Rheumatic Mitral Stenosis Patients Research Articles

Impact of Strict and Lenient Heart Rate Control on Six-Minute Walk Test and Quality of Life in Atrial Fibrillation Patients with Rheumatic Mitral Stenosis: A Preliminary Study

Background: Recent studies showed no outcome difference between strict and lenient rate control in the general Atrial Fibrillation (AF) population. However, for AF and Rheumatic Mitral Stenosis (RMS) patients, evidences were lacking. Objective: To assess the impact of strict and lenient heart rate control on the Six-Minute Walk Test (SMWT) and Health Related Quality of Life (HRQoL) in patients with AF and RMS. Material and Methods: A prospective multicenter trial across tertiary hospitals in East Java assessed strict and lenient heart rate control's impact on the SMWT and HRQoL in AF and RMS patients. Sixty-one participants were randomized into strict and lenient groups over six months from March to August 2023. Medications were adjusted to achieve target heart rates, and HRQoL was assessed using SF-36 and SMWT at baseline and three months post-target heart rate attainment. Result: In our study, 29 patients were under strict heart rate control, and 32 were under lenient control. We found a decrease in HRQoL across all subscales, with significant differences observed in general health perception and physical function among those under strict control (p=0.002 and 0.03, respectively). However, no significant disparity was found in the SMWT distance difference between lenient and strict groups (p=0.529), nor in METs (p=0.326). Conclusion: In the study, lenient heart rate control demonstrates significant effects on the general health perception and physical function subscales compared to strict heart rate control. Keyword: Strict and lenient heart rate, HRQoL, Six-Minute Walk Test, Atrial Fibrillation, Rheumatic Mitral Stenosis.

20-year follow-up of rheumatic mitral stenosis patients after percutaneous mitral commissurotomy: invasive transmitral gradient differential as a predictor of events.

Percutaneous mitral valve commissurotomy (PMC) is a viable alternative to mitral valve (MV) surgery in the treatment of patients with rheumatic mitral stenosis (RMS). In this single-center retrospective study of consecutive patients with RMS submitted to PMC from 1991 to 2008, we analyzed clinical, echocardiographic, and hemodynamic data and events during follow-up (FUP) until December 2021. Major adverse cardiovascular events (MACE) were a combined endpoint of all-cause death, cardiovascular hospitalization, and MV re-intervention. A total of 124 patients were enrolled: 108 (87.1%) were female, with a mean age at PMC of 46 [standard deviation (SD) 11] years. PMC was successful in 91.1%, with a mean reduction in invasive transmitral pressure gradient (TMPG) of 8 (SD 7) mmHg at PMC time. During the mean FUP of 20 (SD 6) years, 51 (41.1%) patients had MV re-intervention (86.3% surgery and 13.7% redo-PMC), 37 (29.8%) were hospitalized, and 30 (24.2%) died. Approximately 75% of patients remained MACE-free after 10 years, and this percentage decreased to around 40% after 20 years; at this time mark, about 8 in 10 patients were alive. A reduction of <5 mmHg in TMPG at PMC time was associated with a 2.7-fold greater rate of MACE compared to a reduction of ≥5 mmHg, independent of MV regurgitation after PMC and moderate disease of other valves (adjusted hazard ratio 2,7; 95% confidence interval 1.395-5.298, p=0.003). In this cohort with favorable long-term results after PMC, a reduction of <5 mmHg in TMPG at PMC time was associated with MACE during FUP. More studies are needed to validate this independent predictor.

Assessment of Left Ventricular Deformation in Rheumatic Mitral Stenosis Patients (Speckle Tracking Study)

Assessment of Left Ventricular Deformation in Rheumatic Mitral Stenosis Patients (Speckle Tracking Study)

Correlation between mitral valve area and left atrial function in rheumatic mitral valve stenosis patients.

Rheumatic heart disease (RHD) continues to be one of the leading causes of cardiovascular morbidity and mortality. The mitral valve frequently develops mitral stenosis (MS), and it is the most prevalent valve lesion in patients with chronic RHD. Left atrial (LA) functional impairment is associated with rheumatic MS. The aim of this study was to evaluate the association between LA function and mitral valve area (MVA) in rheumatic MS patients, and to assess the echocardiographic parameters in sinus rhythm and atrial fibrillation (AF) patients. This was a cross-sectional, descriptive study that involved patients with rheumatic MS. Patients underwent a standard 12-lead electrocardiogram and echocardiographic examination. MVA was assessed and correlated with LA function. Comparison was made between sinus rhythm and AF patients. Eighty-one patients with rheumatic MS were included in this study, with 71.6% of them having associated MR. MVA showed a statistically highly significant positive correlation with LA and right ventricular (RV) function, and a statistically significant/highly significant negative correlation with their dimensions. A higher percentage of patients with severe MS was in AF (58.1%). There was a positive correlation between LA function and MVA in rheumatic MS patients. AF was related to the severity of MS.

Impact of post-percutaneous mitral balloon valvuloplasty mitral valve area indexed for the body size on long-term outcomes in rheumatic mitral stenosis: a 20-year retrospective analysis

Abstract Introduction Percutaneous mitral balloon valvuloplasty (PBMV) remains one of the standard treatments for symptomatic rheumatic mitral stenosis (MS)(1). The procedural success criteria are generally defined as a post-procedural mitral valve area (MVA) of more than 1.5 cm2 without significant mitral regurgitation or in-hospital complications(2, 3). However, the effect of body size on the post-procedural MVA is not well examined. Purpose This study intended to investigate the association between the different methods of indexing post-PBMV MVA for the body size parameters and event-free survival compared to the absolute MVA in rheumatic MS patients treated with PBMV. Methods We retrospectively enrolled clinically significant rheumatic MS patients (MVA ≤1.5 cm2) who underwent PBMV with Inoue balloon between June 2002 and February 2021. The patients who experienced in-hospital complications (stroke, emergency surgery, or death) were excluded. A final number of 584 out of 618 patients were included in the analysis. Post-procedural MVA was assessed using echocardiographic 2D planimetry or pressure half-time if planimetry was not available. Post-PBMV MVA was indexed by body surface area (BSA), body mass index (BMI), body weight or height. The median value of absolute MVA and indexed MVA was used to stratify patients into two groups. The primary outcome was the composite of death, repeat PBMV, and mitral valve surgery. We performed Cox regression analyses to assess the association between groups and outcomes. C-index was calculated to assess the discriminative ability of each index. Results The mean age was 41.5 (±11.9) years, and 490 patients (82.8%) were female. The prevalence of atrial fibrillation was 39.5%. The median Wilkin score was 8 (interquartile range of 7-9). The mean pre-procedural and post-procedural MVA was 0.92 (±0.24) and 1.57 (±0.28) cm2, respectively. The average pre-procedural and post-procedural mean pressure gradient was 13.1 (±6.3) and 5.7 (±3.0) mmHg, respectively. The prevalence of post-procedural MR in a moderately severe to a severe degree was 3.8%. Over a median follow-up of 3.9 years, 194 composite events occurred. Patients with post-procedural indexed MVA of any type greater than a median were not associated with a significantly lower risk of primary outcome compared to those with indexed MVA less than the median (Picture 1). Moreover, absolute MVA greater than a median (1.55 cm2) was independently associated with a lower risk of primary outcome after adjusting with age and gender (Hazard ratio [95% CI] = 0.658 [0.493-0.879], p = 0.005). The discriminative ability of the absolute MVA was highest than the indexed MVA (Picture 2). Conclusion Indexing post-procedural MVA did not provide additional benefit on long-term risk stratification after PBMV compared with the absolute MVA.

Multimodality imaging in PMV: comparison between cardiac computed tomography and echocardiography from multicenter mitral stenosis registry (MASTER registry)

Abstract Background The Wilkins score is a grading system that, from the past to the present, provides vital hints in patients with rheumatic mitral stenosis (MS). However even if the score is modest, complications may occur after percutaneous mitral valvuloplasty (PMV)1. Also Wilkins score alone does not reflect the development of various multi-modality imaging related to mitral stenosis. The purpose of this study was to evaluate the variability between echocardiography and cardiac computed tomography (CT) in measuring the score, and to examine the immediate PMV outcome related to the score measured by each modalities. Methods From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry of 3,140 patients with at least moderate MS, we included 96 rheumatic MS patients (age 56.4±11.5 years, 78 women) who underwent PMV and had remeasurable images between January 2010 and December 2022. We analyzed the discrepancies between the Wilkins score determined by echocardiography (transthoracic echocardiography or transesophageal echo in certain individuals) and the score determined by cardiac CT as a whole or among each parameter. Furthermore, the frequency of composite outcomes with high scores was compared between modalities. A composite outcome was defined as a case in which the outcome following PMV was not optimal (post PMV mitral valve area (MVA) less than 1.5 cm2 or mitral regurgitation (MR) with grade II-III or higher occurred). Results The average Wilkins score obtained by echocardiography was less than that measured by CT. (7.2±1.3 vs. 8.0±2.4) CT displayed higher score values than echocardiography, particularly for thickness (n= 47, 41.7%) and sub-valvular thickness (n= 40, 41.7%). Echo evaluated the presence of calcium, but CT showed no calcium in many cases. (n=19, 19.4% vs. n=38, 39.6%). Based on the previously commonly used Wilkins score of 9 points, when evaluated by echocardiography, there wasn't a significant difference except for the post MVA (1.6±0.2 vs. 1.5±0.2 cm2, p value = 0.015) between less than and more than 9 points. Yet, in 40 patients with a CT-evaluated Wilkins score of 9 or higher, the post MVA was substantially smaller (1.6±0.1 vs. 1.5±0.3 cm2, p = 0.019) than in those without, and MDPG remained elevated even after the procedure. (4.0±1.4 vs. 4.9 ± 1.9 mmHg, p = 0.017) In addition, there were more cases where the MVA remained less than 1.5 cm2 after the procedure (n=10, 17.9% vs. n=22, 55.0%, p&amp;lt;0.001). For this reason, the composite outcome found to be highly likely to occur. Even when the Wilkins score evaluated by echo was low, the composite outcome ratio was similarly high if the CT score was high. Conclusions The average value of the Wilkins score measured by echocardiography was lower than that measured by CT, mainly due to differences in leaflet thickness and sub-valvular thickness evaluation. Cases with a high Wilkins score evaluated by CT were more likely to have suboptimal MVA or significant MR after PMV.Wilkins score measured by each modalitieComposite event rate by Wilkins score

Which factors are associated with low flow in rheumatic mitral stenosis patients?

Stroke volume (SV) raised enthusiasm in the early investigations of rheumatic MS pathophysiology and was considered as a key component triggering dyspnea. Giving the discrepancies uncovered in later studies, its importance was later downgraded. The objective of this study was to assess correlations between LA reservoir function (LASr) and global left ventricular longitudinal strain (LVS) determined by 2D STE and stroke volume index (SVI). We performed TTE in a cohort of patients with rheumatic MS. Basic 2D and doppler parameters were recorded such as mean trans-mitral gradient (MTMG), mitral valve area (MVA) with 2D planimetry and PHT. Studied parameters represent mean of three consecutive cardiac cycles. LASr data was obtained on a dedicated 4C view with STE technique. LVS was generated based on the 3 basic apical views. Low-flow state was defined as a SVI ≤ 35 mL/m2. One hundred and ninety-five patients were included between February 2018 and October 2021. We divided our cohort into two groups: group I with SVI ≤ 35 mL/m2 and group II with SVI > 35 mL/m2. There was not a significant difference in terms of age (49.8 ± 12 vs. 51.6 ± 10 yrs, P = 0.3), sex (70.7 vs. 72.2% were female, P = 0.8) and history of atrial fibrillation (67.4 vs. 55.7%, P = 0.09). 2D MVA was significantly lower in group I (1.22 ± 0.4 vs. 1.43 ± 0.5 cm2, P = 0.003). Surprisingly, MVA determined with PHT did not significantly differ (1.43 ± 0.6 vs. 1.39 ± 0.4 cm2, P = 0.5). The incidence of severe dyspnea was (44.3 vs. 44.4%, P = 0.9). TRVmax levels (3.23 ± 0.6 vs. 3.07 ± 0.6 m/s, P = 0.14) were comparable. Group I had significantly higher MTMG (12.1 ± 7 vs. 9.8 ± 4 mmHg, P = 0.01). LVS and LVEF were significantly lower in low-flow patients: (−15 ± 4 vs. −18 ± 2%, P < 0.001) and (61.1 ± 8% vs. 64.2 ± 5%, P = 0.04) respectively. LASr was higher in normal flow patients but did not reach the statistical significance. (9.5 ± 7 vs. 11.5 ± 6%, P = 0.062). MVA, LVS and LVEF were significant associates of low-flow state in MS patients. LA reservoir function was not significantly correlated to SVI.

Comparison of the Appendicular Emptying Velocity of Left Atrium in patient with moderate versus severe chronic rheumatic mitral stenosis measured by pulsed wave Doppler in Transesophageal echocardiography

Background: Left atrial appendage (LAA) is considered the “most lethal human appendage” as it causes significant mortality and morbidity in chronic rheumatic mitral stenosis patients due to cardiogenic cerebral infract. Presence of LAA dysfunction has been shown to be a strong predictor of thrombus formation and the risk of embolic event, even if no clot is found at the time of initial examination. LAA emptying velocity are measured by trans esophageal echocardiography (TEE) represent as a surrogate marker for left atrial(LA) function .LAA emptying velocities (contraction velocity) &lt; 20cm/s are associated with risk of spontaneous echo contrast(SEC), LAA thrombus, and subsequent cardio embolic events. So early detection of low emptying velocity without SEC or LA thrombus can reduce mortality &amp; morbidity related to cardio embolic stroke and also helps in further management procedure like cardio version etc. So we will compare LAA emptying velocity moderate versus severechronic rheumatic mitral stenosis patients in our population for further attention.&#x0D; Objective: To assess emptying velocity of LAA in patient with moderate versus severe chronic rheumatic mitral stenosis, from a Bangladesh health service perspective.&#x0D; Method: This was a cross sectional study which was conducted in UCC, BSMMU during the period of from February 2019 to September 2019 in Echo lab .&#x0D; Study Procedure: We were enrolled 33 CRHD with MS (moderate to severe) patients who underwent TEE and met inclusion &amp; exclusion criteria. The purpose of the study was explained to each subject &amp; informed written consent was obtained. After getting consent relevant history, physical examination and preprocedural investigation was obtained in predesigned structured data collection sheet. TEE was done with Vivid E9® machine. Pulse wave Doppler was position at the tip of the LAA and then emptying velocity of LAA moderate and severe were compared.&#x0D; Outcome measure: Among 33 patients, 3 patients were excluded due to outlier and inadequate data.. In chronic rheumatic mitral stenosis in moderate versus severe cases average LAA emptying velocities were significantly higher moderate CRHD with MS compare to severe CRHD with MS,(26.57±4.91;31.12±5.04), P=0.018.&#x0D; Conclusion:Appendicular emptying velocity of LAA significantly lower in severe CRHD with MS compare to moderate CRHD with MS and it has temporal relation with MS severity. It can be used as a reliable, simple and sami-invasive tool to early predict severity and prevent complication in CRHD with MS as well as for prophylactic measured taken.&#x0D; University Heart Journal 2022; 18(2): 73-79

Evaluation of compliance of appropriate therapeutic interventions in patients of rheumatic mitral valve stenosis in a tertiary care hospital in central India

Evaluation of compliance of appropriate therapeutic interventions in patients of rheumatic mitral valve stenosis in a tertiary care hospital in central India

A decade of the twenty-first century of percutaneous balloon mitral valvuloplasty in rheumatic mitral stenosis: long-term outcomes and clinical risk score among the AF and non-AF patients

Abstract Backgrounds Percutaneous balloon mitral valvuloplasty (PBMV) is the treatment of choice for anatomically suitable severe rheumatic mitral stenosis (MS). Atrial fibrillation (AF) is one of the most common arrhythmic conditions in rheumatic MS and may decrease successful or alter the long-term outcomes of rheumatic MS patients who are undergoing PBMV. Purpose The purpose of this study is to investigate the long-term outcomes of treatment in patients with AF compared to sinus rhythm (SR). Results Post-PBMV median follow-up time was 10.83±5.69 years. The incidence of the primary endpoint was 57.8% (95% confidence interval [CI]: 48.6% to 66.9%) and 20.0% (95% CI: 10.3% to 29.6%), p-valve &amp;lt;0.001 in AF and SR patients respectively. The adjusted hazard ratio (HR) of the primary endpoint in the AF compare with SR group was 2.377 (95% CI: 1.250 to 4.520, p-valve = 0.008). Not only the rate of death that was greater in AF than SR group with 30% (95% CI: 22% to 39%) and 11% (95% CI: 4% to 19%), p-valve &amp;lt;0.001 respectively but also as in MV surgery, the incidence rate was 30% (95% CI: 22% to 39%) and 10% (95% CI: 2% to 18%). Independence predictors of the primary endpoint were age &amp;gt;55 years (hazard ratio [HR]: 1.765; 95% CI: 1.05 to 2.95, p=0.031) and echocardiographic score &amp;gt;8 (HR: 2.94; 95% CI: 1.22 to 7.09, p=0.017). The MiTrAL-55 score has a C-statistic of 0.71±0.036 reflecting the good ability to predict long-term outcomes. Conclusion Severe rheumatic MS patients with AF had a worse long-term prognosis than SR after PBMV. An early decision to PBMV in patients with MS supporting with the predictive scoring system to minimize morbidity and mortality is necessary. 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 &amp;lt;1.0 cm2), a history of surgery or recent percutaneous mitral valvotomy, combined significant aortic valve dysfunction, left ventricular (LV) ejection fraction &amp;lt;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 &amp;gt;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 &amp;lt;15 mmHg and PASP &amp;lt;60 mmHg, n=29; Group 2, MG &amp;lt;15 mmHg and PASP ≥60 mmHg, n=9; Group 3, MG ≥15 mmHg and PASP &amp;lt;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&amp;gt;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

Association of level of IL-6, IL-10, IL-18, tumour necrosis factor-α with rheumatic mitral stenosis and subsequent pulmonary hypertension

Background: Objective of the study was to provide insight on the immune response in patients of rheumatic heart disease, mitral stenosis and evaluation of various cytokines in pulmonary hypertension secondary to rheumatic heart disease.Methods: Total 163 subjects, more than 18 year of age, were enrolled in this study. 84 subjects with rheumatic mitral stenosis (group A) diagnosed on two-dimensional echocardiography (2D echo) and 79 normal healthy volunteers (group B). Patients with mitral stenosis were further divided into subgroups based on severity of mitral stenosis [mitral valve area (MVA &gt;1 cm2 and MVA &lt;1 cm2) (subgroup Aa and Ab)] and presence or absence of pulmonary hypertension [pulmonary arterial systolic pressure (PASP &gt;36 mm Hg) (subgroup Ac and Ad)]. Interleukins IL-6, IL-10, IL-18, tumour necrosis factor alpha (TNF-α) and high-sensitivity C-reactive protein (hs-CRP) levels were assessed in both groups.Results: Mean IL-6, IL-10, IL-18, TNF-α and hs-CRP in group A and group B was 6.57±3.53 and 2.73±1 (p≤0.001), 8.185±2.8 and 3.51±0.86 (p≤0.001), 136.31±89.0 and 47.96±9.76 (p≤0.001), 21.26±18.59 and 5.36±3.57 (p≤0.001), 4.69±6.3 and 2.63±2.22 (p≤0.008) respectively. On subgroup analysis mean TNF-α in subgroup Aa was 20.71±16.84, while in subgroup Ab was 7.56±1.93 (p≤0.001). Mean IL-10 in subgroup Ac and Ad was 8.74±3.29 and 7.47±1.82, respectively. Differences in levels of other cytokines in these subgroups were not found statistically significant.Conclusions: This study finds increased IL-6, IL-10, IL-18, TNF-α and hs-CRP levels in subjects with rheumatic mitral stenosis. Subjects with severe mitral stenosis had increased TNF-α levels. Subjects of mitral stenosis having pulmonary hypertension had increased IL-10 levels.

Comprehensive echocardiographic and speckle tracking strain analysis in rheumatic mitral stenosis patients before and after transvenous mitral commissurotomy.

Percutaneous Transvenous Mitral Commissurotomy (PTMC) is the first line treatment for rheumatic mitral stenosis (MS). We sought to evaluate (1) changes in 2-dimensional (2D) echocardiographic and strain values and (2) differences in these values for patients in atrial fibrillation (AF) and sinus rhythm (SR) pre, immediately and 6months post PTMC. Retrospective study of 136 patients who underwent PTMC between 2011 and 2021. We analyzed their 2D echocardiogram, Global Longitudinal Strain (GLS), Left Atrial Reservoir Strain (LAr-S) and Right Ventricle Free Wall Strain (RVFW-S) pre, immediately and 6months post PTMC. At 6months, mitral valve area increases from 0.94 ± 0.23cm2 to 1.50 ± 0.42cm2. Ejection fraction (EF) did not change post PTMC (pre; 55.56 ± 6.62%, immediate; 56.68 ± 7.83%, 6months; 56.28 ± 7.00%, p = 0.218). Even though EF is preserved, GLS is lower pre-procedure; -11.52 ± 3.74% with significant improvement at 6months; -15.16 ± 4.28% (p < 0.001). Tricuspid annular plane systolic excursion (TAPSE) improved at 6months from 1.95 ± 0.43 to 2.11 ± 0.49 (p = 0.004). RVFW-S increases at 6months from -17.37 ± 6.03% to -19.75 ± 7.19% (p = 0.011). LAr-S improved from 11.23 ± 6.83% pre PTMC to 16.80 ± 8.82% at 6months (p < 0.001) post PTMC. Pre-procedure patients with AF have lower strain values (More LV, RV and LA dysfunction) with statistically significant difference for LAr-S (p < 0.001), GLS (p < 0.001) and RVFW-S (p < 0.001) than patients in SR. Patients with severe rheumatic MS have subclinical left and right ventricle dysfunction despite preserved EF and relatively normal TAPSE with significant improvement seen at 6months post PTMC. AF patients have lower baseline strain values than SR patients.

Left atrial function by two-dimensional speckle tracking echocardiography in patients with severe rheumatic mitral stenosis and pulmonary hypertension

We studied left atrial (LA) function in severe rheumatic mitral stenosis (MS) patients using two-dimensional speckle tracking echocardiography (STE). Eighty patients with isolated severe MS in sinus rhythm and 40 controls underwent comprehensive echocardiography including STE derived LA strain [reservoir strain (LASr), conduit strain (LAScd) and contractile strain (LASct)]. The mean MVA was 0.93 ± 0.21 cm2. The mean values of LASr (14.73 ± 8.59%), LAScd (−7.61 ± 4.47%) and LASct (−7.16 ± 5.15%) in patients were significantly lower (p < 0.001) vs. controls 44.11 ± 10.44%, −32.45 ± 7.63%, −11.85 ± 6.77% respectively and showed decreasing trend with increasing MS severity and higher NYHA class. In conclusion, LA dysfunction is prevalent in severe MS irrespective of NYHA functional class.

Prevalence and predictors of left atrial appendage inactivity in patients of rheumatic mitral stenosis in sinus rhythm: An observational study.

Systemic thromboembolism is a known complication of rheumatic mitral stenosis (RMS) in sinus rhythm (SR). Left atrial appendage (LAA), the commonest site of thrombus formation is usually hypocontractile (inactive) in such patients. We aimed to study the prevalence of LAA inactivity (LAAI) in severe RMS and assess its independent predictors. The study population consisted of 100 patients of severe RMS in SR. Transthoracic and transesophageal echocardiography were done to assess LAA contractile function. Patients with LAA-peak emptying velocity<25cm/seconds were defined as having LAAI. The mean age of study subjects was 31.66±8.69 years and 56% were females. 73% patients had LAAI (Group A), while remaining 27% had normal LAA function (Group B). Mitral-valve area (MVA) and lateral annulus systolic velocity (Sa-wave) were significantly lower while mitral valve mean gradient (MVMG) and serum fibrinogen were significantly higher (all p-values<0.001) in group A patients. On multivariate binary logistic regression analysis, MVMG (p<0.001), Sa-wave (p=0.02), and serum fibrinogen (p=0.005) were independent predictors of LAAI. Optimal cut-off values of MVMG, Sa-wave and serum fibrinogen for predicting LAAI were 11.5mm Hg, 6.8cm/seconds and 300mg/dl, respectively. Sixty-Seven (90.55%) patients in group A compared to 13(48.1%) in group B had LA/LAA smoke. LAAI was the only independent predictor of left atrium (LA)/LAA smoke with or without associated thrombus. There is high prevalence of LAAI in patients of severe MS in SR. MVMG, Sa-wave, and serum fibrinogen levels are independent predictors of LAAI. LAAI is an independent predictor of LA/LAA smoke with or without associated thrombus.

Risk Stratification and Mortality in Mitral Stenosis Patients

Background: Rheumatic mitral stenosis is the most common valvular abnormalities found in developing countries. Mortality risk in those populations was poorly investigated. In addition, hemodynamic, morphological, and mechanical factors that influence or predict outcome of rheumatic mitral stenosis have not been identified.&#x0D; Aims: To determine predictive factors affecting outcome in rheumatic mitral stenosis patients.&#x0D; Method: This retrospective cohort study was conducted at the National General Hospital Dr. Sardjito, Yogyakarta, Indonesia. The study recruited patients from the Valvular Heart Disease Registry from May 2014 to November 2020. New York Heart Association (NYHA) functional classification, invasive or surgical treatment, and incidence of death were recorded. The baseline rhythm from electrocardiography (ECG) was categorized as sinus rhythm and atrial fibrillation or atrial flutter. Based on the findings of trans thoracal echocardiography (TTE), subjects who had moderate to severe pure rheumatic mitral stenosis (or followed by mitral regurgitation and / or less significant tricuspid regurgitation as a natural history) and subjects with rheumatic mitral stenosis with a combination of other heart valve problems (of which severity more significantly) classified as groups I and II. The mitral valve area (MVA), mitral valve gradient (MVG), left atrial diameter (LA), and mean pulmonary artery pressure (mPAP) were then analyzed.&#x0D; Results: A total of 477 patients (mean age 44.08 ± 10.93 years; 71.5% female) were enrolled in this study. There were 61 deaths during the median follow up of 393 days of which 35 deaths occurred in group I and 26 deaths occurred in group II. Kaplan Meier curve shows the 1 year survival rate is higher in group I than group II which is 92.5% and 92%, respectively. Bivariate followed by multivariate analysis showed MVG and mPAP were predictive risk factors for mortality in group I with p = 0.020 and p = 0.021. MVG parameter values evaluated from echocardiography with a cut-off of more than 10 mmHg and mPAP parameters with a cut-off of more than 50 mmHg were independent predictive risk factors for mortality. Thus, patients were at higher risk of death if MVG &gt; 10 mmHg and mPAP &gt; 50 mmHg&#x0D; Conclusion: One year survival rate in group I was higher than group II. MVG and mPAP were risk factors for predicting mortality in group I.

Evaluation of left and right ventricular functions with three-dimensional speckle tracking in patients with mitral stenosis.

The function of both ventricles has been suggested to be affected in patients with mitral stenosis. In this study, it was aimed to investigate deformation properties of right (RV) and left ventricle (LV) in rheumatic mitral stenosis (MS) patients with three-dimensional speckle tracking echocardiography (3D-STE). A total of 60 patients were included in the study (20 patients with mild MS diagnosis, 20 patients with moderate MS diagnosis, and 20 healthy volunteers). Three-dimensional echocardiography datasets were obtained for both ventricles in all patients. LV global longitudinal strain (GLS), LV torsion, RV free wall (FW) LS, and interventricular septal (IVS) LS measurements were analyzed. The LV ejection fraction (EF), RV fractional area change, peak systolic velocity of the tricuspit annulus, isovolumic acceleration, and tricuspid annular plane systolic excursion values were statistically similar and in the normal range. The LV GLS measurements were significantly different among the groups by being highest in the control group and least in the moderate stenosis group. Patients with MS showed higher torsional values, correlated with MS severity. IVS LS, RVFW LS values obtained by RV analysis also differed significantly among groups. The RVFW-GLS values only showed significant difference between the control group and moderate MS group. Patients with MS showed lower LV-GLS and higher LV torsion values. RV deformation indices showed significant decrease in correlation with the severity of the mitral stenosis. In conclusion, our data suggest that subclinical LV and RV systolic dysfunction is present in mild-moderate MS patients and this dysfunction can be detected by 3D-STE.

Assessment of left atrial appendage contractile function in patients of severe rheumatic mitral stenosis in sinus rhythm and it’s correlation with mitral annular systolic velocity

Assessment of left atrial appendage contractile function in patients of severe rheumatic mitral stenosis in sinus rhythm and it’s correlation with mitral annular systolic velocity

Reverse remodeling of the atria in patients with rheumatic mitral stenosis: impact of balloon mitral commissurotomy plus atrial fibrillation ablation

Abstract Introduction Chronic Atrial stretch is an important determinant for atrial fibrillation (AF) in patients with rheumatic mitral stenosis (RMS). Purpose We analysed the effect of balloon mitral commissurotomy (BMC) plus atrial fibrillation ablation on the long-term occurrence of AF as compared to isolated BMC. Methods We prospectively included 20 patients with severe RMS undergoing BMC+AF ablation (Intervention) and compared it with a retrospective sample of 53 RMS patients that underwent BMC (Control). AF ablation consisted in pulmonary vein isolation and driver ablation identified using intracardiac basket mapping. We followed patients for 1 year after the procedure in both groups. Clinical values were evaluated in both groups. Propensity score matching was computed in order to evaluate the effect of the intervention and to analyse the impact of clinical properties of each group. Results At baseline, there were no statistical differences in gender (90% vs. 85%) and mitral valve area (1.2±0.18 vs. 1.17±0.18 cm2) between intervention and control groups, respectively. In contrast, there were differences in age (65±12 vs. 72±12; p=0.01) and AF incidence prior to the procedure (90% vs. 62%; p=0.001) between intervention and control groups, respectively. Patients undergoing AF ablation underwent successful pulmonary vein isolation in all cases and driver ablation at sites located in the right atrium (RA) in 7 (35%) patients. Median dominant frequency was significantly higher in the right atrium (DF RA 4.9±0.6 vs. DF LA 3.9±0.7 Hz; p=0.003) prior the intervention. After the intervention, it was significantly reduced only in the left atrium (LA) (DF RA 4.5±1 vs. DF LA 3.2±0.6 Hz; p=0.02 for Pre vs. Post DF LA). Three (15%) patients converted to sinus rhythm during ablation, the remaining were cardioverted. After 1-year follow-up, the proportion of patients in sinus rhythm was significantly higher in patients undergoing BMC+AF (90%) vs. isolated BMC (45%; p&amp;lt;0.001) (Graph). In the isolated BMC group, 4 patients converted to sinus rhythm and 1 patient in sinus rhythm prior to the procedure converted to AF at 1-year. Conclusion This observational study demonstrates that the combination of BMC+AF ablation significantly increses the proportion of patients in sinus rhythm at 1-year as compared to isolated BMC. Reverse remodelling of the atrial substrate following isolated BMC also converted to sinus rhythm a small proportion of patients with persistent AF at baseline. Thus, although reversal of atrial stretch changes by BMC could potentially terminate AF in some patients, the combined intervention with catheter ablation will successfully maintain sinus rhythm in the majority of patients in the study. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): FIS by Instituto de Salud Carlos III

Role of inflammation in initiation and maintenance of atrial fibrillation in rheumatic mitral stenosis - An analytical cross-sectional study.

BackgroundInflammation has been implicated in the initiation and perpetuation of non‐valvular atrial fibrillation (AF). However, there is a lack of similar data on AF in rheumatic heart disease (RHD). The objective of this study was to analyze the association of inflammation as measured by serum inflammatory biomarkers with AF in rheumatic mitral stenosis (Rh‐MS).MethodsA comparative cross‐sectional analytical study was conducted on 181 Rh‐MS patients in normal sinus rhythm (NSR; n = 69), subclinical transient AF (SCAF; detected by 24‐hours Holter monitoring; n = 30) and chronic AF (n = 82). Serum hs‐CRP, IL‐6, and sCD‐40L were assessed using ELISA immunoassay and compared in all groups of Rh‐MS with or without AF.ResultsWe found significantly higher serum hs‐CRP and sCD‐40L levels in the overall AF (Chronic AF + SCAF) group (hs‐CRP: 4.5 ± 3.4 vs 2.3 ± 2.9 mg/L, P < .01; sCD‐40L: 6.4 ± 4.8 vs 3.1 ± 3.4 ng/mL, P < .01) and chronic AF subgroup (hs‐CRP: 4.9 ± 3.4 vs 2.3 ± 2.9 mg/L, P < .01; sCD‐40L: 6.9 ± 5.1 vs 3.1 ± 3.4 ng/mL, P < .01) compared to patients with sinus rhythm. There was a statistically significant graded increase of serum IL‐6 level from the NSR to the SCAF (vs NSR: 6.8 ± 3.9 vs 4.0 ± 2.2 pg/mL, P = .03), and chronic AF subgroups (vs NSR: 9.3 ± 6.5 vs 4.0 ± 2.2 pg/mL, P < .01; vs SCAF: 9.3 ± 6.5 vs 6.8 ± 3.9, P = .05) of atrial fibrillation.ConclusionsElevated levels of serum hs‐CRP, IL‐6, and sCD‐40L were strongly associated with overall AF and also with SCAF and chronic AF in Rh‐MS patients indicating a potential role of inflammation in the pathophysiology of rheumatic AF.