Mitral Area Research Articles

Relevance of Functional Mitral Regurgitation in Aortic Valve Stenosis

The clinical relevance of functional-mitral-regurgitation (FMR) in patients with aortic valve stenosis (AS) has been poorly studied using a quantitative approach. In addition, FMR prognostic value has mostly been analyzed after aortic valve replacement. Between 2010 and 2014 the echocardiograms of consecutive AS patients were retrospectively reviewed. Inclusion criteria were calcified aortic valve with transaortic-velocity >2.5 m/s and calculated mitral effective regurgitant orifice area (ERO) in the presence of mitral regurgitation. Organic mitral valve disease was an exclusion-criteria. Primary endpoint was heart failure or death under medical management. Secondary endpoint was heart failure or death. Eligible patients were 189, age 79 ± 8 years, 61% NYHA I/II, indexed aortic valve area (AVA) 0.55 ± 0.17 cm2/m2. Mitral ERO was 7.6 ± 4.2 mm2 (>10 mm2 in 30% of patients). Longitudinal function (by S'-TDI) was associated with mitral ERO independently of ejection fraction and ventricular volumes (p = 0.01). Mitral ERO greater than 10 mm2 (threshold identified by spline survival-modeling) was associated with severe symptoms (Odds ratio [OR] 3.1 [1.6 to 6.0]; p = 0.0006) and higher pulmonary-arterial-pressure (OR 3.0 [1.4 to 5.9]; p = 0.002). Follow-up was completed for 175 patients. After 4.7 [1.4 to 7.2] years, 87 (50%) patients underwent AVR, 66 (38%) had heart-failure, 64 (37%) died. No procedure on FMR was required. Mitral ERO was independently associated with primary and secondary endpoints both as continuous variable (Hazard ratio [HR] 1.15 [1.00 to 1.30]; p = 0.04 and HR 1.23 [1.05 to 1.43]; p = 0.01 per 5 mm2 ERO increase) or as ERO> versus ≤10 mm2. Adjustment for S'-TDI or subgroup-analysis did not affect results. The analysis by AVA revealed the incremental prognostic role of mitral ERO over AS severity. In conclusion, AS patients with concomitant FMR >10 mm2 holds a higher risk during medical follow-up. FMR quantitation, even for volumetrically modest regurgitation, provides incremental prognostic information over AS severity.

Novel approach for automatic mid‐diastole frame detection in 2D echocardiography sequences for performing planimetry of the mitral valve orifice

The mitral valve orifice area is a reliable measure for evaluating mitral valve stenosis (MS) severity, which is obtained by the planimetry of the mid-diastole frame in the echocardiography sequences. Since the manual method for determining this frame is time-consuming and user-dependent, a novel automatic method has been proposed in this study. First, the region of interest (ROI) containing the mitral valve orifice region is detected using circular Hough transform and k-means algorithms. Then, the dimension reduction method is applied to the ROI of each frame to map it into a point in a 2D space. The performance of the local linear embedding (LLE), isometric mapping, kernel principal component analysis (PCA), and linear PCA algorithms has been evaluated in this study. Finally, a distance curve is obtained by calculating the Euclidean distance between consecutive points in 2D space, and the mid-diastole frame is determined by interpreting this curve. The proposed algorithm was validated using 2D echocardiography of the 20 MS patients. Finally, the LLE method showed the best result, and the average frame difference for 20 cases using the proposed method compared with the gold standard (the echo-cardiologist opinion) was 1.40.

Predictors of residual mitral regurgitation after left ventricular assist device implantation.

Patients with advanced heart failure often have functional mitral regurgitation. Left ventricular assist device implantation improves functional mitral regurgitation through left ventricular unloading. However, residual mitral regurgitation after left ventricular assist device implantation leads to adverse outcomes, and whether patients need concomitant mitral valve surgery is not fully elucidated. Therefore, this study aimed to elucidate the predictors of residual mitral regurgitation and to describe the temporal changes in residual mitral regurgitation. We retrospectively enrolled 15 patients with implantable continuous-flow left ventricular assist device, who had significant mitral regurgitation on echocardiography before left ventricular assist device implantation. Three patients had residual mitral regurgitation (mitral regurgitation color jet area/left atrial area >0.2) 1 month after left ventricular assist device implantation. We investigated factors associated with residual mitral regurgitation and compared patients with or without residual mitral regurgitation. On univariate analysis, mitral valve tethering area and mitral regurgitation vena contracta before left ventricular assist device implantation were significantly associated with residual mitral regurgitation (odds ratio, 1.03; p = 0.036 and odds ratio, 10.45; p = 0.0087). One month after left ventricular assist device implantation, the mean pulmonary capillary wedge pressure and pulmonary artery pressure were higher in patients with residual mitral regurgitation (pulmonary capillary wedge pressure: 11.3 ± 3.5 vs 6.4 ± 3.4 mmHg, p = 0.029 and pulmonary artery pressure: 21.3 ± 4.0 vs 15.9 ± 3.3 mmHg, p = 0.023). However, the mitral regurgitation grading and hemodynamics were not significantly different 6 months after left ventricular assist device implantation. The hospitalization-free survival was not significantly different between the two groups. Mitral valve tethering area and mitral regurgitation vena contracta were predictors of residual mitral regurgitation. Residual mitral regurgitation improved until 6 months after left ventricular assist device implantation and might not affect the prognosis.

Transcatheter aortic valve implantation and its impact on mitral valve geometry and function.

The aim of this study was to evaluate the impact of transcatheter aortic valve implantation (TAVI) on mitral valve geometry and function. Eighty-four patients underwent TAVI. Forty-four (52%) patients received a balloon-expandable valve and 40 (48%) were implanted with a self-expandable valve. All patients underwent three-dimensional-volumetric transesophageal echocardiography of the mitral valve before and immediately after TAVI. A dedicated software was used for assisted semiautomatic measurement of mitral annular geometry. During systole, the anterior to posterior (AP) diameter was significantly reduced after the procedure (3.4 ± 0.5 cm vs 3.2 ± 0.5 cm; P < .05). The mitral annular area (10.8 ± 2.8cm2 vs 9.9 ± 2.6cm2 ; P < .05) as well as the tenting area (1.6 ± 0.7 cm2 vs 1.2 ± 0.6 cm2 ; P < .001) measured at mid-systole were reduced after TAVI. Diastolic measures were similar. Patients treated with balloon-expandable valves showed a significantly larger reduction in the AP diameter compared to self-expandable valves (-0.25 cm vs -0.11 cm; P < .05). The reduction of the annular area was higher in the balloon-expandable group (-1.2 ± 1.59 vs -0.22 ± 1.41; P < .05). Grade of mitral regurgitation did improve or remained stable after TAVI. TAVI significantly impacts the mitral valve and mitral annular geometry and morphology. The choice of the prosthesis (balloon- vs self-expandable) may be relevant for those changes.

Impact of COAPT trial exclusion criteria in real-world patients undergoing transcatheter mitral valve repair

BackgroundThe generalizability of the COAPT trial results on the benefit of TMVR in patients with secondary mitral regurgitation is unclear. MethodsFunctional and long-term clinical outcome were examined in 122 consecutive patients with secondary mitral regurgitation and reduced ejection fraction undergoing TMVR. “COAPT-like” patients were defined according to principal COAPT inclusion/exclusion criteria if all of the following was fulfilled: symptomatic mitral regurgitation grade 3+ or more according to American guidelines; left ventricular ejection fraction ≥ 20%, left ventricular end-systolic dimension ≤ 70 mm, estimated pulmonary artery systolic pressure ≤ 70 mmHg, mitral valve orifice area ≥ 4 cm2, no prior mitral valve procedure, no right sided congestive heart failure, no COPD requiring home oxygen therapy and NYHA class less than IVb. Results51% of 122 patients (mean age 74 ± 10 years, 76% male) showed COAPT-like characteristics. COAPT-like patients showed a significantly lower hazard for the composite endpoint of mortality and heart failure hospitalization (HR 0.51, 95%CI 0.30–0.89, p = .017) during a mean follow-up of 16 ± 6 months, with an estimated 1-year event rate of 20% vs 43%, respectively. The improvement in functional outcomes 6 min walking distance (76 ± 136 m vs. 31 ± 90 m), Minnesota Living with Heart Failure Questionnaire (−6 ± 19 vs. −10 ± 23) and Short Form 36 physical component score (3.8 ± 10 vs. 5.5 ± 11) was similar in COAPT-like and the other patients. ConclusionIn this first real world cohort half of the patients undergoing TMVR showed COAPT-like characteristics and these patients showed a substantially better clinical outcome. The mid-term functional benefit was similar in COAPT-like and other patients.

A Pregnant Lady with Thyrotoxic Cardiomyopathy and Pulmonary Hypertension

Thyrotoxic cardiomyopathy is potentially life threatening complications of thyrotoxicosis during pregnancy due to its harmful effects both on mother and fetus. We present a case of 32-year-old pregnant lady presented with non-productive cough, palpitation, restlessness, sweating and weakness after minimum exertion with a small swelling on the right side of her neck for three months. There was tachycardia with normal blood pressure, first and second heart sound were soft with pansystolic murmur on mitral and tricuspid area. After all laboratory investigations, she was diagnosed as dilated cardiomyopathy with moderate to severe pulmonary hypertension with toxic multi nodular goiter with 13 weeks of pregnancy.The thyrotoxic cardiomyopathy during pregnancy is rare due to difficulties in diagnosis. However, physicians should be aware of the risk posed by thyrotoxic cardiomyopathy during pregnancy.&#x0D; KYAMC Journal Vol. 11, No.-1, April 2020, Page 54-56

Left ventricular overloading identified by critical care echocardiography is key in weaning-induced pulmonary edema.

PurposeTo assess the role of left ventricular overload and cumulated fluid balance in the development weaning-induced pulmonary edema (WIPO).MethodsVentilated patients in sinus rhythm with COPD and/or heart failure (ejection fraction ≤ 40%) were studied. Echocardiography was performed immediately before and during a 30-min spontaneous breathing trial (SBT) using a T-tube. Patients who failed were treated according to echocardiography results before undergoing a second SBT.ResultsTwelve of 59 patients failed SBT, all of them developing WIPO. Patients who succeeded SBT had lower body weight (− 2.5 kg [− 4.8; − 1] vs. + 0.75 kg [− 2.95; + 5.57]: p = 0.02) and cumulative fluid balance (− 2326 ml [− 3715; + 863] vs. + 143 ml [− 2654; + 4434]: p = 0.007) than those who developed WIPO. SBT-induced central hemodynamic changes were more pronounced in patients who developed WIPO, with higher E wave velocity (122 cm/s [92; 159] vs. 93 cm/s [74; 109]: p = 0.017) and E/A ratio (2.1 [1.2; 3.6] vs. 0.9 [0.8; 1.4]: p = 0.001), and shorter E wave deceleration time (85 ms [72; 125] vs. 147 ms [103; 175]: p = 0.004). After echocardiography-guided treatment, all patients who failed the first SBT were successfully extubated. Fluid balance was then negative (− 2224 ml [− 7056; + 100] vs. + 146 ml [− 2654; + 4434]: p = 0.005). Left ventricular filling pressures were lower (E/E′: 7.3 [5; 10.4] vs. 8.9 [5.9; 13.1]: p = 0.028); SBT-induced increase in E wave velocity (+ 10.6% [− 2.7/ + 18] vs. + 25.6% [+ 12.7/ + 49]: p = 0.037) and of mitral regurgitation area were significantly smaller.ConclusionIn high-risk patients, WIPO appears related to overloaded left ventricle associated with excessive fluid balance. SBT-induced central hemodynamic changes monitored by CCE help in guiding therapy for successful weaning.Electronic supplementary materialThe online version of this article (10.1007/s00134-020-06061-y) contains supplementary material, which is available to authorized users.

Predicting paravalvular leak after transcatheter mitral valve replacement using commercially available software modeling

BackgroundThere is limited data identifying patients at risk for significant mitral regurgitation (MR) after transcatheter mitral valve replacement (TMVR). We hypothesized that software modeling based on computed tomography angiography (CTA) can predict the risk of moderate or severe MR after TMVR. Methods58 consecutive patients underwent TMVR at two institutions, including 31 valve-in-valve, 16 valve-in-ring, and 11 valve-in-mitral annular calcification. 12 (20%) patients developed moderate or severe MR due to paravalvular leak (PVL). ResultsThe software model correctly predicted 8 (67%) patients with significant PVL, resulting in sensitivity of 67%, specificity 96%, positive predictive value 89%, and negative predictive value 86%. There was excellent agreement between CTA readers using software modeling to predict PVL (kappa 0.92; p < 0.01). On univariate analysis, CTA predictors of moderate or severe PVL included presence of a gap between the virtual valve and mitral annulus on the software model (OR 48; p < 0.01), mitral annular area (OR 1.02; p 0.01), and % valve oversizing (OR 0.9; p 0.01). On multivariate analysis, only presence of a gap on the software model remained significant (OR 36.8; p < 0.01). ConclusionsSoftware modeling using pre-procedural CTA is a straightforward method for predicting the risk of moderate and severe MR due to PVL after TMVR.

Left Vocal Cord Paralysis Secondary to Mitral Valve Disease

Introduction: Ortner’s syndrome, or cardio-vocal syndrome, is a clinical entity characterised by hoarseness (secondary to left-sided recurrent laryngeal nerve palsy) caused by cardiovascular disease. The incidence of Ortner’s syndrome ranges from 0.25 percent to 0.5 percent of all cases of recurrent laryngeal nerve paralysis. Case Report: A 44-year-old Malay gentleman presented with hoarseness and shortness of breath for 4 days. It was associated with mild orthopnea and aspiration symptoms. He denied history of dysphagia, chronic cough, sore throat, chest pain, palpitation and decreased effort tolerance. There was no history of hypertension, diabetes and asthma. He also gave no history of recurrent fever with sore throat during childhood. Results: On examination, the patient appeared tachypnoeic. There was no peripheral oedema, cyanosis or clubbing. His blood pressure was 100/60 mm Hg and his pulse was irregular with a rate of 78/min. Neck examination was normal. Apex beat was not displaced. On auscultation the first heart sound was loud. A grade 3/6 long rumbling diastolic murmur was heard at the mitral area and he had bilateral basal crepitations. Laryngoscopy using 700 scope showed left vocal cord palsy in paramedian position with phonatory gap. Computed tomography (CT) of the thorax showed left atrial enlargement with prominent pulmonary veins. Echochardiography showed left atrial dilatation with thickened mitral valve. Left ventricular systolic function was good with ejection fraction of 70% and coronary angiogram showed normal coronary artery. A diagnosis of severe mitral stenosis with heart failure was made. Preoperatively the patient was stabilized and was referred for dental clearance. Then he underwent surgery for mitral and aortic valve replacement. Post-operatively patient recovered uneventfully. His hoarseness recovered completely after 3 months. Conclusion: Cardiovascular disease should be considered as a differential diagnosis in a patient with hoarseness.

Prevalence of mitral annular disjunction in patients with mitral valve prolapse and severe regurgitation.

Mitral annular disjunction (MAD) is routinely diagnosed by cardiac imaging, mostly by echocardiography, and shown to be a risk factor for ventricular arrhythmias. While MAD is associated with mitral valve (MV) prolapse (MVP), it is unknown which patients with MAD are at higher risk and which additional imaging features may help identify them. The value of cardiac computed tomography (CCT) for the diagnosis of MAD is unknown. Accordingly, we aimed to: (1) develop a standardized CCT approach to identify MAD in patients with MVP and severe mitral regurgitation (MR); (2) determine its prevalence and identify features that are associated with MAD in this population. We retrospectively studied 90 patients (age 63 ± 12years) with MVP and severe MR, who had pre-operative CCT (256-slice scanner) of sufficient quality for analysis. The presence and degree of MAD was assessed by rotating the view plane around the MV center to visualize disjunction along the annulus. Additionally, detailed measurements of MV apparatus and left heart chambers were performed. Univariate logistic regression analysis was performed to determine which parameters were associated with MAD. MAD was identified in 18 patients (20%), and it was typically located adjacent to a prolapsed or flail mitral leaflet scallop. Of these patients, 75% had maximum MAD distance > 4.8mm and 90% > 3.8mm. Female gender was most strongly associated with MAD (p = 0.04). Additionally, smaller end-diastolic mitral annulus area (p = 0.045) and longer posterior leaflet (p = 0.03) were associated with greater MAD. No association was seen between MAD and left ventricular size and function, left atrial size, and papillary muscle geometry. CCT can be used to readily detect MAD, by taking advantage of the 3D nature of this modality. A significant portion of MVP patients referred for mitral valve repair have MAD. The presence of MAD is associated with female gender, smaller annulus size and greater posterior leaflet length.

Factors responsible for left atrial clot formation in patients with mitral stenosis and normal sinus rhythm

Background: The objective of the study was to investigate the factors responsible for left atrial (LA) clot formation in patients with mitral valve stenosis in normal sinus rhythm.Methods: 79 patients (43 males and 36 females) were included in the study. 9 patients with mitral stenosis in normal sinus rhythm had LA clot or LA smoke in echocardiography included in Group A and rest of 70 patients in Group B. LA size, gradient across mitral valve and mitral valve surface area was studied and compared in patients with or without LA clot/smoke.Results: Mean LA size was 4.8 (±0.5) and 4.6 (±0.7) in group A and B respectively with (p=0.304) and mean valve gradient was 11.6 (±2.8) and 10.6 (±3.5) in group A and B respectively with (p=0.507), the difference was not significant in both. Mean mitral valve area was 1.01 (±0.3) and 1.12 (±0.5) in group A and B (p=0.36), the difference was not significant.Conclusions: Study concluded that there was no significant difference in LA size, valve gradient and mitral valve area in patients with or without LA clot having mitral valve stenosis in normal sinus rhythm. Patients with LA clot warrant measures to prevent thromboembolic episodes.

Mechanisms and predictors of ischemic mitral regurgitation at rest and on exertion in patients at early stage of myocardial infarction

Aim. Determination of the mechanisms and predictors of ischemic mitral regurgitation (IMR) at rest and on exertion in patients at early stage of myocardial infarction (MI).Material and methods. Seventy-seven patients with inferoposterior MI and 79 patients with anteroseptal apical MI were examined on the 7th day at rest and after exertion. We determined the degree of IMR (according to the PISA method), posteromedial and anterolateral papillary muscle (PM) displacement, closure height of the mitral valve (MV), systolic and diastolic mitral valve orifice area, volume of the left ventricle (LV), LV contractility index, deformation of the infarction regions, general LV deformation, deformation and systolic dyssinchrony of the PM.Results. IMR was more common in inferior MI (42% vs 28%). LV volumes in cases with anteroseptal apical MI and IMR were greater and LV deformation was less than in patients without IMR. In inferoposterior MI and IMR, differences were observed in the index of local contractility and function of the posteromedial PM. The differences in MI of both localizations and IMR compared with MI without IMR were the areas of the mitral orifice and dyssinchrony of the PM. The degree of IMR after exertion did not depend on the degree of IMR at rest. Predictors of IMR at rest in MI of both localizations were the apical displacement of MV closure and the area of the mitral orifice. In inferoposterior, posteromedial PM displacement, deformation of the infarcted areas, PM dyssinchrony were also predictors. In anteroseptal apical MI, the area of the mitral orifice was the predictor of IMR. Predictors of anteroseptal apical MI after physical exertion after inferior MI were mitral orifice areas, contractility index, displacement and deformation of the posteromedial PM. In anteroseptal apical MI, the IMR predictors were MV closure height and systolic area of mitral orifice.Conclusion. The study confirms the significance of changing the spatial orientation of the MV structures in MI of both localizations, impaired regional contractility in inferoposterior MI and LV volume in anteroseptal apical MI at early stage of the disease.

PRE- VS POST-PROCEDURE MITRAL VALVE AREA AND MEAN DIASTOLIC GRADIENT IN PATIENTS WITH SECONDARY MITRAL REGURGITATION UNDERGOING EDGE-TO-EDGE MITRAL VALVE REPAIR

The impact of transcatheter edge-to-edge mitral valve repair (TMVr) on post-procedure mitral valve orifice area(MVA) and mean diastolic gradient(MnG) in patients with secondary mitral regurgitation is not well defined. We aimed to investigate the impact of TMVr on MVA and MnG. We retrospectively

A Novel 3-Dimensional Approach for the Echocardiographic Evaluation of Mitral Valve Area After Repair for Degenerative Disease.

Currently available 2-dimensional (2D) echocardiographic methods for accurately assessing the mitral valve orifice area (MVA) after mitral valve repair (MVr) are limited due to its complex 3-dimensional (3D) geometry. We compared repaired MVAs obtained with commonly used 2D and 3D echocardiographic methods to a 3D orifice area (3DOA), which is a novel echocardiographic measurement and independent of geometric assumptions. Intraoperative 2D and 3D transesophageal echocardiography (TEE) images from 20 adult cardiac surgery patients who underwent MVr for mitral regurgitation obtained immediately after repair were retrospectively reviewed. MVAs obtained by pressure half-time (PHT), 2D planimetry (2DP), and 3D planimetry (3DP) were compared to those derived by 3DOA. MVAs (mean value ± standard deviation [SD]) after MVr were obtained by PHT (3 ± 0.6 cm), 2DP (3.58 ± 0.75 cm), 3D planimetry (3DP; 2.78 ± 0.74 cm), and 3DOA (2.32 ± 0.76 cm). MVAs obtained by the 3DOA method were significantly smaller compared to those obtained by PHT (mean difference, 0.68 cm; P = .0003), 2DP (mean difference, 1.26 cm; P < .0001), and 3DP (mean difference, 0.46 cm; P = .003). In addition, MVA defined as an area ≤1.5 cm was identified by 3DOA in 2 patients and by 3DP in 1 patient. Post-MVr MVAs obtained using the novel 3DOA method were significantly smaller than those obtained by conventional echocardiographic methods and may be consistent with a higher incidence of MVA reduction when compared to 2D techniques. Further studies are still needed to establish the clinical significance of 3D echocardiographic techniques used to measure MVA after MVr.

Quantification of rheumatic mitral stenosis severity with three dimensional vena contracta area

Rheumatic mitral stenosis is a real public health problem in developing countries. Assessment of the mitral valve area (MVA) is essential for the choice of the intervention time. Most of the evaluation parameters of rheumatic MS are derived of two-dimensional echocardiography (2D). Three-dimensional transthoracic echocardiography (3D) is commonly used in our daily practice today. The purpose of this study was to evaluate the value of the vena contracta area (VCA) to predict the severity of rheumatic MS by comparing 3D planimetry. Patients who were diagnosed with severe rheumatic MS with conventional methods (half-pressure, planimetry) by 2D transthoracic echocardiography (TTE), underwent 3D TTE assessment. The VCA of the mitral valve was measured at maximum opening, with measurement planimetry MVA by metre/cropping TTE 3D. We studied 92 patients (mean age: 42 years) with Rheumatic MS. 15% (14 cases) had a 3D mitral area smaller than the mitral area per vena contracta, 80% (73 cases) the mitral area per vena contracta was smaller than 3D and 5% (5 cas) SP was equal in the two methods. The results of our study provide evidence that the VCA of the 3D TTE mitral valve can be used routinely to detect the severity of mitral stenosis.

Factors predicting mitral restenosis after successful percutaneous mitral commissurotomy

Percutaneous mitral commissurotomy (PMC) is the alternative treatment of choice for mitral stenosis (MS). Its immediate and medium term results are comparable to those of surgical commissurotomy, however in the long term there is a risk of restenosis. The purpose of this study is to determine the factors predicting restenosis after PMC. 322 patients (66% women), average age: 35 ± 3 years (9–75 years) having a tight MS and treated by PMC with Inoué balloon. The anatomic aspect of the mitral apparatus before PMC has been studied according to the criteria of the Wilkins score with a concomitant study of the state of mitral commissures. The primary success of PMC is defined as follows: mitral area (MA) post-PMC > 1.5 cm 2 and gain in MA > 25% and mitral regurgitation (MR) ≤ grade 2. Mitral restenosis is defined as a MA < 1.5 cm 2 and/or loss > 50% of initial gain in MA. The rate of primary success of PMC was 86% and mean MA post PMC was 1.82 ± 0.33 cm 2 compared to MA pre-PMC of 1 ± 0.18 cm 2 ( P < 0.0001). Opening of two commissures has been observed in 74% of patients. After an average period of 62 ± 32 months, only 12% of patients had a dyspnea stage III-IV of NYHA, MA was 1.64 ± 0.3 cm 2 ( P < 0.001) and mitral restenosis happened in 47 patients (20%) after a period of 60.48 ± 27 months (22–124 months). The independent predictors of mitral restenosis after a successful PMC were: previous surgical commisurotomy, Wilkins score > 8, MA after PMC < 1.8 cm 2 and absence of bicommissural opening post PMC. A favorable anatomy of mitral apparatus and the optimisation of immediate result of PMC are the guaranty for the maintenance of good result in the long term.

Percutaneous mitral dilatation in pregnant women: Short-term results

Rheumatic mitral stenosis (MS) is one of the most common valvulopathies in north Africa. Among her circumstances of discovery,pregnancy. Percutaneous mitral dilatation (PMD) is currently the treatment of choice for tight MS. To describe the short-term results of PMD performed for pregnant women with tight MS. This is a retrospective study of 8 pregnant women with a tight MS hospitalized in our Cardiology Department between 2012 and 2018 for PMD. For each patient, clinical, echocardiographic(TTE), and hemodynamic data were analyzed before and after PMD. There were 8 patients with an average age of 28.5 years (from 25 to 37). Two patients were known to have a MS and had previous PMD. All patients consulted for NYHA stage III dyspnea. At the ECG: 6 were in sinus rhythm. TTE pre-dilatation showed: an average mitral surface area at 1.1 cm 2 ,the average transmitral gradient was on average 12.05 mmHg. There was a bi-commissure fusion of the mitral valve in 6 patients. Mitral insufficiency (MI) was: minimal in 2 cases and moderate in 1 case, 5 patients had pulmonary arterial hypertension with mean SPAP at 43.2 mmHg. The right cavities were dilated in two women. The result of PMD was satisfactory in all patients. MI worsened one grade in one patient, and two grades in another, while a MI was newly created in one case. A transition to atrial fibrillation was noted in 1 patient who was well tolerated. TTE control immediately after PMD in the catheterization room showed: an average mitral area of 1.9 cm 2 (1.4 to 2.4 cm 2 ) so an improvement of more than 50% in the initial mitral area. The average transmitral gradient became 4.67 mmHg. Both commissures were completely opened in 7 patients. Dyspnea became class I in one patient while the others became asymptomatic. All patients delivered at term. The newborns were all in good health. PMD is still the treatment of choice in pregnant women with symptomatic MS if the anatomy of the valve allows it.

Percutaneous balloon mitral valvuloplasty in pregnant patients with rheumatic mitral stenosis: A ten-year single-center experience

Rheumatic mitral Stenosis is a common issue in Tunisia causing significant morbidity and mortality. Women with severe mitral stenosis often do not tolerate cardiovascular demands of pregnancy despite medical therapy, with an urgent need to enhance mitral valve area by percutaneous balloon mitral valvuloplasty (BMV). To determine immediate and long-term maternal and fœtal outcomes after BMV during pregnancy. This was retrospective single center experience, analysing data from BMV registry from January 2008 to December 2018. During the study period, 40 pregnant women among a total of 461 patients (9%) underwent BMV for severe mitral stenosis. The mean age was 35 ± 5 years. The mean gestational age was 26 ± 8 weeks. The BMV was successful in 38 out of 40 patients (95%), achieving mitral area > 1.5 cm 2 with a drop in left atrial mean pressure from 30 ± 9 mmHg to 16 ± 5 mmHg. In all successful procedures, patients improved their NYHA status by at least one stage. There was no maternal mortality in our series. One procedure had to be abandoned because of failed septal puncture. One patient developed severe mitral regurgitation secondary to chordae rupture, and had as a consequence emergent valve replacement. Thirty-three patients had a normal delivery while seven patients underwent a caesarean section. We reported a single neonatal death 48 hours after delivery caused by preterm respiratory distress. The BMV permitted a clinical and hemodynamic improvement and allowed the pursuit of pregnancy until end of term in most of cases. On 57-month mean follow-up, there were 3 cases of mitral restenosis, all babies maintained normal growth and development. Percutaneous balloon mitral valvuloplasty was associated with low maternal and fœtal risk and should be considered as the treatment of choice in pregnant women with severe mitral stenosis.

P762 Preserved mitral apparatus dynamics predict the improvement of acute ischemic mitral regurgitation: four-dimensional quantitative echocardiographic study

Abstract Background We sought to evaluate the predictive value of acute stage mitral apparatus geometry and dynamics for the reduction of ischemic mitral regurgitation (IMR) in the remote phase after successful primary percutaneous coronary intervention (pPCI) by using real-time 3D-transthoracic echocardiography (3D-TTE). Methods We performed 2D and 3D-TTE in consecutive 44 first acute MI patients with more than mild IMR within 3 days after successful pPCI. 3DTTE of left ventricle (LV) volumes and mitral apparatus dynamics through the cardiac cycle were quantified offline. We compared the 3D geometric and dynamic parameters in the acute phase between 1)20 remained MR group and 2)24 improved MR group in 6-to-12 months after MI onset. Results Ejection fraction (EF) was preserved in the improved MR group compared to the remained MR group (49.0 ± 11.2 vs. 56.5 ± 7.0%, p = 0.013). Mitral valve annulus area, leaflet tenting length and papillary muscles spatial position had no significant difference between the two groups (all p &amp;gt; 0.05) throughout cardiac cycle. In contrast, mitral annulus saddle shape was preserved in the improved MR group than the remained MR group (p = 0.010) and annular area changed dynamically through early- to late-systole in the improved MR group (phasic p = 0.017) despite it was adynamic in remained MR group (phasic p = 0.201). Conclusions: IMR improvement in the remote phase after AMI associated with preserved EF, mitral annulus saddle shape and dynamics during systole in the acute phase of MI. 4D dynamics of the mitral apparatus can be clinically useful predictor of the improvement in acute IMR and may contribute to the clinical decision making including surgical or percutaneous intervention for IMR.

P1754 Regional left ventricular longitudinal myocardial dysfunction in mitral valve prolapse could be primary

Abstract Background Regional left ventricular dysfunction in patients with mitral valve prolapse (MVP) and normal ejection fraction has been described by different Authors, and recent data point to a dysfunction (prevalently longitudinal strain) of the myocardium of the LV base secondary to dilatation of the mitral annulus. Purpose To investigate degree and extent of regional LV dysfunction and its mechanisms in patients with MVP, severe regurgitation and normal global systolic function, compared to patients with equivalent degree of regurgitation but functional etiology (FMR). Methods Speckle-tracking echocardiography was performed in 30 controls (N), and in severe primary (MVP, n= 50) or functional (FMR, n= 20) mitral regurgitation, to measure global, regional and segmental longitudinal peak systolic strain (LPSS, %), and time delay of peak maximum strain (TTPd, ms, calculated as time to peak maximum strain - time of aortic valve closure). Maximum and minimum mitral annulus diameters and area were measured with 3D echo. We also evaluated as recommended: LV end-diastolic volume index (EDVi, ml/m2), ejection fraction (EF, %), and left atrial end-systolic volume index (LAESVi, ml/m2) with 2D echo; LV stroke volume index, and non-invasive pulmonary systolic (PSP, mmHg) and diastolic pressures (PDP), mmHg) with Doppler echo. Results Age, heart rate, BSA and systolic blood pressure were similar between groups. Atrial fibrillation was present in 34% of MVP and 71% of FMR patients. LV EF was normal in MVP and reduced in FMR (43 ± 14 % vs N, p&amp;lt;.001). LV EDVi (MVP: 77 ± 20 ml/m2; FMR: 107 ± 35, both p&amp;lt;.001 vs N) and LAESVi (MVP: 91 ± 26 ml/m2; FMR: 80 ± 30, both p&amp;lt;.001 vs N) were similarly increased (volume overload) in MVP and FMR, as were PSP (MVP: 42 ± 23 ml/m2; FMR: 52 ± 25, both p&amp;lt;.001 vs N) and PDP (MVP: 16 ± 6 ml/m2; MVP: 15 ± 5, both p&amp;lt;.001 vs N). In FMR, LPSS was reduced globally (-12.8 ± 3.3, p&amp;lt;.001 vs N and MVP) and similarly at LV base, papillary and apical levels. In contrast, in MVP global (-19.4 ± 3.7%) and apical (-23.4 ± 4.5%) LPSS were normal, whereas LV base (-12.3 ± 5.8%, p=.003 vs N) and papillary (-17.1 ± 4%, p=.024 vs N) LPSS were reduced; further, LPSS reduction was localized to the anterior (-16 ± 4, p=.028 vs N), lateral (-17 ± 5, p=.006 vs N) and posterior (-16 ± 6, p=.007 vs N) segments, and was associated with an increased TTPd in the same segments in MVP but not in FMR patients. At multivariate analysis, degree and localisation of regional myocardial dysfunction in patients with MVP was not related to the prolapsing scallop, dimension of the mitral annulus, degree of volume overload or pulmonary pressures, or stroke volume index. Conclusions In patients with MVP, severe regurgitation and normal EF, there is a specific dysfunction pattern of regional LV longitudinal function which appears to be primary and not dependent on the degree of preload increase, mitral annulus dilatation, or localization of the prolapsing scallop.