Mitral Valve Area Research Articles

Acute impact of transcatheter edge-to-edge repair for mitral regurgitation on left ventricular function

Abstract Introduction Transcatheter Edge-to-Edge repair (TEER) for the therapy of mitral valve regurgitation (MR) is an alternative to surgery for high risk patients. It is a minimal invasive procedure but the acute impact of the pre- and afterload decrease, due to the reduction of both MR and mitral valve area (MVA), on the left ventricle (LV) systolic function was never formally evaluated. Method Fifty patients with mixed MR etiologies from our TEER register with complete 3D datasets of the LV before and after TEER were included in this study. LV volumes and function, as evaluate by ejection fraction (LVEF), global longitudinal strain (LV-GLS) and global circumferential strain (LV-GCS), and the MR (3D vena contracta area, 3D VCA) were evaluated before and at the end of the therapy. Results The majority of patients suffered from secondary MR (54%), one TEER device was implanted in 64% and two in 36% of the population. TEER leads to a significant reduction of all the LV volume and function parameters excepted for the end-diastolic volume which increased non-significantly (Table 1). The decrease of the LVEF was linked to a decrease of both GLS and GCS in a multivariate analysis (r 0.85), the decrease of GCS having a higher influence (beta −0.606 vs −0.435). In the univariate linear analysis, the reduction of LVEF, GLS and GCS were inverse proportional to the LVEF before TEER and direct proportional to the reduction of the 3D VCA. LVEF decrease was also directly linked to MVA percental reduction. After multivariate evaluation, LVEF reduction kept linked to LVEF before TEER and VCA 3D reduction (r=0.51, p=0.001), GCS decrease only to VCA 3D reduction (r=0.371, P=0.08) and GLS diminution only to LVEF before TEER (r=0.313, p=0.027). Conclusion After TEER, left ventricular function reduction seems principally linked to the afterload increase (i.e. the MR reduction); the circumferential function and the left ventricles with the highest ejection fractions being apparently maximally impacted. Funding Acknowledgement Type of funding sources: None.

Long-term success in percutaneous valve commissurotomy – is Wilkins score over 9 a definitive limit?

Abstract Background Percutaneous valve commissurotomy (PMC) is an established treatment in patients with significative mitral stenosis (MS). Although rheumatic MS incidence has decreased in the last century, it remains a prevalent pathology worldwide. The Wilkins score (WS) is a reference in echocardiographic assessment of MS; a score ≤8 is considered a predictor of treatment success and score between 9 and 11 is a “grey zone” (WGZ) in which doubts persists regarding PMC success. Purpose To evaluate the early and long-term results of PMC in patients with rheumatic MS and to compare long-term events between patients with WS ≤8 and patients in WGZ. Methods We retrospectively analysed all patients between 1991 and 2008 with significative rheumatic MS undergoing PMC. Data were collected at baseline and during long-term follow-up. M ACE was defined as a composite of all-cause mortality, mitral valve re-intervention or cardiovascular hospitalization. Results In our cohort, 124 patients were included. Most were female (87%), mean age at the time of repair was 46±11 year-old and mean follow-up was 20±6 years. Before the procedure, 81% had WS ≤8 and 19% were in WGZ. Both groups had similar baseline characteristics, namely age at first intervention, NYHA class and follow-up time. All patients had preserved biventricular systolic function, 83% presented PH, mean transvalvular gradient (TVG) and mitral valve area (MVA) were 12.8 mmHg and 1.0 cm2, respectively. Most of the procedures were successful (91%) and without complications (94%). Mean MVA improvement was similar in both groups [0.9 cm2 in WS ≤8 and 0.8 cm2 in WGZ, t(102)=0.173, p=0.863]; there was also no significative difference in TVG and PASP reduction after PMC. During long-term follow-up, re-intervention and mortality occurred in 40% and 23% in WS ≤8 and in 50% and 29% in WGZ, respectively, and none of these differences was statistically significant (p=0.389 and p=0.544, respectively). Concerning time-to-event analysis, approximately 80% of patients kept uneventful and >90% alive after 10 years in both groups and no significant difference in M ACE events and all-cause mortality between WS ≤8 and WGZ was observed (Log Rank, p=0,419 and p=0.950, respectively). Conclusion PMC was safe and effective in clinically significant rheumatic MS in both WS ≤8 and WS 9–11, with similar MVA improvement. After 10 years, approximately 80% of patients were MACE-free and >90% alive in both groups. There was no difference in all-cause mortality and in a composite of all-cause death, mitral valve re-intervention or cardiovascular hospitalization concerning WS groups. Funding Acknowledgement Type of funding sources: None.

Determinants of exercise-induced pulmonary hypertension in rheumatic mitral stenosis: a study with exercise stress and speckle tracking echocardiography

Abstract Backgrounds Exercise stress echocardiography is helpful in assessing hemodynamic consequence of mitral stenosis (MS) and in guiding treatment. Exercised-induced pulmonary hypertension (PH) is result of severity of MS, but myocardial function of left ventricle and clinical factors can also have effect. Purpose We aimed to evaluate the associated factors with the pulmonary artery systolic pressure (PASP) in exercise stress echocardiography through 2D, Doppler, and speckle tracking imaging in patients with rheumatic MS. Methods A total of 164 patients with rheumatic MS underwent a graded, symptom-limited, supine bicycle exercise with echocardiography. After exclusion of patients who had very severe MS (valve area <1.0 cm2), a history of surgery or recent percutaneous mitral valvotomy, combined significant aortic valve dysfunction, left ventricular (LV) ejection fraction <50%, we analyzed 113 patients (77.6% female; mean age, 56±9 years). Echocardiographic parameters at rest, each stage (25 watt increment every 3 minutes), and peak exercise were obtained. Exercised induced PH was defined as present if PASP >60 mmHg at peak exercise. LV global longitudinal strain (LV-GLS) and left atrial (LA) strain were analyzed by software. The subjects were divided into 4 groups according to mean transmitral pressure gradient (MG) (15 mmHg) and PASP (60 mmHg) at peak exercise (Group 1, MG <15 mmHg and PASP <60 mmHg, n=29; Group 2, MG <15 mmHg and PASP ≥60 mmHg, n=9; Group 3, MG ≥15 mmHg and PASP <60 mmHg, n=23; Group 4, MG ≥15 mmHg and PASP ≥6 0mmHg, n=52). Results The mean mitral valve area was 1.30±0.23 cm2. PASP increased from 30.0±8.0 mmHg at rest to 61.0±14.8 mmHg at peak exercise, along with increase MG. 61 (53.9%) subjects had PASP>60 mmHg at peak exercise. Compared to group 1, group 2 had higher incidence of diabetes mellitus (DM) and significantly elevated PASP at baseline and impaired LV-GLS. However, there was no statical difference in LA strain between the two groups. In subjects with MG above 15 mmHg (Group 3 and 4), a similar trend was observed in occurrence of exercise-induced PH. On logistic multivariate regression, exercised induced PH was independently associated with female (HR: 5.35, 95% CI: 1.51–24.95; p=0.032), DM (HR: 10.05, 95% CI, 1.35–74.45; p=0.024), MG at peak exercise (HR: 1.17, 95% CI, 1.02–1.34; p=0.002), PASP at rest (HR: 1.17, 95% CI, 1.05–1.30; p=0.002), and LV-GLS (HR: 1.45, 95% CI, 1.09–1.91; p=0.009), but not with LA strain. The predictive value for exercised induced PH was highest when adding LV-GLS to the clinical factor (age, sex, DM) and echocardiographic parameters (Figure 1). Conclusions Exercised induced PH is affected by not only hemodynamic consequence of MS, but also myocardial function of left ventricle and clinical factors. Therefore, when determining the optimal timing of intervention based on exercise-induced PH in rheumatic MS patients, LV-GLS should be evaluated comprehensively along with MS characteristics. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): Yonsei University College of Medicine

Optimal CW-Doppler derived parameter for the diagnosis of iatrogenic mitral stenosis during transcatheter edge-to-edge repair for mitral regurgitation

Abstract Introduction Transcatheter Edge-to-Edge repair (TEER) for mitral regurgitation (MR) is a minimal invasive alternative to surgery for high risk patients. One of the principal disadvantage is the risk of creating a stenosis (MS). The optimal parameter and its cut-off to monitor mitral valve area (MVA) during TEER is currently not defined and usually only the mean transmitral gradient (Gd) is used. Method 116 patients with complete 3D MVA measurements and CW-Doppler derived mean and maximal diastolic transmitral Gd, and pressure half time (PHT) before the intervention and after each TEER device implantation were included in this study. A clinically significant MS was defined as a 3D MVA <1.5 cm2 according to the ESC guidelines. Because the mean Gd is known to be extremely dependent on the heart rate (HR) this parameter was “normalized” for a frequency of 60/min: norm. mean Gd = (mean Gd/HR) × 60. The accuracy of the different CW-derived parameters to diagnose or predict a MS was evaluated using a ROC analysis. Results 47% of the patients suffered from a secondary MR, 53% were treated with one device and 47% with two. According to the 3D MVA measurements, after one device 16 and after two devices 12 patients had a clinically significant MS. The ROC analyses for the diagnosis of a significant MS after one device (Figure 1) show a maximal AUC of 0.99 for PHT with an optimal cut-off of 151ms (sensitivity 94%, specificity 95%), followed by norm. mean Gd (AUC 0.96, 3.16mmHg, 100%, 82%), mean Gd (AUC 0.92, 3.6mmHg, 88%, 83%) and max. Gd (AUC 0.92, 8.5mmHg, 94%, 83%). Combining three different cut-offs (PHT 164ms or norm. mean Gd 4.7mmHg or max. Gd 12mmHg) a sensitivity of 100% and a specificity of 98% was achieved. The prognostic value of these same parameters to predict a MS after two devices was much less optimal according to the ROC analyses: PHT, AUC 0.82, 100ms, 83%, 59%; norm. mean Gd AUC 0.73, 2.8mmHg, 67%, 81%; mean Gd AUC 0.70, 2.4mmHg, 83%, 51%; max. Gd AUC 0.69, 8.4mmHg, 50%, 85%. The diagnostic value of the CW-derived parameters measured after the implantation of two devices to detect a MS was better (Figure 2): PHT, AUC 0.92, 142ms, 92%, 78%; norm. mean Gd, AUC 0.87, 3.4mmHg, 92%, 73%; mean Gd, AUC 0.81, 3.9mmHg, 92%, 71%; max. Gd AUC 0.74, 8.6mmHg, 83%, 66%. The cut-offs for PHT without false negative and with the maximal specificity were: 140ms (specificity 86%) to diagnose a MS after one device, 93ms (specificity 56%) to predict a MS after a second device implantation and 133ms (specificity 63%) to detect a MS after two devices. Conclusion PHT is the most accurate CW-derived parameter to diagnose or make a prognostic of clinically significant mitral stenosis after TEER. Given the possible disastrous consequence of a iatrogenic stenosis, these parameters should only be used with cut-offs offering a sensitivity of 100% and when a value above these limits is measured, then decisions should be based of 3D MVA measurements. Funding Acknowledgement Type of funding sources: None.

Long-term prognostic impact of pulmonary vascular resistance in patients with rheumatic mitral stenosis undergoing percutaneous mitral balloon valvuloplasty

Abstract Background Pulmonary hypertension (PH) has a well-known impact on the prognosis of patients with rheumatic mitral stenosis (MS). Some patients can present pre-capillary PH, defined as a pulmonary vascular resistance (PVR) ≥3.0 woods, and there is few data regarding the prognostic value of invasive measures of PVR in this context. Purpose To assess the impact of PVR on the long-term outcomes of patients with rheumatic MS undergoing percutaneous mitral balloon valvuloplasty (PMBV). Methods Unicentric, retrospective study, including patients with rheumatic MS undergoing PMBV from 2016 to 2020. All patients underwent clinical and laboratorial evaluation, and transthoracic echocardiogram before and after the procedure. During PMBV, transesophageal echocardiogram and hemodynamic measures were performed. The composite endpoint included death, reintervention and persistent NYHA FC III–IV in long-term follow-up. Results 58 patients were included with a median age of 50.5 [42–60.5] years and 82.8% were female. Most important comorbidities were hypertension (55.2%), previous valvular intervention (22.4%), diabetes (20.7%), atrial fibrillation (18%), previous stroke/transient ischemic attack (3.4%), coronary artery disease (1.7%). Median mitral valve area was 1.2 [0.9–1.3] cm2, mean transmitral gradient was 8 [6–12] mmHg and pulmonary artery systolic pressure (PASP) was 42 [35–51] mmHg. Pre-procedure hemodynamic right atrium pressure (RAP) was 8 [6–10] mmHg, pulmonary artery mean pressure (mPAP) was 26 [21–31] mmHg, pulmonary capillary pressure (PCP) was 18 [15–22] mmHg and PVR was 2.15 [1.5–3.46] mmHg/min. Thirty-five (60.3%) patients underwent 1 balloon dilation, 10 (17.2%) 2 dilations, 3 (5.3%) 3 dilations and 1 (1.7%) 4 dilations. Only 1 (1.7%) case need conversion to open surgery. Post-procedure hemodynamic Δ mPAP was 4 [1–8] mmHg, Δ PCP was 5 [2–7] mmHg and Δ PVR was 0.03 [−0.072–0.99] mmHg/min. Median follow-up was 32.9 [20.2–43] months. Need for reintervention (surgery or PMBV) was 6.9%, mortality during follow-up was 1.7% and the composite endpoint occurred in 13 (22.4%) patients. By univariate analysis, echocardiographic PSAP (HR: 1.069, 95% CI 1.010–1.130, p=0.021), RAP (HR: 1.267, 95% CI 1.028–1.562, p=0.027), Δ hemodynamic PASP (HR: 0.927, 95% CI 0.866–0.991, p=0.026) and moderate or severe tricuspid regurgitation (HR: 6.318, 95% CI 1.734–23.023, p=0.005) were associated with the composite endpoint. By multivariate analysis adjusted by RVP, RAP (HR: 1.626, 95% CI 1.005–2.630, p=0.047) was the only independent predictor of the composite endpoint. The RAP cutoff found through the Youden index was 9.5 mmhg (Figure 1). Conclusion In patients with severe MS undergoing PMBV, RAP measurement in cardiac catheterization was the only independent predictor of combined outcome of death, reintervention and persistent NYHA FC III–IV in long-term follow-up. PVR had no impact on long-term outcomes. Funding Acknowledgement Type of funding sources: None.

Does Chronic Inflammation Play a Role in Rheumatic Mitral Valve Restenosis after Percutaneous Transvenous Mitral Commissurotomy?

ABSTRACT
 Background: Mitral valve restenosis is defined as decreased mitral valve area (MVA) <1.5 cm2 or decreased MVA >50% after PTMC. It is time-dependent and associated with major adverse cardiovascular events (MACE), such as congestive heart failure, cardiac death, mitral valve replacement, and redo PTMC. The mechanism is not yet known; however, chronic inflammation may have a role. Objective: To know the association between chronic inflammation and mitral valve restenosis after PTMC. Methods: A total of 40 patients with mitral valve stenosis who underwent successful PTMC were matched and classified into restenosis/case group (n=20) and no restenosis/control group (n=20). Secondary data was taken from electronic medical records such as patient characteristics (gender, age & 2nd prophylaxis), echocardiography data before PTMC (Wilkins’ score and MVA before PTMC), and echocardiography data after PTMC (MVA after PTMC). Follow-up echocardiography examination (follow-up MVA) and laboratory assessment of chronic inflammation marker (IL-6) were done on all patients. Statistical analyses were done to look for an association between the level of chronic inflammation marker & other independent variables with mitral valve restenosis. Results: Median IL-6 concentration was 2.39 (0.03 – 11.4) pg/mL. There was no statistically significant difference in IL-6 levels between both groups (p-value >0.05). MVA decrement was 0.13 (0 – 0.62) cm2/year with rate of MVA decrement ≥0.155 cm2/year was predictor of mitral valve restenosis (p-value <0.001, OR = 46.72, 95% CI 6.69 – 326.19). Conclusion: Chronic inflammation assessed by IL-6 was not associated with mitral valve restenosis.

Evaluation of the impact of successful percutaneous balloon mitral valvuloplasty on the left ventricular twist and untwist mechanics by the two dimensional speckle tracking imaging

Background: MS is one of the most prevalent valve abnormalities in people with chronic rheumatic heart disease (RHD). The effect of Inoue and multi-track successful percutaneous balloon mitral valvuloplasty (PBMV) on the twist and untwist mechanisms of the left ventricle was evaluated using non-invasive two-dimensional speckle tracking imaging (STI). Methods: This study was conducted on patients with mitral stenosis of rheumatic origin fulfilling the criteria for PBMV. Cases were categorized into two equal groups; group 1: 30 Patients underwent PBMV using Inoue technique and group 2: 30 Patients underwent PBMV using multi-track technique. All patients were subjected to full history and clinical examination, twelve leads surface electrocardiogram (ECG) before and after the procedure, two-dimensional and Doppler echocardiography, LV twist and untwist measured by the 2D the two-dimensional speckle tracking imaging (STI) before and after the procedure and PBMV. Results: In both techniques; the mitral valve area (MVA) was highly significantly increased after balloon mitral valvuloplasty (BMV), while mean pressure gradient (MPG) and the estimated systolic pulmonary artery pressure (PAP) were highly significantly decreased. The apical rotation, basal rotation, twist and untwist were highly significantly decreased after the procedure in each technique.

Rivaroxaban in Rheumatic Heart Disease–Associated Atrial Fibrillation

BackgroundTesting of factor Xa inhibitors for the prevention of cardiovascular events in patients with rheumatic heart disease–associated atrial fibrillation has been limited.MethodsWe enrolled patients with atrial fibrillation and echocardiographically documented rheumatic heart disease who had any of the following: a CHA2DS2VASc score of at least 2 (on a scale from 0 to 9, with higher scores indicating a higher risk of stroke), a mitral-valve area of no more than 2 cm2, left atrial spontaneous echo contrast, or left atrial thrombus. Patients were randomly assigned to receive standard doses of rivaroxaban or dose-adjusted vitamin K antagonist. The primary efficacy outcome was a composite of stroke, systemic embolism, myocardial infarction, or death from vascular (cardiac or noncardiac) or unknown causes. We hypothesized that rivaroxaban therapy would be noninferior to vitamin K antagonist therapy. The primary safety outcome was major bleeding according to the International Society of Thrombosis and Hemostasis.ResultsOf 4565 enrolled patients, 4531 were included in the final analysis. The mean age of the patients was 50.5 years, and 72.3% were women. Permanent discontinuation of trial medication was more common with rivaroxaban than with vitamin K antagonist therapy at all visits. In the intention-to-treat analysis, 560 patients in the rivaroxaban group and 446 in the vitamin K antagonist group had a primary-outcome event. Survival curves were nonproportional. The restricted mean survival time was 1599 days in the rivaroxaban group and 1675 days in the vitamin K antagonist group (difference, −76 days; 95% confidence interval [CI], −121 to −31; P<0.001). A higher incidence of death occurred in the rivaroxaban group than in the vitamin K antagonist group (restricted mean survival time, 1608 days vs. 1680 days; difference, −72 days; 95% CI, −117 to −28). No significant between-group difference in the rate of major bleeding was noted.ConclusionsAmong patients with rheumatic heart disease–associated atrial fibrillation, vitamin K antagonist therapy led to a lower rate of a composite of cardiovascular events or death than rivaroxaban therapy, without a higher rate of bleeding. (Funded by Bayer; INVICTUS ClinicalTrials.gov number, NCT02832544.)

Reference Values and Repeatability of Pulsed Wave Doppler Echocardiography Parameters in Normal Donkeys.

Simple SummaryCardiovascular disease is underreported in donkeys, possibly related to their limited athletic posture and frequent poor performance-related examinations. Reports on treatments for cardiovascular disease are anecdotal in donkey. Normal echocardiographic parameters have been reported in healthy donkeys. The aim of the present study was to establish the reference values and repeatability for Pulsed Wave Doppler echocardiographic variables of the mitral valve, aortic valve and myocardial performance. Two-dimensional Color flow mapping and spectral Doppler modes were performed. For the mitral valve, the mean velocity, pressure gradient and duration of E-wave were 57.7 ± 12.5 cm/s, 1.4 ± 0.7 mmHg and 0.4 ± 0.13 s, respectively. The results of the present study provide the reference values of PW echocardiographic parameters measurements in normal adult donkeys. Such reference values are helpful, especially when confronted with clinical cases with cardiovascular disorders.In the present study, thirty clinically healthy donkeys were used to establish the reference values and repeatability for Pulsed Wave Doppler echocardiographic variables of the mitral valve, aortic valve and myocardial performance. 2-dimensional Color flow mapping and spectral Doppler modes were performed. For the mitral valve, the mean velocity, pressure gradient and duration of E-wave were 57.7 ± 12.5 cm/s, 1.4 ± 0.7 mmHg and 0.4 ± 0.13 s, respectively. The velocity, pressure gradient and duration of the A-wave were 32.3 ± 9.1 cm/s, 0.3 ± 0.04 mmHg and 0.3 ± 0.1 s, respectively. The mitral valve area, pressure half time, pulsatility index (PI), resistance index (RI) and velocity time integral (VTI) were 1.8 ± 0.5 cm2, 66 ± 17 ms, 2.8 ± 1.4, 0.9 ± 0.03 and 19.1 ± 5.7 cm, respectively. For the aortic valve, the mean velocity was 64.9 ± 10.4 cm/s, pressure gradient was 1.8 ± 0.4 mmHg, pulsatility index was 1.4 ± 0.3, resistance index was 0.9 ± 0.02, VTI was 25.02 ± 6.2 cm, systolic/diastolic was 19 ± 4.7 and heart rate was 95.7 ± 28.9 per minute. For Myocardial Performance Index (LV)–Tei Index, the mean ejection, isovolumic relaxation, isovolumic contraction time and myocardial performance index were 0.24 ± 0.01, 0.14 ± 0.01, 0.14 ± 0.02 and 1.2 ± 0.1 s, respectively. The results of the present study provide the reference values of PW echocardiographic parameter measurements in normal adult donkeys. Such reference values are helpful, especially when confronted with clinical cases with cardiovascular disorders.

Effect of transcatheter edge-to-edge repair device position on diastolic hemodynamic parameters: An echocardiography-based simulation study.

BackgroundTranscatheter edge-to-edge repair (TEER) has developed from innovative technology to an established treatment strategy of mitral regurgitation (MR). The risk of iatrogenic mitral stenosis after TEER is, however, a critical factor in the conflict of interest between maximal reduction of MR and minimal impairment of left ventricular filling. We aim to investigate systematically the impact of device position on the post treatment hemodynamic outcome by involving the patient-specific segmentation of the diseased mitral valve.Materials and methodsTransesophageal echocardiographic image data of ten patients with severe MR (age: 57 ± 8 years, 20% female) were segmented and virtually treated with TEER at three positions by using a position based dynamics approach. Pre- and post-interventional patient geometries were preprocessed for computational fluid dynamics (CFD) and simulated at peak-diastole with patient-specific blood flow boundary conditions. Simulations were performed with boundary conditions mimicking rest and stress. The simulation results were compared with clinical data acquired for a cohort of 21 symptomatic MR patients (age: 79 ± 6 years, 43% female) treated with TEER.ResultsVirtual TEER reduces the mitral valve area (MVA) from 7.5 ± 1.6 to 2.6 ± 0.6 cm2. Central device positioning resulted in a 14% smaller MVA than eccentric device positions. Furthermore, residual MVA is better predictable for central than for eccentric device positions (R2 = 0.81 vs. R2 = 0.49). The MVA reduction led to significantly higher maximal diastolic velocities (pre: 0.9 ± 0.2 m/s, post: 2.0 ± 0.5 m/s) and pressure gradients (pre: 1.5 ± 0.6 mmHg, post: 16.3 ± 9 mmHg) in spite of a mean flow rate reduction by 23% due to reduced MR after the treatment. On average, velocities were 12% and pressure gradients were 25% higher with devices in central compared to lateral or medial positions.ConclusionVirtual TEER treatment combined with CFD is a promising tool for predicting individual morphometric and hemodynamic outcomes. Such a tool can potentially be used to support clinical decision making, procedure planning, and risk estimation to prevent post-procedural iatrogenic mitral stenosis.

Aortic valve stenosis associated with valvular heterotopic ossification with extramedullary haematopoiesis in a horse

SummaryThis report describes a case of functional aortic stenosis with heterotopic ossification in the aortic valve of a 20‐year‐old Thoroughbred mare. The aortic valve pathology was associated with aortic outflow obstruction, dilation of the left ventricle and left atrial enlargement ultimately leading to pulmonary hypertension and clinical signs of right‐sided heart failure. Histopathological examination demonstrated the presence of haemopoietic cells within the calcified aortic valve leaflets, which is a rare finding, and revealed myxomatous degenerative changes in the mitral valve and multifocal areas of fibrous tissue within the myocardium. There is marked similarity between this case and the human condition of calcific aortic valvular disease (CAVD), which is the most common reason for valve replacement surgery. In this case, we report the clinical and pathological features in this first reported case of equine aortic valve stenosis.

Multiperspective Three-Dimensional Transthoracic Echocardiographic Assessment of Mitral Valve Area in Patients With Rheumatic Mitral Stenosis

Rheumatic mitral stenosis (MS) remains common in low- and middle-income countries with significant morbidity and mortality.1,2 Echocardiographic planimetry of the mitral valve (MV) area (MVA) correlates with anatomic MVA of explanted valves better than MVA estimated by other methods.3 Three-dimensional (3D) echocardiography provides better alignment of the imaging plane at the mitral leaflet tips, yielding a more accurate planimetric measurement of the MVA.4

Closed Mitral Valvotomy Reenvision.

In developing countries, like the Indian subcontinent, population overload, malnutrition, poor socio-economic status of affected groups, and health care facilities affect the treatment outcome. Nowadays procedures such as percutaneous balloon mitral valvotomy (PBMV) and open heart mitral valve replacement are offered to patients with mitral stenosis. Whenever PBMV is unavailable due to financial constraints and open surgical management cannot be offered due to overburdened healthcare facilities, closed mitral valvotomy (CMV) provides an excellent choice for patients with favorable mitral valve pathology. Many centers do not practice CMV and thus this procedure is dying out. The young generation of surgeons are not been trained in CMV. The purpose of our study is to reenvision CMV and emphasize its vital role in mitral stenosis patient subsets like pregnant women and young adults. We reviewed the literature for various valvotomy techniques done for mitral valve stenosis and restenosis. Immediate and late outcomes were compared between the patients receiving Percutaneous balloon mitral valvotomy and closed mitral valvotomy.The immediate and late-term results are comparable for PBMV and CMV and no statistically significant difference exists. The post-PBMV Mitral valve area (MVA) ranged from 2.1 +/- 0.7 cm^2 to 2.3 +/-0.94 cm^2 and post CMV MVA ranged from 1.3+/-0.3 cm^2 to 2.2+/-0.85 cm^2. Complications developing in both techniques are also nearly similar. Operative mortality in CMV patients ranged from 1% to 4.2%, also observed in PBMV patients in various studies. Mitral Regurgitation occurred in both groups equally and ranged from 0.3% to 14%. Restenosis was observed in both groups in the range of 4% to 5%. High fetal loss of around 20% mortality was witnessed in pregnant mitral stenosis patients undergoing open heart surgery.It's time to re-envision CMV since it is providing substantial outcomes and remitting the need for open-heart surgery at a very low cost in patients with mitral stenosis with a pliable valve.

Clinical and Echocardiographic Predictor of Atrial Fibrillation in Patient with Rheumatic Mitral Valve Disease

Background: Rheumatic fever principally influences kids in developing states, particularly where deficiency is common. Atrial fibrosis is a mutual characteristic of clinical atrial fibrillation (AF) and is accompanying with AF in a diversity of experiment sittings,&#x0D; Aim and Objectives: The current work aimed to assess whether there are any clinical or echo-cardiographic parameters that expect the existence of AF among cases with rheumatic mitral valve disorder (RMVD),&#x0D; Subjects and Methods: The current study was a comparative cross-sectional was conducted on 100 RMVD cases at cardio-vascular medicine department Tanta university hospitals within 6-mths starting from September 2019. Cases have been allocated into 2 groups: Group-I: 50 cases with sinus rhythm. Group-II: 50 cases with AF,&#x0D; Results: A significant change was found among study groups regarding Fibrosis characteristics, There is a highly significant difference between the three different types regarding mitral valve area (MVA), LA-diameter, LA volume, LA-diameter/BSA and LA volume index, Age, area of mitral valve, LA-diameter and LA volume were found to be significant predictors for AF,&#x0D; Conclusion: Echo-cardiography factors could recognize cases at higher danger of advancing AF among RMVD cases who may benefit from preventive measures.

Clinical and Hemodynamic Factors Associated with Low Gradient Severe Rheumatic Mitral Stenosis.

Discrepancy between narrowed mitral valve area and transmitral gradient is not uncommon, suggesting the presence of low gradient (LG)-severe mitral stenosis (MS). Some clinical and hemodynamic factors are believed to associate with LG-severe MS. Transthoracic echocardiography reports were reviewed retrospectively to evaluate the association of all clinical and hemodynamic parameters with LG-severe MS. A 36% of total 322 patients was in the LG-severe MS group. In multivariate analysis, atrial fibrillation (95% confidence interval [CI] 4.60-16.71, odds ratio [OR] 8.77), net atrioventricular compliance > 4 mL/mm Hg (95% CI 3.96-14.25, OR 7.51), tricuspid regurgitation maximal velocity (TR Vmax) > 3.4 m/s (95% CI 0.13-0.48, OR 0.25), stroke volume index ≤ 35 mL/m 2 (95% CI 1.49-6.25, OR 3.05), female gender (95% CI 1.30-5.33, OR 2.63), and severe tricuspid regurgitation (95% CI 1.04-5.50, OR 2.39) were found to be associated with LG-severe MS. Atrial fibrillation, net atrioventricular compliance, TR Vmax, stroke volume index, female gender, and severe TR were associated with low transmitral gradient in patients with severe MS.

Imaging of Mitral Valve Area by Cardiac Magnetic Resonance in Patients with Rheumatic Mitral Stenosis

Background: Rheumatic heart disease which is a result of rheumatic fever is still a major health problem in developing countries. Rheumatic mitral stenosis (MS) is the commonest delayed valvular affection as a consequence of rheumatic fever. The assessment of MS severity by measuring mitral valve area (MVA) is very essential for patient management. Different imaging modalities are available for MVA assessment including echocardiography and cardiovascular magnetic resonance (CMR). Objectives: The aim of this study is to compare the planimetric MVA between CMR and two dimensional echocardiography in MS patients. Patients and methods: A forty adult patients with symptomatic mitral stenosis were included in the study. Other significant valvular lesions, atrial fibrillation, poor echocardiographic window, contraindications to CMR, and NYHA IV were excluded from the study. All patients were assessed by 2D echocardiography and CMR for MVA measurement. Results: The mean 2D TTE MVA was 1.2±0.26 cm2 , while the mean CMR MVA 1.2±0.28 cm2 . No significant statistical difference was found between both methods (P value 0.842) with a very strong correlation between both methods (r = 0.93 and p-value &lt; 0.0001). The mean difference of MVA between the two methods was 0.012 cm2 . Conclusion: CMR is a non-invasive imaging modality that provides MVA measurement and is a reliable method in the diagnosis of MS patients.

EFFICACY AND IMMEDIATE OUTCOMES OF PERCUTANEOUS BALLOON MITRAL VALVULOPLASTY IN SEVERE RHEUMATIC MITRAL STENOSIS

Objectives: To assess the frequency of successful Percutaneous Balloon Mitral Valvuloplasty (PBMV) and immediate post-procedure outcomes in patients with severe rheumatic mitral stenosis (SRMS). Methodology: This descriptive cross-sectional study was conducted at the Department of Cardiology at a tertiary care hospital, from 1st January 2018 to 31st December 2019. According to inclusion criteria, 200 patients with severe symptomatic mitral stenosis (SSMS) were recruited in the study, and written informed permission was acquired from patients or next of kin. Pre- and post-PBMV mitral valve area (MVA) and hemodynamics were recorded. Data were retrieved from the hospital chart record and collected on a pre-designed proforma. Results: In 176 (88%, n=200) patients mean MVA following PBMV increased from 0.93±0.31 cm2 to 1.73±0.16 cm2 (p ˂0.05) and mean pulmonary artery systolic pressure (PASP) reduced from 56.62 mmHg ± 16.02 to 30.37±7.30 mmHg (p&lt;0.05). Perioperative complications included severe mitral regurgitation (MR) in 2 (1%, n=200), moderate MR in 40 (20%, n=200), thromboembolic cerebrovascular accident in 1 (0.5%, n=200), pericardial effusion in 4 (2%, n=200), and new-onset atrial fibrillation in11 (5.5%, n=200), however, there was no mortality related to the procedure. Conclusion: PBMV was effective with reasonable immediate post-procedure outcomes in 88% of patients. However, efficacy can be increased by selecting patients with favourable valve morphology for PBMV.

Maternal and Fetal Outcomes Following Percutaneous Transluminal Mitral Commissurotomy in Pregnant Women with Critical Mitral Stenosis: An Experience of a Tertiary Care Center from Northern India.

Background:Rheumatic mitral stenosis is the common valvular heart disease seen during pregnancy. Percutaneous transvenous mitral commissurotomy is an effective, safe, and recommended treatment for critical mitral stenosis during pregnancy. We hereby report the maternal and fetal outcomes of pregnant women subjected to percutaneous transvenous mitral commissurotomy at our institute. Methods:Seventy consecutive pregnant women with critical mitral stenosis, who underwent PTMC during the last 10 years, were retrospectively analyzed. All patients had a detailed clinical and obstetric evaluation and were optimally managed with drugs, before the intervention. A comprehensive pre- and post-percutaneous transvenous mitral commissurotomy transthoracic echocardiographic evaluation was performed. Detailed obstetric and fetal outcomes were noted at the time of delivery. Six weeks of post-­partum follow-up was noted in all patients. Results:The mean gestational age at the time of percutaneous transvenous mitral commissurotomy was 29.5 ± 6.68 weeks. Percutaneous transvenous mitral commissurotomy was successful in 97% of patients. Post-percutaneous transvenous mitral commissurotomy New York Heart Association functional class, mitral valve area, trans-mitral pressure gradient, and left atrial pressure had a significant improvement (P < .001). The mean gestational age at the time of delivery was 36.92 ± 3.02 weeks. The mean birth weight of live newborn was 2.29 ± 0.55 kg. The fetal complications include growth restriction in 62.85%, preterm delivery in 34.37%, and low birth weight in 67.21%. A delayed percutaneous transvenous mitral commissurotomy at about 30 weeks of gestation did not affect the maternal and fetal outcomes. Conclusion:Percutaneous transvenous mitral commissurotomy is safe and efficacious in managing pregnant women with critical mitral stenosis. There was a significant improvement in clinical symptoms and echocardiographic parameters following percutaneous transvenous mitral commissurotomy.

Percutaneous transluminal mitral valve commissurotomy Via Veno-Arterial loop method.

Background: Since its inception in 1984 by Inoue and colleagues, percutaneous trans venous mitral commissurotomy (PTMC) is the first line treatment option for severe mitral stenosis with favorable valve morphology. Critical mitral stenosis can however pose a challenge for balloon crossing to the left ventricle. Various techniques have been demonstrated to overcome this difficulty. We use a novel technique to cross mitral valve.&#x0D; Case Presentation: We describe a case where critical stenosis of rheumatic mitral valve in a young lady which was not amenable to conventional PTMC procedure, was successfully performed via veno-arterial rail method.&#x0D; Management &amp; Results: After crossing the interatrial septum, mitral valve was tried to cross with the standard technique using Inoue balloon, but failed because the stenosis was very tight. So we have crossed mitral valve through exchanged length terumo wire which was snared in descending aorta and externalized through right femoral artery and then we were able to pass the balloon through the tight mitral valve and the procedure was completed without any complication. Post procedure the pressure gradient dropped to 4mmHg and the mitral valve area was recorded as 1.8cm 2 with 2D echo planimetry.&#x0D; Conclusion: In difficult to cross MV during PTMC, the veno-arterial rail method can be used easily for a successful procedure.

Invasive Hemodynamic Predictors of Survival in Patients With Mitral Stenosis Secondary to Mitral Annular Calcification

BackgroundThe aim of this study was to establish prognostic hemodynamic parameters in patients with mitral stenosis secondary to mitral annular calcification.Methods and ResultsA retrospective cohort of 105 patients undergoing transseptal catheterization for hemodynamic evaluation of mitral annular calcification–related mitral stenosis between 2004 and 2020 was studied. Mitral valve gradient (MVG) and mitral valve area (MVA; calculated by the Gorlin formula) were measured using direct left atrial and left ventricular pressures. The median age of the patients was 70.3 years (58.4–76.7 years), and 53.3% were women. The median MVA was 1.7 cm2 (1.3–2.3 cm2) and MVG was 7.3 mm Hg (5.3–10.3 mm Hg); left ventricular end‐diastolic pressure was 17.6±28.3 mm Hg. During a median of 2.1 years (0.7–4.5 years), there were 63 deaths; 1‐ and 5‐year survival were 76% and 40%, respectively. There was no association between left ventricular end‐diastolic pressure and survival. After adjusting for age and comorbidities, both MVA (hazard ratio [HR], 0.50 per cm2; 95% CI, 0.34–0.73) and MVG (HR, 1.1 per mm Hg; 95% CI, 1.05–1.20) were independent predictors of death. Atrial fibrillation was also independently associated with mortality. When added to a combined model, MVA remained associated with death (HR, 0.51 per cm2; 95% CI, 0.33–0.79) while MVG was not.ConclusionsIn patients with mitral annular calcification–related mitral stenosis, survival was poor. MVA and MVG were independently associated with death, but MVA was a better predictor of outcomes.