Severe Rheumatic Mitral Stenosis Research Articles

Abstract 4138330: Clinical outcomes in rheumatic mitral stenosis and the novel Yeo’s index

Introduction: Yeo’s index, the product of the mitral leaflet separation index and dimensionless index of mitral valve, was recently described to accurately identify severe rheumatic mitral stenosis (MS). We aimed to study the association between Yeo’s index and clinical outcomes in patients with rheumatic MS. Methods: We studied 297 patients with rheumatic MS. Clinical and echocardiographic data were obtained from the electronic medical record and Yeo’s index was measured in all cases. The outcome studied was a composite of all cause death, heart failure (HF) hospitalisation, mitral valve intervention and stroke or transient ischaemic attack. We also performed subgroup analysis of patients without pre-existing atrial fibrillation (AF) to assess for association with new onset AF. Results: After a median follow up of 6.3 years, 145 patients (48.8%) developed the composite outcome. Yeo’s index ( p <0.001), mitral valve area (MVA) by pressure half-time (PHT) ( p= 0.028) and planimetry ( p <0.001), age ( p =0.016), history of diabetes mellitus ( p =0.029), previous HF ( p =0.021), left ventricular ejection fraction ( p =0.022), and pulmonary artery systolic pressure ( p =0.007) were univariately associated with the composite outcome. Yeo’s index remained independently associated ( p <0.001, HR 0.094, 95% CI 0.260-0.340) with the composite outcome in multivariate analysis. In subgroup analysis of patients without pre-existing AF, Yeo’s index was independently associated ( p =0.024, HR 0.354, 95% CI 0.143-0.874) with new onset AF. MVA by PHT and planimetry were not associated with new onset AF. Conclusion: Yeo’s index was independently associated with clinical outcomes in patients with rheumatic MS.

Differentiation of severe from non-severe mitral stenosis with dimensionless index and its prognostic implications in patients with rheumatic mitral stenosis

Abstract Introduction Accurate identification of the severity of rheumatic mitral stenosis (MS) commonly relies on measurement of mitral valve area (MVA) by transthoracic echocardiography (TTE). The dimensionless index (DI) of mitral valve (MV) was recently shown to be useful in identifying severity of degenerative MS. It is uncertain if DI MV is useful in rheumatic MS. Purpose We aimed to validate the DI MV in rheumatic mitral stenosis, identify threshold values of the DI MV for the accurate identification of severe and non-severe rheumatic MS, and study its association with clinically significant outcomes. Methods We studied DI MV in 406 cases of rheumatic MS, with 174 cases in a derivation cohort , 121 cases in a TTE validation cohort, and 111 cases in a transoesophageal echocardiography (TEE) validation cohort. Outcome data were collected in the derivation and TTE validation cohorts. DI MV was calculated by dividing the left ventricular outflow tract pulsed-wave Doppler time-velocity integral (TVI) by the MV continuous-wave Doppler TVI. Results In the derivation cohort, ROC analysis showed that MV DI was significantly associated with MS severity (AUC = 0.838, 95% CI, 0.780-0.897, p<0.001) but no threshold value was able to identify severe MS (MVA ≤ 1.5 cm2) with both sensitivity and specificity greater than 80%. DI MV ≤ 0.34 had the best combination of sensitivity and specificity (78.5% and 75.8% respectively). However, with an approach using two threshold values, namely DI MV ≤ 0.25 to identify severe MS and DI MV ≥ 0.40 to identify non-severe MS, both values showed a high specificity of 93.7%. When tested in the validation cohorts, these values have similar high specificity for identifying severe (93.8%) and non severe MS (91.4%). DI MV was univariately significant (HR = 0.075, 95% CI 0.0215-0.378, p=0.002) in Cox regression analysis for a composite outcome of death and MV intervention. Multivariate analysis incorporating age, sex, DI MV, pulmonary artery systolic pressure (PASP) and left ventricular ejection fraction (LVEF) showed that age, DI MV and PASP were independently associated with the composite outcome. Conclusion While not a replacement for MVA in the assessment of MS severity, the DI MV can rule-in or rule-out severe MS with a high specificity and is useful as a complementary tool in the integrative assessment of MS severity. DI MV is independently associated with composite outcomes of death and MV intervention.Receiver operating characteristic curveSensitivity and Specificity of DI MV

Evaluation of right ventricular mechanics using exercise echocardiography in asymptomatic patients with severe mitral stenosis.

We aimed to evaluate the effect of exercise echocardiography (EE) on Right ventricular (RV) deformation parameters in asymptomatic patients with severe rheumatic mitral stenosis (MS) (mitral valve area ≤ 1.5 cm2, stage C) and to determine the relation between symptoms and severity of MS. 38 rheumatic MS patients in stage C underwent EE. 20 Patients were defined; as an exercise intolerance group who couldn't reach a maximum heart rate according to their age during exercise due to developing dyspnea The remaining 18 patients who reached a maximum heart rate without dyspnea were defined; as an exercise tolerance group. RV echocardiographic parameters at baseline and peak exercise were compared between the groups. While RV global strain (RV GLS) (21.02 ± 3.33 vs. 21.92 ± 3.03) and RV free wall longitudinal strain (RV FWLS) (23.41 ± 5.66 vs. 25.08 ± 5.00) at baseline were similar in both groups (P = 0.390 P = 0.343), RV GLS (23.38 ± 4.30 vs. 26.05 ± 3.24) and RV FWLS (24.24 ± 5.78 vs. 28.05 ± 4.62) at peak exercise were reduced in exercise intolerance group (P = 0.040 P = 0.033). The best correlations were found between exercise capacity and RV FWLS at baseline and peak exercise in all MS patients (respectively; r = 0.627 P < 0.001; r = 0.697 P < 0.001). RV mechanics has approved the reliability of EE in patients with asymptomatic patients with severe MS. During exercise RV contractile reserve could diminish in MS patients with stage C who develop dyspnea. Moreover, since our study has a close relationship between exercise capacity and RV mechanics, using RV mechanics during exercise echocardiography may be useful for risk stratification in MS patients with severe MS.

Prognostic Value of Pulmonary Artery Systolic Pressure in Severe Rheumatic Mitral Stenosis.

Current guidelines recommend intervention for asymptomatic rheumatic mitral stenosis (MS) with mitral valve area ≤1.5 cm2 based on indicators including pulmonary arterial systolic pressure (PASP) >50 mm Hg and new-onset atrial fibrillation; however, evidence supporting this is lacking. This single-center retrospective study included patients with rheumatic MS between 2006 and 2022. Pulmonary hypertension was evaluated by using echocardiography to estimate PASP. Primary outcomes were major adverse cardiovascular events (MACE), including all-cause mortality, hospitalization for heart failure, and arterial thromboembolic events for up to 5 years. Overall, 287 patients with severe rheumatic MS were enrolled (mean age, 62.5±11.3 years; 74.6% women). During a median follow-up of 2.52 years, MACE occurred in 99 patients. There were no differences in echocardiographic parameters, such as the mean mitral valve pressure gradient, mitral valve area, and proportion of mitral valve area <1.0 cm2, between patients who developed primary outcomes and those who did not. Survival analysis showed a worse prognosis in patients with estimated PASP (ePASP) >50 mm Hg than in those with ePASP ≤50 mm Hg (log-rank P<0.001); however, atrial fibrillation was not a significant prognostic indicator. As a continuous variable, ePASP (mm Hg) was a significant predictor of MACE (adjusted hazard ratio, 1.027 [95% CI, 1.011-1.042]; P<0.001). Receiver operating characteristic analysis revealed an optimal ePASP threshold of >45 mm Hg, which was an independent predictor of MACE in patients with severe rheumatic MS (adjusted hazard ratio, 2.127 [95% CI, 1.424-3.177]; P<0.001). Competing risk analysis considering mitral valve intervention as a competing risk showed similar results. Our study demonstrated the prognostic significance of ePASP, rather than atrial fibrillation, in relation to MACE among patients with severe rheumatic MS. Additionally, we proposed a lower ePASP threshold (>45 mm Hg) as a predictor of an unfavorable prognosis.

Influence of Right Atrial Pressure on the Prognosis of Patients with Rheumatic Mitral Stenosis Undergoing Percutaneous Mitral Balloon Valvuloplasty.

Pulmonary hypertension (PH) often complicates mitral stenosis (MS). The prognostic impact of pulmonary vascular resistance (PVR) in MS patients remains unclear. Previous study has demonstrated the prognostic impact of right atrial pressure (RAP) in patients with primary PH. We aim to determine the prognostic impact of PVR and RAP in patients with rheumatic MS undergoing percutaneous mitral balloon valvuloplasty (PMBV). A total of 58 patients with symptomatic severe rheumatic MS who underwent PMBV between 2016 and 2020 were included. Patients were divided into two groups: PVR ≤ 2WU (N = 26) and PVR > 2WU (N = 32). The composite endpoint included death, reintervention or persistent NYHA functional class III-IV during follow-up. The median age was 50 (42-60) years, with 82.8% being female. Median pulmonary artery systolic pressure (PASP) was 42 (35-50.5) mmHg. Patients with PVR ≤ 2WU had lower PASP on both echocardiogram and catheterization. The PMBV success rate was 75.9%. Multivariate analysis, adjusted for PVR, showed RAP as the only independent predictor of the composite endpoint (HR:1.507, 95% CI:1.015-2.237, p = 0.042). The optimal RAP cutoff was 9.5 mmHg (HR:3.481, 95% CI:1.041-11.641; p = 0.043). RAP was an independent predictor of adverse outcomes in patients with rheumatic MS undergoing PMBV, while PVR did not show prognostic significance. These findings suggest that the prognostic value of PVR may be lower than expected.

Immediate and short-term outcomes of percutaneous balloon mitral commissurotomy for severe mitral stenosis at a Resource Limited Setting, Addis Ababa, Ethiopia

BackgroundRheumatic heart disease is a common cause of mitral stenosis (MS) in developing nations. Percutaneous mitral balloon commissurotomy (PMBC) is the treatment of choice for patients with MS with favorable anatomy. ObjectiveThis study aimed to assess immediate and short-term outcomes of percutaneous balloon mitral commissurotomy for symptomatic patients with rheumatic severe mitral stenosis. MethodsThe clinical records of patients who underwent Percutaneous Mitral Balloon Commissurotomy (PBMC) at Saint Paul Hospital Millennium Medical College, Cardiac Center were reviewed. A retrospective observational study was conducted from February 01, 2018, to August 30, 2021. All eligible patients who underwent Percutaneous Mitral Balloon Commissurotomy during the study period at the cardiac center were included in this study. Ninety-one patients were enrolled in the study after excluding repeat procedures, those with incomplete data, and lost medical records. Data were collected through chart reviews using a structured questionnaire by trained physicians, with daily supervision by the investigators. Data analysis was performed using SPSS version 25. Associations were checked using a paired t-test and Fisher's Exact Test, with statistical significance set at a p-value of <0.05. ResultPercutaneous mitral balloon commissurotomy was successful in 91.2 % of patients. Following the procedure, there was a significant increase in the mean mitral valve area from 0.799 cm2 to 1.674 cm2 and a reduction in the trans-mitral mean pressure gradient from 20 mmHg to 7.71 mmHg (P < 0.001). Atrial fibrillation and a high Wilkins score were identified as correlates of non-successful PMBC. A Wilkin's score of ≤8 and a post-procedure mitral valve area > 1.5 cm2 were associated with New York Heart Association functional class improvement three months after the procedure. ConclusionIn this study, percutaneous mitral balloon Commissurotomy (PMBC) demonstrated an excellent success rate. The majority of patients exhibited significant improvement in the New York Heart Association (NYHA) functional class.

Bilateral Acute Limb Ischemia due to Severe Rheumatic Mitral Stenosis and Atrial Fibrillation with Neglected International Normalized Ratio Control

Bilateral Acute Limb Ischemia due to Severe Rheumatic Mitral Stenosis and Atrial Fibrillation with Neglected International Normalized Ratio Control

Impact of Procedural Success Definitions on Long-Term Outcomes in Patients With Rheumatic Mitral Stenosis Treated With Percutaneous Balloon Mitral Valvuloplasty: A Multicenter, Retrospective Cohort Study.

It is uncertain which percutaneous balloon mitral valvuloplasty (PBMV) success definitions should be used because there are no studies comparing the effects of these definitions on subsequent outcomes. We evaluated the association between 3 success definitions and long-term clinical outcomes in patients with rheumatic mitral stenosis who underwent PBMV. This multicenter retrospective study included patients with severe rheumatic mitral stenosis who underwent PBMV. Three definitions were used as follows: (A) post-PBMV mitral valve area (MVA) ≥1.5 cm2 or ≥50% increase in MVA with MR <3+; (B) post-PBMV MVA ≥1.5 cm2 and MR ≤2+; and (C) post-PBMV MVA ≥1.5 cm2 or ≥50% increase in MVA, with no more than 1-grade increment in MR. Multivariable Cox regression analyses were performed to evaluate the associations between PBMV success and the composite of all-cause mortality, mitral surgery, and repeat PBMV. Successful PBMV, according to definitionsA, B, and C was associated with a lower risk of the composite outcomes (definitionA-hazard ratio [HR], 0.55 [95% CI, 0.43-0.69], definitionB-HR, 0.55 [95% CI, 0.43-0.69], definitionC-HR, 0.55 [95% CI, 0.44-0.69]). Patients meeting all 3 success definitions had the lowest risk compared with those who did not meet any definition or met 1 or 2 definitions. All 3 success definitions had a prognostic impact on outcomes. Patients who achieved post-PBMV MVA ≥1.5 cm2, irrespective of the percentage increase in MVA, and MR ≤grade 2, with no more than a 1-grade increment in MR, had the most favorable outcomes.

Mid-term results of percutaneous transmitral commissurotomy (PTMC) in central iran

Objectives: Percutaneous Trans-Mitral Commissurotomy (PTMC) is an effective non-surgical treatment in patients with severe rheumatic mitral valve stenosis. This study aimed to evaluate the mid-term results of this procedure in central Iran. Methods: This retrospective study was performed on 101 patients with severe mitral valve stenosis who underwent successful PTMC from March 2011 to September 2018 in Afshar Hospital in Yazd. At follow-up, all patients underwent clinical examination, two-dimensional and color Doppler echocardiography, and events were recorded. Data were analyzed using SPSS software version 19. Results: The mean age of the patients was 44.79± 11.72 years, and 83.3% were female. The mean follow-up time was 38.98 23.33 months (6-94 months).25.8% had AF rhythm, and 12% had previous PTMC or OMVC or CMVC. After percutaneous Trans-Mitral Commissurotomy, 97% of patients were in NYHA functional class I, II and the mitral valve area (MVA) increased from 0.92 ± 0.18 to 1.66± 0.29 cm2 (p&lt;0.0001). Pulmonary artery systolic pressure decreased from 46.96± 18.56 mmHg to 38.43±14.02 mmHg (p&lt;0.0001). The Mean mitral valve gradient decreased from 12.37± 3.99 mmHg to 4.79± 2.38 mmHg (p&lt;0.0001). Restenosis rate and severe mitral regurgitation resulting in mitral valve replacement (MVR) were 10.9% and 2%, respectively. Two patients died because of intracranial hemorrhage (ICH). During the follow-up event, free survival was 82.2%. Multivariable analysis revealed that the predictors of shorter event-free survival were AF rhythm (HR; 4.5, 95%CI;1.59-12.9, P=0.005) and post PTMC higher NYHA functional class (HR;2.2, CI;1-4.8,p=0.049). Conclusions: Mid-term results of percutaneous transmitral commissurotomy (PTMC) in central Iran are the same as in other parts of the world. This procedure is an effective and low-risk treatment for severe mitral valve stenosis.

Incidence and predictors of adverse outcomes in patients with rheumatic mitral stenosis following percutaneous balloon mitral valvuloplasty: a study from a tertiary center in Thailand

BackgroundRheumatic mitral stenosis (MS) remains a common and concerning health problem in Asia. Percutaneous balloon mitral valvuloplasty (PBMV) is the standard treatment for patients with symptomatic severe MS and favorable valve morphology. However, studies on the incidence and predictors of adverse cardiac outcomes following PBMV in Asia have been limited. This study aims to evaluate the incidence and predictors of adverse outcomes in patients with rheumatic MS following PBMV.MethodsA retrospective cohort study was conducted on patients with symptomatic severe MS who underwent successful PBMV between 2002 and 2020 at a tertiary academic institute in Thailand. Patients were followed up to assess adverse outcomes, defined as a composite of cardiac death, heart failure hospitalization, repeat PBMV, or mitral valve surgery. Univariable and multivariable analyses were performed to identify predictors of adverse outcomes. A p-value of < 0.05 was considered statistically significant.ResultsA total of 379 patients were included in the study (mean age 43 ± 11 years, 80% female). During a median follow-up of 5.9 years (IQR 1.7–11.7), 74 patients (19.5%) experienced adverse outcomes, with an annualized event rate of 2.7%. Multivariable analysis showed that age (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.008–1.05, p = 0.006), significant tricuspid regurgitation (HR 2.17, 95% CI 1.33–3.56, p = 0.002), immediate post-PBMV mitral valve area (HR 0.39, 95% CI 0.25–0.64, p = 0.01), and immediate post-PBMV mitral regurgitation (HR 1.91, 95% CI 1.18–3.07, p = 0.008) were independent predictors of adverse outcomes.ConclusionsIn patients with symptomatic severe rheumatic MS, the incidence of adverse outcomes following PBMV was 2.7% per year. Age, significant tricuspid regurgitation, immediate post-PBMV mitral valve area, and immediate post-PBMV mitral regurgitation were identified as independent predictors of these adverse outcomes.

Assessment of Coagulation Factors in Patients with Severe Rheumatic Mitral Stenosis in Sinus Rhythm with Left Atrial Appendage Inactivity

BackgroundPatients with severe mitral stenosis (MS) in normal sinus rhythm (NSR), presenting with left atrial appendage (LAA) inactivity and associated left atrial spontaneous echo contrast (LASEC) are prone to left atrium (LA) or LAA thrombus formation. But unlike for atrial fibrillation, oral anticoagulants are not commonly prescribed for this patient subset. This study aimed to compare the levels of procoagulants and fibrinogen in both local (LA) and systemic contexts between patients with severe MS in NSR vs those in healthy control subjects. MethodsThe study involved 35 patients with severe MS in NSR with LAA inactivity and LASEC who were eligible for balloon mitral valvuloplasty vs 35 healthy controls. All patients underwent transthoracic and transesophageal echocardiography to assess MS severity, LAA activity, and LASEC grade, and had blood samples analyzed for procoagulant levels. ResultsResults showed comparable baseline characteristics between groups, with most patients in the New York Heart Association II or III functional classes, and with varying LASEC grades. Patients exhibited significantly higher levels of prothrombin fragment 1 + 2 [patient vs control, 9017 pg/mL (6228.0-10,963.5) vs 1790 pg/mL (842.3-2712), P < 0.0001], thrombin-antithrombin III [patient vs control, 39 ng/mL (5.45-74.85) vs 2.80 ng/mL (1.6-6.5), P < 0.0001], plasminogen activator inhibitor-1 (patients vs controls, 26.09 ± 8.18 ng/mL vs 8.05 ± 3.53 ng/mL, P < 0.0001), and fibrinogen (3.48 ± 0.89 g/L vs 3.01 ± 0.53 g/L, P = 0.029) in the LA of patients, compared to those in control subjects. Systemic procoagulant levels also were elevated in patients, but D-dimer levels were similar between the 2 groups. ConclusionsThe findings suggest a hypercoagulable state in patients, similar to that in patients with atrial fibrillation. The study advocates for consideration of use of oral anticoagulants in these patients until LA and LAA function improves, to mitigate thrombus formation.

Giant Eustachian Valve Mimicking an Inter-atrial Septal Defect

A 68-year-old woman presented with dyspnoea attributed to acute pulmonary oedema. Due to an audible diastolic murmur, a transthoracic and transoesophageal echocardiogram (TEE) was performed revealing severe rheumatic mitral stenosis and regurgitation. Although initial assessment of the interatrial septum did not reveal any atrial septal defects, upon TEE evaluation using a 112° window, an interatrial defect was seen, with turbulent flow seen through this. However, using multiplanar imaging, a separate elongated Eustachian valve was shown to be mimicking an ‘arm’ of the interatrial septum and giving rise to the illusion of a defect. The Eustachian valve is a congenital remnant which often regresses at birth but can exist as an elongated structure originating from the inferior portion of the right atrium and may appear as an atrial septal defect. By employing multiplanar imaging on TEE, we were able to systematically discern the reason behind the apparent defect and avoid further delays to the patient’s care.

Percutaneous Mitral Balloon Valvuloplasty in a Patient with Situs Inversus with Dextrocardia: A Case Report

Situs inversus with dextrocardia is a rare congenital disorder. There is a rare coincidence of rheumatic severe mitral stenosis in a patient with situs inversus and dextrocardia. Most of these patients undergo surgery due to technical difficulty, here we report a case of a 41-year-old male managed successfully with percutaneous intervention. Percutaneous mitral balloon valvuloplasty (PMBV) is feasible in these rare group patient with some additional modifications of the standard Accura balloon technique. Procedure should be carried out under Transthoracic echocardiography (TEE) guidance with surgical team standby in case emergency need of surgery. Despite all the precautions, careful watch on these patients has to be kept during immediate post procedure phase for at least 12 hours for any untoward complication.

Serum 25(OH)D Levels and Mitral Valve Calcification in Patients with Severe Rheumatic Mitral Stenosis

Background: Rheumatic heart disease (RHD) imposes a significant burden on patients and the health system, especially in the developing countries. Recently, the role of vitamin D deficiency in increasing the severity of valve involvement and calcification in patients with RHD has been suggested. However, its role in the severe stenosis of the mitral valve is unknown. The aim of this study was to determine the relationship between serum levels of 25(OH)D and mitral involvement severity scores in patients with severe mitral stenosis (MS). Materials and Methods: In this cross-sectional study conducted in Shahid Madani Heart Center, Tabriz, Iran, 104 patients with severe rheumatic MS were reviewed, in the absence of other underlying diseases. Trans-esophageal Echocardiography was performed for all patients, and mitral valve Wilkins score and mitral valve area were calculated. Blood samples were taken from patients and levels of 25(OH)D, total calcium, phosphorus, and i-PTH were measured. Results: Eighty eight cases were female and 16 were male. Eighty-one patients had mild to moderate mitral calcification and in 23 patients with mitral valve was severely calcified. Furthermore, 54 were vitamin D deficient, while 35 had insufficient vitamin D levels, and only 15 had normal blood levels of vitamin D. In addition high serum iPTH levels were present in 83 patients (80%). The levels of 25(OH)D, calcium, phosphorous, and iPTH with total Wilkins score, calcification score and mitral valve area were not significantly correlated (p&gt;0.05 for all above). Conclusions: Although no correlation was found between the severity of mitral valve involvement, and vitamin D and iPTH levels, vitamin D deficiency and secondary hyperparathyroidism tend to be common among patients with severe rheumatic MS, which may play a role in the progression of the disease.

Relationship between New York functional class and duke activity status index with the severity of mitral valve stenosis and echocardiographic parameters: is left atrial strain a better predictor?

Purpose This study aimed to investigate the relationship between symptoms of patients with severe mitral stenosis (MS), evaluated by the New York Heart Association (NYHA) functional class and Duke Activity Status Index (DASI) score, and echocardiographic parameters. We evaluated patients with severe rheumatic MS diagnosed as mitral valve area (MVA) less than 1.5 cm2. All patients underwent transthoracic echocardiography and the left atrium (LA) reservoir auto-strain (LASr) analysis. In addition, DASI and NYHA scores were determined to evaluate the functional capacity and symptoms of MS patients. We evaluated 60 patients with MS with a mean age of 50.13 ± 10.28 and a median DASI score of 26.95 (26.38). There were 6 (10%) and 28 (46.7%) patients with NYHA class I and II, and 25 (40.0%) and 2 (3.3%) patients with NYHA class III and IV, respectively. NYHA class was positively correlated with LA area (LAA, r = 0.638), LA volume (LAV, r = 0.652), LAV index (LAVI, r = 0.62), E (r = 0.45), A (r = 0.25), and pulmonary artery pressure (PAP, r = 0.34), while negatively correlated with LASr (r=-0.73) and MVA (r=-0.417). Furthermore, the DASI score was positively associated with LASr (r = 0.81) and MVA (r = 0.52) while negatively correlated with LAA (r=-0.62), LAV (r=-0.65), LAVI (r=-0.56), E (r=-0.46), A (r=-0.3), and PAP (r= -0.32). Our findings indicate that LAA, LAV, LAVI, E, A, PAP, MVA, and LASr are associated with NYHA and DASI scores in MS patients. Additionally, the LASr had the strongest correlation between all measured parameters in severe MS patients.

Transthoracic echocardiography-guided PBMV for severe rheumatic mitral stenosis with pregnancy.

Transthoracic echocardiography-guided PBMV for severe rheumatic mitral stenosis with pregnancy.

Left Ventricle Myocardial Work Correlated with Functional Capacity in Severe Rheumatic Mitral Stenosis with Preserved Left Ventricular Ejection Fraction.

Functional capacity is reduced in mitral stenosis (MS) patients. Previous studies showed a correlation between left atrial strain and functional capacity in this population. However, currently, no left ventricle (LV) echocardiographic parameters were associated with functional capacity in patients with MS. Noninvasive LV pressure-strain loop analysis is a new echocardiographic method for evaluating LV function, integrating longitudinal strain from speckle-tracking analysis and noninvasively measured blood pressure to estimate myocardial work (MW) that overcomes the preload-dependent characteristics conventional parameters by integrating afterload. This study aimed to evaluate the association between MW and functional capacity measured using exercise tests in patients with severe MS and preserved LV ejection fraction (LVEF). Adult patients with symptomatic severe rheumatic MS (mitral valve area <1.5 cm2), and preserved LVEF (>50%) and sinus rhythm who underwent echocardiography and exercise stress test in our hospital from 2019 to 2021 were included. Exclusion criteria were suboptimal image quality for myocardial deformation analysis, significant mitral regurgitation or aortic valve lesions, coronary artery disease, intracardiac shunt, and atrial fibrillation. Standard echocardiographic parameters were measured, and all MW parameters were included. Exercise treadmill testing was performed using the modified Bruce protocol. A total of 33 individuals with isolated severe rheumatic MS in sinus rhythm (age 39.8 ± 9.8 years) were included in the study. Patients with severe isolated MS showed significantly impaired LV-global longitudinal strain values compared to normal reference values. Furthermore, patients with severe MS showed significantly lower values of global work index, global constructive work, and efficiency compared to normal values and higher wasted work. Global work efficiency was significantly correlated to the duration of exercise (P = 0.025, Pearson's r = 0.389). In stable patients with isolated severe mitral stenosis, MW efficiency significantly correlated with functional capacity measured objectively through exercise testing.

Balloon mitral valvuloplasty in low gradient severe rheumatic mitral stenosis: Immediate and short-term outcomes

BackgroundEfficacy of balloon mitral valvuloplasty (BMV) in low gradient severe rheumatic mitral stenosis (MS) is not very well defined. This study was undertaken to evaluate the outcomes of BMV in low gradient severe rheumatic MS. MethodsSevere MS was defined as mitral valve area < 1.5 cm2. Low gradient was defined as mean diastolic trans-mitral gradient (MG) < 10 mmHg and low flow as stroke volume index < 35 ml/m2 on echocardiography. Sixty patients were divided into normal-flow/low-gradient (NFLG) (40) and low-flow/low-gradient (LFLG) (20) groups. Post-BMV parameters were recorded after 72 h and at the end of one year. ResultsMean age was 36.2 ± 6.6 years in NFLG group and 40.6 ± 2.6 years in LFLG group (p < 0.01) and females were 75 % (n = 30) in NFLG group as compared to 60 % (n = 12) in LFLG group. Patients in the LFLG group had higher Wilkins score (p < 0.02) and prevalence of atrial fibrillation (n = 8, 40 %) as compared to NFLG group (n = 7, 17.5 %; p < 0.01). A greater decrease in MG was observed in NFLG group (p < 0.01), whereas increase in MVA was comparable in both the groups (p > 0.05). Ninety percent (n = 36) patients improved in NFLG group in comparison to 70 % (n = 14) in LFLG group (p < 0.01). At the end of one-year, symptomatic improvement persisted in all patients who became asymptomatic post-BMV. ConclusionSymptomatic improvement following BMV was better seen in NFLG group because of greater decrease in MG in comparison to LFLG group. Results of BMV were suboptimal in LFLG group because of higher sub-valvular obstruction, increased age and higher prevalence of AF.

An unusual angiogram finding in a patient with rheumatic heart disease.

A woman in her early fifties with a known case of severe rheumatic mitral stenosis presented to the out-patient department with increasing breathlessness.

Optimizing Percutaneous Mitral Valvuloplasty for Rheumatic Mitral Stenosis - Clinical Significance of Changes in Mitral Valve Area.

Percutaneous mitral valvuloplasty (PMV) is a standard treatment for severe rheumatic mitral stenosis (RMS). However, the prognostic significance of the change in mitral valve area (∆MVA) during PMV is not fully understood.Methods and Results: This study analyzed data from the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, which included 3,140 patients with severe RMS. We focused on patients with severe RMS undergoing their first PMV. Changes in echocardiographic parameters, including MVA quantified before and after PMV, and composite outcomes, including mitral valve reintervention, heart failure admission, stroke, and all-cause death, were evaluated. An optimal result was defined as a postprocedural MVA ≥1.5 cm2without mitral regurgitation greater than Grade II. Of the 308 patients included in the study, those with optimal results and ∆MVA >0.5 cm² had a better prognosis (log-rank P<0.001). Patients who achieved optimal results but with ∆MVA ≤0.5 cm² had a greater risk of composite outcomes than those with optimal outcomes and ∆MVA >0.5 cm² (nested Cox regression analysis, hazard ratio 2.27; 95% confidence interval 1.09-4.73; P=0.028). Achieving an increase in ∆MVA of >0.5 cm2was found to be correlated with improved outcomes. This suggests that, in addition to achieving traditional optimal results, targeting an increase in ∆MVA of >0.5 cm2could be a beneficial objective in PMV treatment for RMS.