Presence Of Mitral Valve Disease Research Articles

Abstract 20912: The Impact of Mitral Valve Disease on Atrial Fibrillation Ablation Outcome

Introduction: Mitral Valve Disease (MVD) is associated with atrial fibrillation (AF) and can worsen its prognosis. Left Atrial (LA) fibrosis is a known substrate for AF and its extent affects the management. Hypothesis: We hypothesize MVD increases LA fibrosis in AF patients and the chance of AF ablation failure. Secondly, even in patients with low levels of LA fibrosis that are optimal candidates for ablation, presence of MVD still worsens the outcome. Methods: Patients were categorized in two groups: 140 patients had coexisting MVD and AF, and 100 patients AF without MVD. MVD was defined as any dysfunctionality of mitral valve including mitral stenosis, mitral regurgitation, and history of previous mitral valve surgery . LA fibrosis was quantified by Late Gadolinium Enhancement MRI (LGE-MRI). Baseline characteristics were gathered through chart reviewing. Following ablation, patients were followed for median of 71 months for AF recurrence. Results: Patients were 76.4 ± 10.7 years of age in MVD+AF group and 64.2 ± 14.7 in AF group (p < 0.0001). Extent of LA fibrosis was 18.1% ± 9.3 and 10.3% ± 5.3 in MVD+AF and AF group, respectively (p < 0.0001). The result of our statistical model adjusted for possible cofounders showed that coexistence of MVD in AF patients result in presence of 6.4% more LA fibrosis (p < 0.00001) and lowered the chance of remaining AF free after the ablation (recurrence-free ratio of 0.554 vs 0.757 in MVD+AF and AF group respectively, P < 0.05) (Figure 1). In patients with LA fibrosis less than 20% who would be ideal AF ablation candidate, the presence of MVD decreased the chance to remain AF free (0.574 vs 0.775 in MVD+AF and AF respectively, p < 0.05) (Figure 2). Conclusions: MVD increases LA fibrosis in AF patients and the chance of AF recurrence post-ablation.

Mid-term Results for the Maze Procedure in Patients with Non-mitral Valvular Atrial Fibrillation

The Maze procedure in patients without mitral valve disease remains controversial, because of the increased invasiveness and operation time required to create additional incisions in the atria. The aim of this study was to assess prognosis following the Maze procedure in patients without mitral valve disease. One hundred and seven consecutive patients who underwent the Maze procedure between 2002 and 2008 was enrolled in this study. Patients were divided into two groups based on the presence or absence of mitral valve disease. Freedom from atrial fibrillation was compared by multivariate logistic regression analysis at discharge. The Kaplan-Meier method and Cox-proportional hazard analysis adjusted for other predictors were estimated to compare freedom from atrial fibrillation at follow-up. Follow-up was 98% complete and mean duration of follow-up was 457 days. Operation and aorta cross-clamp times were similar between groups. No differences were identified in freedom from atrial fibrillation at discharge (non-mitral valve surgery, 55% vs. mitral valve surgery, 66%) or follow-up (57% vs. 61%, respectively). In multivariate Cox proportional hazard modelling, the presence of mitral valve disease was not associated with a poor success rate of conversion. Results of the Maze procedure for atrial fibrillation without mitral valve disease were acceptable. The Maze procedure could be a beneficial option for these patients to avoid adverse events of atrial fibrillation.

Syncope with a Twist

Left atrial ball thrombus is an uncommon entity, seen more commonly in the presence of mitral valve disease. We present here a case of a large left atrial thrombus presenting as sudden cardiac death.

Left Atrial Free-Floating Ball Thrombus in a Case of Hyperthrophic Cardiomyopathy

Left atrial free-floating ball thrombus is a rarely seen pathology in the absence or presence of mitral valve disease. This pathologic condition carries high risks of embolic complications and deterioration of hemodynamics. The case reported here is a 34-year-old woman who had been followed-up by another center with the diagnosis of hypertrophic cardiomyopathy (HCM) was admitted to our emergency department in cardiogenic shock due to left atrial free-floating ball thrombus partially obstructed the left ventricular inflow. Emergency surgery was undertaken to remove the ball mass, additionally septal myectomy and mitral valve replacement were performed. Pathologic examination of the mass confirmed the thrombus formation. This rare case of left atrial free floating ball thrombus associated with HCM is presented and current literature is reviewed.

Course of intraatrial thrombi resolution using transesophageal echocardiography.

Thromboembolic events are associated with atrial fibrillation and with cardioversion to sinus rhythm. Although studies have demonstrated the risk of this complication is reduced by a 3-week period of anticoagulation prior to cardioversion, limited data have suggested a longer period of anticoagulation is necessary for thrombus resolution. We identified and followed 25 patients noted to have intraatrial thrombi on an initial transesophageal echocardiogram (TEE) who subsequently had a follow-up TEE. The majority of patients had a single thrombus, often but not uniformly located in the left atrial appendage with the largest found in those patients with mitral stenosis. Repeat TEE was performed at a mean of 4 +/- 6 months and persistent thrombus was noted in 19 of 25 patients (76%). Seven of 19 patients with persistent thrombi were cardioverted and one of these patients had a neurologic event following the procedure (14%). The only findings associated with persistent thrombus were the presence of mitral valve disease and atrial fibrillation. Our findings suggest that intraatrial thrombi do not generally resolve following several weeks of anticoagulation and that persistent left-sided intraatrial thrombi may be associated with an increased risk for events following cardioversion. Given that a TEE-guided approach to cardioversion is being utilized more frequently, it may be important to determine thrombus characteristics on follow-up that would be predictive of embolic events following cardioversion.

Cardioversion of atrial fibrillation with ibutilide: when is it most effective?

Atrial fibrillation (AF) is found in 1% of persons above the age of 60 years. More than 5% of the population older than 69 years and about 14% of octogenarians are at risk for this arrhythmia. It is estimated that 1.5 to 3 million persons in the United States alone suffer from AF. The public health implications and attendant morbidity are a significant drain on our health care system. The purpose of this study was to determine the clinical and echocardiographic predictors of success in converting AF of > or = 24 h duration. Demographic and clinical and echocardiographic parameters of 101 patients with recent onset AF (> 24 h) who received ibutilide were studied. Of 101 patients, 56 (55%) converted to sinus rhythm. Age, gender, hypertension, diabetes mellitus, left ventricular ejection fraction (< or = 35%), congestive heart failure, and previous medication for rate control had no significant effect on the conversion rate. Conversion rate was only 30% (9/30 patients) in the presence of an enlarged left atrium (LA > or = 5 cm) and 37.7% (23/61 patients) in the presence of mitral valve disease (MVD), whereas the conversion rate was 82.5% (33/40 patients) in the absence of MVD and 85% (29/34 patients) in the absence of both enlarged LA and MVD (p = <0.001). Patients with coronary artery disease (CAD) also exhibited a significantly greater response to ibutilide than patients without CAD (77 vs. 46%, p-value 0.005). As a therapy for cardioversion of AF, ibutilide is most effective in a selected subgroup patients, such as in patients with CAD and in patients without MVD and/or markedly enlarged left atrium.

Serial antiarrhythmic drug treatment to maintain sinus rhythm after electrical cardioversion for chronic atrial fibrillation or atrial flutter

The sequential use of different types of antiarrhythmic drugs may improve arrhythmia prognosis in chronic atrial fibrillation or flutter after successful electrical cardioversion. The rationale for serial treatment is that the arrhythmogenic mechanism may vary between patients, leading to different responses to 1 specific drug. To investigate this issue prospectively, 127 patients having chronic fibrillation or flutter exclusively, underwent serial drug treatment with flecainide (stage I) followed by sotalol or, if contraindicated, quinidine (stage II) and eventually amiodarone (stage III). Stages II and III were entered after electrical recardioversion for a recurrence during stages I or II, respectively. Calculated on an actuarial basis, the 2-year cumulative percentage of patients free of the arrhythmia increased from 31% after stage I to 63% at the end of serial treatment. To reach this result, a mean of 1.8 ± 0.8 cardioversions per patient were needed, with 53 patients progressing to stage II and 34 to stage III. Sixteen patients stopped serial treatment prematurely and 15 patients were considered to have intractable atrial fibrillation at the end of stage III. Incidence of proarrhythmia was low. Multivariate analysis disclosed that an older age, in combination with a large number of previous episodes of arrhythmia, a long previous duration of arrhythmia and presence of mitral valve disease, were predictive for medical refractoriness during serial treatment. It is concluded that serial treatment may improve arrhythmia prognosis in atrial fibrillation or flutter, with an acceptable incidence of proarrhythmic events.

Doppler echocardiographic predictors of recurrence of atrial fibrillation after cardioversion

To determine if the return of atrial contraction as evidenced by progressive return of the A wave on the Doppler atrial profile could better predict long-term success of cardioversion than other clinical and echocardiographic parameters, 50 patients were studied 4 hours, 24 hours and, if sinus rhythm persisted, up to 180 days after cardioversion. Recurrence of atrial fibrillation (AF) was 64% at 6 months. Age, sex, prior episodes of AF, presence of mitral valve disease or magnitude of mitral valve gradient did not predict recurrence, but duration of AF was significantly longer in the failure group (p < 0.01). Left atrial dimension ≥45 mm had a positive predictive value of 66%, with a sensitivity of 59% and a specificity of 61%. Presence or magnitude of the A wave at 4 hours did not predict long-term success of cardioversion. Percent increase of the A wave from 4 to 24 hours <10% had the highest positive predictive value (80%) for recurrence of AF (sensitivity 71% and specificity 71%) and can be obtained in the immediate postcardioversion period to better establish prognosis and adjust therapeutic regimens.

Use of planigraphy in demonstration of calcification of heart valves and its significance.

PRESENT-DAY popularity of surgery for cardiac valve disease of acquired origin has made precise diagnosis of valve lesions of the utmost importance. Success of surgery may depend, among other factors, upon the nature of the pathologic changes within the valve itself and upon the total number of valves involved. Our anatomic studies have shown how often associated valve lesions are overlooked in the presence of mitral valve disease.1These findings likewise have emphasized the importance and the frequency of multivalvular lesions in persons with rheumatic heart disease who die and particularly those who die of congestive heart failure. By implication, these findings have further emphasized the well-known fact that murmurs which are so frequently characteristic of specific valve lesions may also be uncharacteristic for them. A single murmur may represent an auditory fusion of murmurs originating from several valve abnormalities. Moreover, with changing cardiac function, murmurs may change their