Mitral Valve Effective Orifice Area Research Articles

Non-invasive evaluation of pulmonary capillary wedge pressure using the left atrial expansion index in mitral valve stenosis, prosthesis and repair.

Pulmonary capillary wedge pressure (PCWP) non-invasive evaluation is limited in patients with mitral valve (MV) stenosis, prosthesis, and surgical repair. This study aimed to assess the left atrial expansion index (LAEI) measured through transthoracic echocardiography (TTE) as a novel parameter for estimating PCWP in these challenging cardiac conditions. We performed a retrospective, cross-sectional study, including chronic cardiac patients receiving within 24h a clinically indicated right heart catheterization (RHC) and transthoracic echocardiographic (TTE) exam. PCWP measured during RHC was used as the reference. TTE measurements were performed offline, blinded to RHC results. LAEI was calculated as LAEI = [(LAmaxVolume-LAminVolume)/LAminVolume] × 100. We included 167 patients (age = 73 ± 11.5years; PCWP = 18 ± 7.7mmHg) with rheumatic mitral valve (MV) stenosis (16.2%), degenerative MV stenosis (51.2%), MV prosthesis (18.0%), and MV surgical repair (13.8%). LAEI correlated logarithmically with PCWP, and the log-transformed LAEI (lnLAEI) showed a good linear association with PCWP (r = -0.616; p < 0.001). lnLAEI was an independent PCWP determinant, providing added predictive value over conventional clinical (age, atrial fibrillation, heart rate, MV subgroups) and echocardiographic variables (LVEF, MV effective orifice area, MV mean gradient, net atrioventricular compliance, and pulmonary arterial systolic pressure). lnLAEI identified PCWP > 12mmHg with AUC = 0.870, p < 0.001; and PCWP > 15mmHg with AUC = 0.797, p < 0.001, with an optimal cut-off of lnLAEI < 3.69. The derived equation PCWP = 36.8-5.5xlnLAEI estimated the invasively measured PCWP ± 6.1mmHg. In this cohort of patients with MV stenosis, prosthesis, and surgical repair, lnLAEI resulted in a helpful echocardiographic parameter for PCWP estimation.

Transcatheter Mitral Valve-in-Valve Implantations Using Inverted J-Valve.

BackgroundAs bioprosthetic valves are being widely used, the incidence of structural valve deterioration increases, as well as the need for reoperation. Transcatheter mitral valve-in-valve implantations are being increasingly adopted as an alternative to redo-surgical mitral replacement for patients with high surgical risks. This study reports a series of transcatheter mitral valve-in-valve implantations using inverted J-valves.MethodsFrom April 2019 to September 2021, 17 symptomatic high-risk patients with mitral bioprosthetic valve dysfunction underwent transapical transcatheter mitral valve-in-valve implantations using inverted J-valves at our institution.ResultsThe median age was 70 years, with 76.5% being female. The median Society of Thoracic Surgeons predicted risk of mortality (STS PROM) was 17.2% (8.7–82.24%). All patients had successful transapical transcatheter mitral valve-in-valve implantations except for one intraoperative death due to left ventricle rupture. Four patients underwent simultaneous transcatheter aortic valve implantation, two of which had valve-in-valve transcatheter aortic valve implantation. There was no major complication except one case of bleeding. Thirty-day mortality was 11.8% (2/17), and 90-days mortality was 23.5% (4/17). Percentages of patients with New York Heart Association class III/IV symptoms decreased from 100 (17/17) to 20% (3/15) at 30-days. Median mitral inflow velocity was 1.95 mm/s at 30 days, compared to 2.7 mm/s at baseline. Median mitral valve effective orifice area increases from 1.5 mm at baseline to 1.85 mm at 30 days.ConclusionTranscatheter transapical valve-in-valve implantations with J-valve can be a plausible solution to failed mitral bioprosthesis with acceptable results for high-risk patients.

Clinical role of transthoracic and transesophageal echocardiography in transapical mitral valve repair

Objective To evaluate the role of transthoracic echocardiography(TTE) and transesophageal echocardiography(TEE) in the process of transapical mitral valve repair using a novel edge-to-edge device(ValveClamp) and this device′s efficacy and safety in a preliminary clinical trial. Methods Six patients with moderate to severe or severe degenerative mitral regurgitation (DMR) confirmed by TTE and TEE were enrolled. TTE was performed pre and post procedure as well as 30 days post procedures.Related cardiac structure and hemodynamic parameters, including mitral regurgitation area(MRA-max), vena contracta width(VCW), mitral valve effective orifice area(MVEOA), left ventricular end diastolic diameter(LVEDD), left ventricular end systolic diameter(LVESD), left ventricular ejection fraction(LVEF), max and mean mitral valve pressure gradient(MVPG-max and MVPG-mean) were recorded and evaluated in a central core laboratory. Results All the procedures were successfully performed.MRA-max, VCW and MVEOA decreased significantly post procedures (all P 0.05). Meanwhile, MVPG-max and MVPG-mean slightly increased (all P 0.05). Conclusions Transapical mitral valve repair using ValveClamp can be performed safely and a significant reduction in mitral regurgitation can be achieved in patients with DMR. TEE and TTE facilitate the patient selection for ValveClamp procedures as well as perioperative navigation and assessment. Key words: Echocardiography, transthoracic; Echocardiography, transesophageal; Transcatheter mitral valve repair; Mitral regurgitation

Effect of prosthesis patient mismatch in mitral position on pulmonary hypertension.

Pulmonary arterial hypertension (PAH) is associated with poor outcome after mitral valve replacement (MVR). We proposed to evaluate the effect of valve prosthesis patient mismatch (PPM) on pulmonary arterial (PA) pressure following MVR. Five hundred patients who have undergone MVR were studied retrospectively. Postoperative PA systolic pressure (PASP) measured 6 months postoperatively by Doppler echocardiography was compared with preoperative values. PASP ≥ 40 mmHg was defined as PAH. Mitral valve effective orifice area was calculated by the continuity equation and indexed for body surface area. PPM was defined as indexed effective orifice area ≤ 1.2 cm2/m2. A multivariate model was constructed to ascertain the independent determinants of systolic PA pressure. Also, a propensity score model was constructed to overcome the baseline differences between the PPM and no PPM groups. The incidence of PPM in this study was 37.2%. The average postoperative PASPs were 30.49 and 42.35 mmHg in the no PPM and PPM groups, respectively; (P < 0.001). Regression of PAH in the PPM and no PPM groups was 76.26% and 20.64%, respectively; (P < 0.001). The indexed effective orifice area correlated well with postoperative PASP (r = 0.71). The overall survival and freedom from cardiac death at 10 years were 79.8% and 85.3%; and at 20 years were 66.5% and 74.3%, respectively. Both, overall survival and the freedom from cardiac death were higher in the no PPM group than in the PPM group; (P < 0.001). Propensity score matching analysis yielded 112 pairs of the PPM and no PPM cohorts, which revealed higher overall survival and freedom from cardiac death in the no PPM group; (P = 0.028 and 0.012, respectively). Mitral PPM is an independent predictor of persistent PAH after MVR along with associated morbidity and reduced survival.

Bioprosthetic mitral valve effective orifice area using 4D flow cardiac magnetic resonance derived time velocity integral. An in vitro comparison with Doppler Echocardiography

\Background 4D Flow Cardiac Magnetic Resonance (CMR) is a novel imaging modality to assess bioprosthetic mitral valve (BMV) function. We describe a new, 4D Flow derived velocity time integral (TVI) based method to assess effective orifice area (EOA) for BMVs. Methods In our MRI-compatible circulatory loop 4 stented porcine BMVs (27, 29, 31, 33mm) underwent CMR with a 1.5T Siemens scanner. The valves were evaluated at forward stroke volumes of 70, 90 and 110ml at a beat rate of 70bpm. We plotted instantaneous peak velocities and calculated TVI for each scenario. 4D CMR-EOA was

Bioprosthetic mitral valve effective orifice area by phase-contrast CMR. An in vitro comparison with Doppler echocardiography

Background Introduction: Current guidelines for the functional evaluation of bioprosthetic heart valves recommend the effective orifice area (EOA) as the product of the transvalvular stroke volume divided by Doppler derived diastolic time velocity integral (TVI). Phase contrast CMR may offer an alternative imaging modality to assess bioprosthetic valve EOA when Doppler methods are technically limited or unreliable. Methods Our circulatory loop includes a mock ventricle and a heart valve imaging chamber that has been fabricated using MRI-compatible components. In this study 3 different sized stented porcine mitral valve bioprostheses were evaluated (27 mm, 29 mm, 31 mm) replicating three different hemodynamic conditions with forward stroke volume of 70 ml, 90 ml and 110 ml respectively at a beat rate of 70 bpm. Imaging was performed with a

Impact of prosthesis–patient mismatch on tricuspid valve regurgitation and pulmonary hypertension following mitral valve replacement

Mitral PPM can be equated to residual mitral stenosis, which may halt the expected postoperative improvement of PH and concomitant functional tricuspid regurgitation (fTR). Aim of the present study is to evaluate the impact of mitral prosthesis-patient mismatch (PPM) on late tricuspid valve regurgitation and pulmonary hypertension (PH). A total of 210 patients undergoing isolated mitral valve replacement (MVR) were investigated. Mitral valve effective orifice area was determined by the continuity equation and indexed for body surface area (EOAi) and PPM was defined as EOAi ≤ 1.2 cm(2)/m(2). Pulmonary hypertension (PH) was defined as systolic pulmonary artery pressure (sPAP) > 40 mmHg. Clinical and echocardiographic follow-up (median 27 months) was 100% completed. A total of 88/210 (42%) patients developed mitral PPM. There were no significative differences in baseline and operative characteristics between patients with and without PPM. At follow-up, the prevalence of fTR ≥ 2+ (57%vs.22%; p = 0.0001), and PH (62%vs.24%;p < 0.0001) were significantly higher in patients with PPM. On multivariable regression analysis, EOAi (p < 0.0001) and preoperative left ventricular (LV) end-diastolic diameter (p < 0.0001) were found to be independently associated with fTR decrease after MVR. In addition, EOAi (p < 0.0001) and LV ejection fraction (p < 0.0001) were independently associated with PH decrease after MVR. No significant differences in mortality rates were found between patients having or not PPM. This study shows that mitral PPM is associated with the persistence of fTR and PH following MVR. These findings support the realization of tricuspid valve annuloplasty when PPM is anticipated at the time of operation.

Does Stringent Restrictive Annuloplasty for Functional Mitral Regurgitation Cause Functional Mitral Stenosis and Pulmonary Hypertension?

It remains controversial whether restrictive mitral annuloplasty (RMA) for functional mitral regurgitation (MR) can induce functional mitral stenosis (MS) that may cause postoperative residual pulmonary hypertension (PH). One hundred eight patients with left ventricular (LV) dysfunction and severe MR underwent RMA with stringent downsizing of the mitral annulus. Systolic pulmonary artery pressure (PAP) and mitral valve performance variables were determined by Doppler echocardiography prospectively and 1 month after RMA. Fifty-eight patients underwent postoperative hemodynamic measurements. Postoperative echocardiography showed a mean pressure half-time of 92 ± 14 ms, a transmitral mean gradient of 2.9 ± 1.1 mm Hg, and a mitral valve effective orifice area of 2.4 ± 0.4 cm(2), consistent with functional MS. Doppler-derived systolic PAP was 32 ± 8 mm Hg, which correlated weakly with the transmitral mean gradient (ρ=0.23, P=0.02). Postoperative cardiac catheterization also showed significant improvements in LV volume and systolic function, pulmonary capillary wedge pressure, cardiac index, and systolic PAP; the latter was associated with LV end-diastolic pressure [standardized partial regression coefficient (SPRC)=0.51], pulmonary vascular resistance (SPRC=0.47), cardiac index (SPRC=0.37), and transmitral pressure gradient (SPRC=0.20). In a multivariate Cox proportional hazard model, postoperative PH (systolic PAP >40 mm Hg), but not mitral valve performance variables, was strongly associated with adverse cardiac events. RMA for functional MR resulted in varying degrees of functional MS. However, our data were more consistent with the residual PH being caused by LV dysfunction and pulmonary vascular disease than by the functional MS. The residual PH, not functional MS, was the major predictor of post-RMA adverse cardiac events.

Surgical Management of Ischemic Mitral Regurgitation

Case presentation: A 62-year-old man visited his cardiologist describing a 6-month history of increasing fatigue and shortness of breath on exertion. His medical history included an inferoposterior myocardial infarction (MI) 3 years previously that was treated with drug-eluting stents to his left circumflex and right coronary arteries. The result of physical examination was remarkable for crackles audible throughout the lower half of both lung fields, an elevated jugular venous pulse to the angle of the jaw, and a grade 3/6 holosystolic murmur loudest at the apex with radiation to the left axilla. An echocardiogram revealed a left ventricular ejection fraction (LVEF) of 15% to 20%, severe mitral regurgitation (MR), and a left ventricular end systolic dimension of 70 mm. The patient underwent a repeat cardiac angiogram that revealed patent stents in the circumflex and right coronary arteries and no other significant stenoses. The decision was made to surgically correct the patient’s MR with a mitral valve operation. He was brought to the operating room, where he was given general anesthesia, and a transesophageal echocardiogram was performed. Examination of the mitral valve revealed poor leaflet coaptation with a degree of leaflet tethering that resulted in severe MR. Inasmuch as the valve leaflets appeared structurally normal, a mitral valve repair procedure using a complete rigid annuloplasty ring was performed. A postoperative echocardiogram revealed trace MR, and the patient experienced no postoperative complications. This patient is a typical example of a growing problem in our aging population, namely, ischemic mitral regurgitation (IMR). IMR clearly has a negative impact on survival in patients with coronary artery disease, even in patients with mild to moderate MR; greater degrees of MR portend an even worse prognosis.1 With almost a fifth of patients who experience an MI followed by the development of IMR,2,3 and over …

Usefulness of Measuring Net Atrioventricular Compliance by Doppler Echocardiography in Patients With Mitral Stenosis

Twenty-six patients with severe pure mitral stenosis underwent Doppler echocardiographic examination and cardiac catheterization within the same day before the realization of mitral valve balloon valvuloplasty. Net atrioventricular compliance estimated by Doppler echocardiography from the ratio of mitral valve effective orifice area and E-wave downslope was a major independent determinant of left atrial and pulmonary arterial pressures measured by catheterization.

Impact of valve prosthesis-patient mismatch on pulmonary arterial pressure after mitral valve replacement

We sought to determine the impact of valve prosthesis-patient mismatch (PPM) on pulmonary arterial (PA) pressure after mitral valve replacement (MVR). Pulmonary arterial hypertension is a serious complication of mitral valve disease, and it is a major risk factor for poor outcome after MVR. We hypothesized that valve PPM might be a determinant of PA hypertension after MVR. Systolic PA pressure was measured by Doppler echocardiography in 56 patients with normally functioning mitral prosthetic valves. Mitral valve effective orifice area (EOA) was determined by the continuity equation and indexed for body surface area. Thirty patients (54%) had PA hypertension defined as systolic PA pressure >40 mm Hg, whereas 40 patients (71%) had PPM defined as an indexed EOA < or =1.2 cm(2)/m(2). There was a significant correlation (r = 0.64) between systolic PA pressure and indexed EOA. The average systolic PA pressure and prevalence of PA hypertension were 34 +/- 8 mm Hg and 19% in patients with no PPM versus 46 +/- 8 mm Hg and 68% in patients with PPM (p < 0.001). In multivariate analysis, the indexed EOA was by far the strongest predictor of systolic PA pressure. Persistent PA hypertension is frequent after MVR and strongly associated with the presence of PPM. The clinical implications of these findings are important given that PPM can largely be avoided by using a simple prospective strategy at the time of operation.