19 patients (8%). Comparison of the Inoue and Mansfield techniques showed a significantly lower Gorlin mitral valve area after PBMV (1.55 ± 0.56 vs 1.74 ± 0.74 cm 2; p < 0.05), but a lower incidence of mitral regurgitation by color Doppler echocardiography (1.1 ± 0.7 vs 1.5 ± 0.8; p < 0.05) in the Inoue group. Patients were divided into those with nonpliable (valve score >8; group I) and pliable (score ≤ 8; group II) valves. Although significant increases in mitral valve area were obtained in both groups, mitral valve area by planimetry was significantly lower in group I (1.49 ± 0.46 vs 1.86 ± 0.44 cm 2; p < 0.05), whereas there was no difference in the amount of color Doppler mitral regurgitation (1.5 ± 1.0 vs 1.2 ± 0.7; p = NS). It is concluded that (1) in young patients with mitral stenosis, PBMV offers excellent palliation even in those with less ideally pliable valves; and (2) although the Inoue technique achieves smaller valve areas, it is accompanied by a lower incidence of mitral regurgitation.

Plasma noradrenaline as an indicator of functional state in hearts with mitral stenosis: the influence of acutely reduced left atrial pressure by balloon mitral commissurotomy.

To investigate the mechanism in which plasma noradrenaline concentration (pNA) is elevated in heart failure, the effect of balloon mitral valvuloplasty was used as a model of acute manipulation of the left atrial pressure reduction in ten patients with mitral stenosis. Gorlin mitral valve area and pNA were correlated with New York Heart Association functional class and found to have a significant exponential inverse relationship with each other ([pNA, pg/ml] = 198.9 x [mitral valve area, cm2]-0.696; P = 0.003). Elevated pNA could be partially explained by a reduced cardiac index (CI) ([pNA, pg/ml] = 403.4 x [CI, l/min/m2]-0.889; P = 0.027; r = 0.495), especially in severely failed hearts, but not by pulmonary capillary wedge pressure (PCWP). However, the percent changes (% delta) of variables early after balloon valvuloplasty exhibited a paradoxical contrast; % delta pNA showing a clear negative exponential correlation with % delta PCWP ([% delta pNA] = 436.0 x [% delta PCWP + 80]-0.679 - 80; P = 0.021), but not with % delta CI. These results suggest that pNA should be considered an indicator of cardiac functional class in mitral stenosis. PNA is modulated by both cardiac index and pulmonary capillary pressure, but in different ways.

Percutaneous balloon mitral valvuloplasty in eight pregnant women with severe mitral stenosis.

Normal gestation is associated with a hyperdynamic adaptive state. The circulatory changes represent an additional burden on the cardiovascular system of women with rheumatic mitral stenosis (MS). Life-threatening complications can occur in pregnant women with severe MS. We successfully performed percutaneous balloon mitral valvotomy (PMV) in eight pregnant patients (mean age 28 +/- 6.9 years, range 21-38 years). Pregnancy mean age was 24.6 +/- 6.5 weeks. Five patients were in NYHA functional class III and three patients were in class IV. Emergency PMV seemed to be life saving to both mother and foetus in one case. All patients but one had pliable valves. PMV was achieved using the double balloon transseptal technique. To protect the foetus from radiation, the patient's pelvic-abdominal area was shielded and left ventriculography was not performed. The total mean time of PMV was 72 +/- 19 min and that of fluoroscopy was 16.6 +/- 7.8 min. Gorlin's mitral valve area increased from 0.83 +/- 0.15 to 2.4 +/- 0.34 cm2 and the cardiac index from 3.1 +/- 0.77 to 4.2 +/- 0.79 l.min-1.m-2. Left atrium pressure decreased from 29 +/- 10 to 14 +/- 5 mmHg and mitral valve gradient from 21 +/- 7 to 6 +/- 3 mmHg. There were no complications or residual MS. At a mean follow-up of 13.2 +/- 9.4 months, all patients were in NYHA class I and had a normal course of pregnancy. The eight women delivered healthy full-term babies. At 1-25 months post-partum follow-up, the eight infants had shown normal growth and development.(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral regurgitation following mitral balloon valvotomy. Differing mechanisms for severe versus mild-to-moderate lesions.

This study was designed to evaluate the incidence and mechanisms of mitral regurgitation following mitral balloon valvotomy (MBV) in 40 consecutive patients with symptomatic tight pliable mitral stenosis. Transthoracic echocardiography with color flow mapping was performed before and 24 hours after the procedure. Patients who developed significant mitral regurgitation following MBV also underwent transesophageal echocardiography. The relation between increased mitral regurgitation and both valvular morphology and procedure-related factors was examined. Gorlin mitral valve area increased from 0.81 +/- 0.3 to 1.95 +/- 0.7 cm2 (p less than 0.001). No patient had more than 2+ mitral regurgitation by angiography and color Doppler prior to MBV. There was a moderate correlation between Doppler and angiographic increase in mitral regurgitation (r = 0.73, p less than 0.0001). By Doppler criteria 33 patients had no (n = 6) or mild (n = 27) increase in mitral regurgitation (group 1), and seven developed significant new mitral regurgitation (group 2). Baseline clinical, echocardiographic, and procedure-related data for the two groups were similar. Multiple regression analysis did not select any individual valve characteristic (valvular thickening, mobility, calcification, and subvalvular disease), total echocardiographic score, balloon diameter, or ratio of balloon to mitral annular diameter as disruption with a torn anterior or posterior mitral leaflet in six and a ruptured papillary muscle in one. Two of these patients have required mitral valve replacement (6 and 9 months following the procedure), whereas the remainder are significantly symptomatic. By contrast, mitral regurgitation in group 1 either occurred at the site of commissural split (n = 20) or was associated with prolapse of the anterior mitral leaflet (n = 6). Thus, severe new mitral regurgitation following MBV is due to noncommissural tearing of the mitral leaflet and confers an adverse long-term prognosis. A mild increase in mitral regurgitation following MBV is frequent and occurs at the site of commissural split or is associated with prolapse of the anterior leaflet. Furthermore, in this study, an increase in mitral regurgitation could not be predicted from any valvular or procedure-related factor.

Effect of mitral regurgitation and volume loading on pressure half-time before and after balloon valvotomy in mitral stenosis

Doppler pressure half-time (PHT) is frequently used to assess mitral valve area (MVA), but the reliability of PHT has recently been challenged, specifically in the setting of balloon mitral valvotomy when hemodynamics have been abruptly altered. The effect of volume loading both before and after balloon mitral valvotomy on computation of MVA by Gorlin and by PHT in 18 patients with high-fidelity micromanometer measurements of left atrial and left ventricular pressure was therefore examined. Echocardiographic MVA increased from 0.91 ± 0.15 to 1.97 ± 0.42 cm 2 after valvotomy. Volume loading produced significant increases in left atrial pressure (16 to 23 before and 12 to 20 mm Hg after valvotomy), in cardiac output (3.7 to 4.1 before and 3.9 to 4.6 liters/min after valvotomy), and in mitral valve gradient (11 to 14 before and 5 to 7 mm Hg after valvotomy). These hemodynamic changes were associated with modest but significant decreases in PHT and increases in MVA estimated by 220/PHT (0.66 to 0.81 before and 1.64 to 1.96 cm 2 after valvotomy), whereas the MVA by Gorlin was not affected in a consistent fashion by volume loading (0.85 to 0.89 before and 1.66 to 1.69 cm 2 after valvotomy). The correlation between Gorlin MVA and 220/PHT was only fair (r = 0.73, p < 0.001) and was significantly poorer among patients with > 1+ mitral regurgitation (r = 0.72) than among those with less or no regurgitation (r = 0.79) (p = 0.001 by analysis of covariance for mitral regurgitation effect). In patients with mitral regurgitation after valvotomy, the Gorlin formula underestimated MVA (1.66 cm 2) compared with both MVA by echocardiography (2.08 cm 2) and MVA by 220/PHT (2.29 cm 2). Thus, (1) MVA by 220/PHT tends to underestimate MVA by echocardiography and, in the absence of mitral regurgitation, by Gorlin; (2) PHT is affected by volume loading, which tends to correct this discrepancy; (3) the Gorlin formula underestimates MVA in mitral regurgitation, and PHT is a useful alternative measure of MVA, which may be particularly valuable in the presence of mitral regurgitation after balloon valvotomy.

A new formula for the measurement of diastolic mitral valve orifice area.

This study evaluated the accuracy of a new formula for the calculation of mitral valve area. Fifty-two patients with mitral stenosis who underwent cardiac catheterization were evaluated by the standard Gorlin and the new formulas. The correlation between the two formulas was excellent (r = 0.89) for valve areas of 0-1.5 cm2. When the new valve area formula yielded an area greater than 1.5 cm2, there was no correlation with the Gorlin formula. However, the likelihood of the Gorlin mitral valve area being less than 1.0 cm2 was low (10%). The results of the new formula do not appear to be affected by atrial fibrillation and are probably subject to the same limitations when used in the presence of a regurgitant lesion. Therefore, with moderate to severe mitral stenosis, this new formula shows a good correlation. However, with mild stenosis, further work is needed to determine the accuracy and limitations of the new formula.