Rheumatic Mitral Stenosis Research Articles

Predictors of Procedural Success and Durable Outcomes in Percutaneous Mitral Balloon Valvuloplasty: Not Just the Wilkins Score

Global migration means rheumatic heart disease (RHD) and mitral stenosis (MS) remain important issues in Western health systems. Percutaneous mitral balloon valvuloplasty (PMBV) is a durable treatment strategy relying on suitable leaflet characteristics adjudged by a Wilkins score. Commissural calcification alone has been thought as reliable as Wilkins score. Timing PMBV is also important. Falling left atrial ejection fraction (LAEF) has been theorised to predict future MS intervention. This study compared Wilkins score and commissural calcification as predictors of procedural success and durability; and, observed if LAEF improved post-valvuloplasty.

Bioprosthetic tricuspid valve stenosis in a case of rheumatic mitral valve stenosis and tricuspid valve replacement

Very little is known about the occurrence of bioprosthetic tricuspid valve stenosis in the Indian population that usually occurs within 8–10 years following tricuspid valve replacement (TVR) with a bioprosthetic valve. Here, we present a case of a 43-year-old woman suffering from chronic rheumatic heart disease who underwent prior two open mitral valvotomies and a TVR, now presented with severe mitral regurgitation and severe bioprosthetic tricuspid valve stenosis.

Good Prognosis of Pregnant Women with Severe Rheumatic Mitral Valve Stenosis: Adherence to the Guideline Recommendations.

Good Prognosis of Pregnant Women with Severe Rheumatic Mitral Valve Stenosis: Adherence to the Guideline Recommendations.

Prognostički doprinos dvodimenzionalnog opterećenja leve pretkomore kod pacijenata sa asimptomatskom mitralnom stenozom u tuniskoj populaciji

Objective. The two-dimensional strain is an objective echocardiographic technique allowing the quantification of myocardial deformation. The aim of this study was to specify prognostic contribution of left atrial strain in patients with asymptomatic mitral stenosis. Methods. We included consecutive patients followed for severe or moderately severe rheumatic Mitral Stenosis (MS), asymptomatic, during the period from January 2015 to June 2020 in the Military Hospital of Tunis. The patients followed were divided into two groups according to one criterion of judgment composed of: Cardiac mortality, The occurrence of hospitalization for cardiac reasons, The occurrence of atrial fibrillation (AF), The occurrence of a thromboembolic event, and the need for cardiac surgery or mitral valvuloplasty. Results. Initially eighty patients were selected, but only 53 were followed and then divided into two groups: 30 patients had at least one event and 23 patients had no events according to the occurrence of the major endpoint of the study. In a univariate study and for conventional echocardiographic parameters, we determined that if Left Atrium Area (LAA) is larger than 30 cm 2 and left atrium volume (LAV) more than 100ml/m 2, the risk of occurrence of an event increased significantly respectively (LAA: 69% vs 10%; p = 0.01; OR = 6.6; 95% CI [1.5-28]) and (LAV: 71.4% vs 39%; p = 0.002; OR = 4; 95% CI [1.1-13]). The same was true for left atrium deformation parameters, both Peak Atrial Longitudinal Strain (PALS) <25% and Peak Atrial Contraction Strain (PACS) <10 % were predictive of events in univariate study with the following respective odds ratios (ORs) (PALS: 83% vs 30.4%; p = 0.0001; OR = 11.4; 95% CI [3-42]), and (PACS: 90% vs 47%; p = 0.001; OR = 9.8; 95% CI [2.3-41]). In a multivariate study, the only independent parameter of the occurrence of an event was PACS <10% (p = 0.013; OR = 44; 95% CI [2.19-80]). Conclusion. PACS have prognostic value in asymptomatic MS as it predicts the occurrence of pathologic events in the followup of asymptomatic patients.

Immediate clinical and echocardiographic results of percutaneous mitral commissurotomy guided with TTE

PTMC is an established non-surgical treatment of rheumatic mitral stenosis. The study aimed to assess the safety and efficacy of this procedure guided with transthoracic echocardiography. Twenty-nine consecutive patients undergoing PTMC enrolled in this retrospective study. Mitral valve area (MVA), transmitral valve gradient (MVG), and severity of mitral regurgitation (MR) were assessed before the procedure by transthoracic and transesophageal echocardiography. Mitral valve morphology was evaluated before the procedure using Wilkin's criteria. The procedure was guided only with TTE. Mitral valve area increased from 1.00 ± 0.21 cm2 to 1.96 ± 0.34 cm2 (P < 0.001) and a gain of more than 100% surface in 14 (48.3%) patients. Mean gradient of mitral valve decreased from 12.4 ± 4.4 mmHg to 5.9 ± 1.8 mmHg (P < 0.001). Pulmonary artery pressure decreased from 44.2 ± 15.2 to 30.6 ± 9.9 (P < 0.001). No major complications were observed and moderate mitral regurgitation was occurred in 6 (20.7%) patients. Percutaneous mitral commissurotomy guided with TTE is feasible and safety with an acceptable result.

Unusual Findings and Outcomes of Balloon Mitral Valvotomy

Balloon mitral valvotomy is a common procedure done for rheumatic mitral stenosis. However, certain cases may pose challenges and rarely may be life-threatening. Here, three unusual cases of balloon mitral valvotomy are presented. Case 1 had procedural challenge in terms of Interatrial Septal (IAS) fibrotic thickening and calcification, posing difficulty in trans-septal puncture and crossing IAS with valvotomy balloon. Case 2 had bidirectional Ventricular Tachycardia (VT) with a single dose of intravenous digoxin, and stress cardiomyopathy. Case 3 had difficulty in negotiating valvotomy balloon towards apex and in the process, there was left ventricular free wall perforation.

Surgical treatment of complicated severe rheumatic mitral stenosis

Surgical treatment of complicated severe rheumatic mitral stenosis

Left atrium reservoir function is central in patients with rheumatic mitral stenosis.

We investigated the relationship between Left Atrium strain reservoir function and symptoms and its impact on modulating Left Ventricular mechanics, diastolic filling, stroke volume, mean trans-mitral gradient and pulmonary pressure in mitral stenosis (MS) patients. We examined 195 full spectrum MS patients which were divided into two groups: Group 1 (n = 109) included patients with NYHA I & II functional class and group 2 (n = 86) included patients with NYHA III & IV functional class. LA strain reservoir function and classical echocardiographic parameters were calculated. LASr was significantly higher in group 1 versus group 2 in patients with MVA ≤ 1cm2 [8.8(6.0-12.6) vs 6.8(4.1-8.9), p = 0.03) and when 1cm2 < MVA ≤ 1.5 cm2 [10.0 (5.4-13.8) vs 6.7(4.5-9.0), p = 0.02). In patients with Pulmonary Hypertension, group 1 had significantly higher LASr than group 2 [11.1(6.6-14.8) vs 5.9(4.3-9.0), p = 0.002) By multivariate analysis, diabetes (OR = 4.11, 95%CI: 1.6-10.4), stroke (OR = 2.9, 95%CI: 1.1-7.9), LASr (OR = 0.9, 95%CI: 0.80-0.99) and LV ejection fraction (LVEF)(OR = 0.9, 95%CI: 0.91-0.99) were independently associated with NYHA functional class. LASr was significantly and positively correlated to MVA (r = 0.3, p < 10-3), stroke volume (r = 0.25, p = 10-3), mitral inflow (r = 0.4, p < 10-3) and LVEF(r = 0.14, p = 0.05). It was significantly and negatively correlated to left ventricular strain (r = -0.65, p < 10-3), LA indexed volume (r = -0.40, p < 10-3), maximum tricuspid regurgitation velocity (r = -0.25, p = 0.003), MTMG (r = -0.25, p = 10-3), and heart rate (r = -0.4, p < 10-3). We demonstrated a large range of interaction between LASr and mitral valve echocardiographic parameters. This may explain the reasons we identified LASr as an independent factor for MS functional tolerance.

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.

Left Atrial Deformation Imaging and Atrial Fibrillation in Patients with Rheumatic Mitral Stenosis

Atrial fibrillation (AF) is a frequent complication of rheumatic mitral stenosis (MS) and is associated with worse outcomes. Prediction of new-onset AF by assessing left atrial (LA) mechanics with speckle-tracking echocardiography might be useful for risk stratification and guiding therapeutic strategies. Therefore, the aim of this study was to assess the association of LA reservoir strain (LASr) and strain rate (LASRr) with AF at follow-up in patients with rheumatic MS. Left atrial reservoir strain and LASRr measured by speckle-tracking echocardiography were assessed in 125 patients (mean age, 50±15years; 80.8% female) with rheumatic MS and without a history of AF. Patients were followed up for the occurrence of a first episode of AF after the index echocardiogram. During a median follow-up of 32 (9.5-70) months, 41 patients (32.8%) developed new-onset AF. Patients who developed AF had significantly more impaired LASr (13.4%±5.2% vs 18.9%±8.2%; P<.001) and LASRr (0.72±0.26s-1 vs 0.98±0.36s-1;P<.001) compared with patients who remained in sinus rhythm. On multivariable Cox regression analysis, LASr < 21% and LASRr < 0.8s-1 were independently associated with the development of AF at follow-up (hazard ratio=7.03, 95% CI, 2.08-23.77, P=.002; and hazard ratio=3.42, 95% CI, 1.59-7.34, P=.002, respectively). LASr and LASRr are impaired in patients with rheumatic MS, and the degree of impairment is associated with new-onset AF at follow-up.

Cardioembolic stroke: classification of causes and prevention strategies

This literature review covers the diversity of cardioembolic stroke (CES), the heterogeneity of the embolism sources and the morphological characteristics of the embolic substrate. It is emphasized that the determination of the individual tactics of secondary prevention is based on the verification of specific cardiac causes of stroke, for convenience, stratified as pathology of chambers, heart valves and variants of paradoxical embolism (PE). It has been shown that the leading pathology of the heart chambers associated with CES is nonvalvular atrial fibrillation and left ventricular thrombosis, and the main basis for the prevention of stroke in this pathology is oral anticoagulant therapy with direct oral anticoagulants or vitamin K antagonists (warfarin). The main types of heart valve pathology are prosthetic valves and rheumatic mitral stenosis. In this case, oral anticoagulant therapy also serves as the basis for secondary prevention. In the absence of the need to prescribe anticoagulants (mainly in the pathology of natural heart valves) acetylsalicylic acid is the drug of choice. In infective endocarditis (IE), the basic prevention strategies are antibiotic therapy and surgery. Surgical tactics also remain the main one for the prevention of CES in tumors of the left heart. Transcatheter closure of the patent foramen ovale and occlusion of the left atrial appendage are being introduced into the daily practice of interventional medicine in order to prevent ischemic stroke. A balanced individual approach to the patient, a targeted cardiological examination, a comprehensive analysis of clinical and instrumental data and the reasonable use of funds that have proven their effectiveness and safety in the main strategies for stroke prevention, are essential in effective prevention of CES.

Management of mitral stenosis: a systematic review of clinical practice guidelines and recommendations.

A number of guidelines exist with recommendations for diagnosis and management of mitral stenosis (MS). We systematically reviewed existing guidelines for diagnosis and management of MS, highlighting their similarities and differences, in order to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (5/4/2011-5/9/2021), the Guidelines International Network, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations. Two independent reviewers screened titles and abstracts, and the full text of potentially relevant articles where needed. Selected guidelines were assessed for rigor of development; only guidelines with Appraisal of Guidelines for Research and Evaluation II instrument score &gt;50% were included in the final analysis. Four guidelines were retained for analysis. There was consensus for percutaneous mitral balloon commissurotomy as first-line treatment of symptomatic severe rheumatic MS with suitable anatomy. In patients with unfavourable anatomy, surgical intervention should be considered. Exercise testing is indicated if discrepancy exists between symptoms and echocardiographic measurements. There was no clear divide between rheumatic MS and degenerative MS for their respective diagnoses and management. Pregnancy in severe MS is discouraged and the stenosis should be treated before conception. Long-term antibiotic prophylaxis is recommended for patients with rheumatic MS. Recommendations for the management of patients with mixed valvular diseases are lacking.

Plasma proadrenomedullin level and severity of the disease in patients with isolated rheumatic mitral stenosis

Plasma proadrenomedullin level and severity of the disease in patients with isolated rheumatic mitral stenosis

To study the anatomy and function of left atrial appendage and its correlation with the incidence of left atrial and appendage thrombus formation in patients with rheumatic mitral stenosis

To study the anatomy and function of left atrial appendage and its correlation with the incidence of left atrial and appendage thrombus formation in patients with rheumatic mitral stenosis

OR23. Correlation of Right Ventricular Systolic Function by Right Ventricular Global Longitudinal Strain in Rheumatic Mitral Stenosis compared to Mitral Regurgitation before and after Intervention

Abstract Background and Aims Right ventricle systolic dysfunction develop prior to the onset of clinical systemic congestion; thus, early detection is beneficial for both diagnostic and therapeutic value. We aim to asses changes of Right Ventricular Global Longitudinal Strain (RVGLS) in rheumatic mitral valve disease, and assess correlation between Right Ventricular Systolic Pressure (RVSP) and RVGLS before and after intervention. Methods and Results Our study consisted of 21 patients with an established diagnosis of significant MS or MR and normal RV function, who were admitted for either Balloon Mitral Valvulotomy (BMV) or Mitral Valve Replacement (MVR). 2D echocardiography and measurement of RVGLS was obtained from RV-focused A4CH view. Patients were divided into 2 groups: (1) significant MS consists of 11 patients, (2) significant MR consists of 10 patients. Prior to intervention, MS group had significantly lower RVGLS compared to MR group (-11.64 vs. -18.29; p = 0.001). After MVR, the RVGLS of MS group was significantly increased compared to MR group (MS -11.64 to -15.59, p = 0.001 vs. MR -18.29 to -19.39, p = 0.069). Both MS and MR groups showed significant negative correlation between RVSP and RVGLS before and after intervention (r=-0.642; p = 0.002; r=-0.670; p = 0.001). Conclusion Pre-intervention with a background normal RV function, RVGLS was impaired significantly in MS group compared to MR group. Post intervention RVGLS improved significantly in MS group compared to MR group. Both groups showed significant negative correlation between RVSP and RVGLS before and after intervention.

Percutaneous Mitral Balloon Valvuloplasty: Technique and Results

Background: Percutaneous balloon mitral valvuloplasty is a procedure used to dilate the mitral valve in cases of rheumatic mitral stenosis. The catheter is inserted into the female vein to the right atrium and atrial septum. The mitral valve is then passed through the inflated balloon to facilitate effective integration of mitral adhesions, which increases the area of the mitral valve and decreases the rate of mitral stenosis. Mitral regurgitation is a potential problem, and thus balloon percutaneous mitral valvuloplasty (PBMV) is prevented in moderate to severe relapse. The Wilkins score studies mitral valve morphology and evaluation by echocardiography to assess the viability of PBMVs based on specific echocardiographic conditions.&#x0D; Conclusion: There are many factors in the immediate and long-term outcomes of patients undergoing PMV. Echo-Sc can be used in combination with other clinical and morphological predictions of PMV effects to identify patients who experience the best effects on PMV.

Abstract 12912: Cardiovascular Magnetic Resonance Characterization of Rheumatic Mitral Stenosis: Findings From India, China, and Mexico

Introduction: Cardiac remodeling in rheumatic mitral stenosis (MS) is incompletely understood. Cardiac magnetic resonance (CMR) imaging has the potential to provide more precise characterization of morphologic and functional changes that occur in response to MS. The objective of this study was to describe CMR findings in rheumatic MS to characterize cardiac structural and functional changes in this population. Methods: This retrospective study included 40 patients with rheumatic MS, including 15 patients from China, 19 patients from India, and 6 patients from Mexico. Patients were included in the rheumatic MS cohort if they did not have a prior mitral valve procedure, other concomitant moderate-severe or severe valve disease, or other known cardiovascular conditions. Twenty patients were included in the control group from India. CMR variables pertaining to morphology and function were collected. Late gadolinium enhancement (LGE) sequences were acquired for tissue characterization. Results: Forty patients with rheumatic MS (median (interquartile range (IQR)) age: 45 (34-55) years; 75% women) were studied. Compared to the control group, patients with MS had lower left ventricular (LV) ejection fraction (EF) (51% (42%-55%) vs 60% (57%-65%), p = 0.0001), lower right ventricular (RV) EF (44% (40%-52%) vs 64% (59%-67%), p &lt; 0.0001), larger RV end-diastolic volumes (72 (58-87) mL/m 2 vs 59 (49-69) mL/m 2 , p = 0.003), and larger LA and RA sizes. LGE was prevalent in patients with MS, located at the RV insertion sites. Representative CMR images are shown in the Figure, with the arrows pointing to areas of LGE at the RV insertion sites. Conclusions: These findings further our understanding of the structural and functional changes that occur in response to rheumatic MS, and demonstrate that biventricular dysfunction is underappreciated in contemporary rheumatic MS. Further studies are required to understand the prognostic implications of these findings.

Abstract 11497: Echocardiographic Features of Severe Mitral Stenosis in Three Different Etiologies

Background: In our Heart Center, the cause of mitral stenosis (MS) is usually classified into 3 different categories/etiologies, namely, rheumatic disease, degenerative disease with annular or leaflet calcification, and MS as a consequence of a transcatheter mitral repair with clips for mitral regurgitation. However, differences in the morphology and echocardiographic evaluation among the three etiologies have not been fully elucidated. The aim of this study is therefore to investigate differences in echocardiographic features of these three etiologies of MS. Method: We retrospectively studied 157 patients who underwent three-dimensional transesophageal echocardiography (3D TEE) at Cedars-Sinai Medical Center between January 2012 and December 2020, and had severe mitral stenosis defined as 3D TEE derived mitral valve orifice area (MVA) of ≤ 1.0 cm 2 .These patients also had a mean transmitral pressure gradient of ≥ 5 mmHg on transthoracic echocardiography which was performed within 6 months before and after TEE. Other clinical and echocardiographic characteristics were obtained from medical records. Result: Of 157 patients, 37 patients had rheumatic MS, 60 patients had degenerative calcific MS and 60 patients had post-clip MS. There was no significant difference among the three groups in 3D TEE derived MVA (Table). Despite comparable 3D derived MVA, patients with post-clip MS had significantly lower mean transmitral pressure gradient than those with other 2 types of MS. Patients with rheumatic MS had larger indexed left atrial volume than patients with other 2 types of MS. Patients with degenerative calcific MS and those with post-clip MS had larger MVA both by pressure half time and by continuity equation than patients with rheumatic MS. Conclusion: There were distinct differences in echocardiographic features among the three MS etiologies. The optimal evaluation method and multi-parameter determined grading of MS severity may differ depending on the etiology.

Abstract 10012: The Relationship Between Mitral Valve Regurgitation and Left Atrial Enlargement on the Risk of Stroke and Systemic Embolism in Japanese Atrial Fibrillation Patients: The Fushimi Af Registry

Background: We previously reported that left atrial enlargement (LAE) was an independent predictor of stroke/systemic embolism (SE) in Japanese atrial fibrillation (AF) patients. Mitral regurgitation (MR) likely accompanies LAE; it sometimes causes LAE and conversely LAE can cause secondary MR. However, the relationship between MR and LAE on the risk of stroke/SE is unknown. Purpose: The aim of this study is to investigate the impact of LAE on stroke/SE in AF patients with or without MR. Method: The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto, which is a typical urban district of Japan. We started to enroll patients from March 2011, and follow-up data were available for 4,472 patients by the end of October 2020. In the entire cohort, echocardiography data were available for 3,622 patients. 131 AF patients with rheumatic mitral stenosis or prosthetic valve and 63 patients without data of left atrial diameter (LAD) were excluded. We divided eligible 3,428 patients in MR group (n=393) and non-MR group (n=3,035). We compared clinical characteristics and rates of stroke/SE between patients with LAE (LAD &amp;gt; 45mm) and without LAE (Non-LAE) in each group. Result: In both MR and non-MR groups, patients with LAE were, as compared with non-LAE, more in body weight, more often persistent/permanent type, more likely to have chronic kidney disease. LAE group was older, more likely have heart failure, hypertension, diabetes mellitus and more often received oral anticoagulant in non-MR group, but not in MR group. During the median follow-up of 1,804 days, the incidence rate of stroke/SE was higher in LAE than non-LAE in non-MR group (2.13 vs. 1.08 per 100 person-years, respectively, log rank p&amp;lt;0.001), but it was comparable between LAE and non-LAE groups in MR group (1.23 vs. 1.82 per 100 person-years, respectively, log rank p=0.41). Conclusion: The incidence rate of stroke/SE was higher in LAE than non-LAE in non-MR group, but not in MR group.

Abstract 9414: Utilization of Antithrombotic Therapies in Patients With Atrial Fibrillation Across the Spectrum of Stroke Risk

Introduction: OAC are recommended for AF patients with CHA 2 DS 2 -VASc ≥2 in men or ≥3 in women (high-risk group), may be considered in patients with CHA 2 DS 2 -VASc 1 in men or 2 in women (medium-risk group), and are reasonable to omit in patients with CHA 2 DS 2 -VASc 0 in men or 1 in women (low-risk group). Furthermore, NOACs are recommended over warfarin in most AF patients. This study aimed to investigate AF stroke prevention treatment patterns in patients managed in routine practice, in particular, the under-use of OAC in the high-risk group and over-use in the low-risk group. Methods: Adult patients with AF were identified using de-identified claims for commercial and Medicare Advantage enrollees in the OptumLabs Data Warehouse. Prescription fills were assessed within 90 days of a patient’s AF encounter between 1/1/2016-12/31/2020. Patients with other indications for OAC, such as VTE, recent joint replacement, prior mechanical or bioprosthetic valve replacement, rheumatic mitral stenosis, and patients who underwent LAAO were excluded. Results: Among the 339,197 AF patients, 4.4%, 8.0%, and 87.6% were in the low-, medium-, and high-risk groups, respectively. The mean age was 51.2 ±10.5 yr, 59.9 ±9.4 yr, and 75.1 ±8.8 yr. In the low-risk group, 29.6% were treated with OAC, whereas in the high-risk group, 40.3% were not treated with any antithrombotic therapy and 7.5% used thienopyridine only. Although 71% of patients on OAC were on a NOAC, the proportion of patients on NOAC decreased from 91% in the low-risk group to 69% in the high-risk group. Conclusions: There are potentially both under-use of guideline-recommended stroke prevention therapies in the high-risk patients and over-use in the low-risk group. Because patients at a high risk of stroke are also at a high risk of major and intracranial bleeding who might benefit from NOACs, the decreased use of NOAC in high-risk patients might highlight the need for future quality improvement efforts.