Severe Rheumatic Mitral Stenosis Research Articles

Shifts in Clinical Characteristics, Treatment, and Outcome for Rheumatic Mitral Stenosis: Insights From a 20-Year Multicentre Registry Study in Korea.

The rapid economic development of South Korea provides a unique model to study changes in the clinical characteristics, treatment approaches, and clinical outcomes of patients with rheumatic mitral stenosis (MS) relative to socioeconomic growth. From the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, 2,337 patients diagnosed with moderate or severe rheumatic MS between January 2001 and December 2020 were analyzed. Patients were grouped into consecutive 5-year intervals based on their year of diagnosis. Clinical characteristics, echocardiographic data, and clinical outcomes were assessed. Over 20 years, the severity of mitral stenosis increased from 79.1% to 90.2%; similarly, the average age at diagnosis increased from 54.3 to 63.0 years (all P < 0.001). Comorbidities such as hypertension and atrial fibrillation increased (6.3% to 29.5% and 41.4% to 46.9%, respectively; all P for trend < 0.05). The rate of mitral intervention within five years after diagnosis increased from 31.2% to 47.4% (P for trend < 0.001). However, clinical outcomes of rheumatic mitral stenosis deteriorated over time in the composite outcomes (log-rank test, P < 0.001). Conversely, the incidence of stroke remained stable (60.6-73.7%; P < 0.001), which might be attributed to the increased use of anticoagulation therapy. This study observed an increase in patient age, comorbidities, and valve disease severity as the country transitioned from a developing to developed status. Despite a rise in mitral valve interventions, clinical outcomes deteriorated over 20 years, highlighting the need for modified treatment approaches to improve patient outcomes.

Severe Mitral Stenosis Presenting as Chronic Liver Disease: A Rare Case Report

High Serum Ascites Albumin Gradient (SAAG) ascites in severe rheumatic mitral stenosis is very uncommon. Hereby, the authors present a similar case with this rare combination. The present case report describes a 42-year-old male with no history of hypertension or diabetes, but occasional alcohol consumption, who presented to department with complaints of recurrent anasarca over the past five years. The electrocardiogram showed an irregular R-R interval with no P waves, indicating atrial fibrillation. Ascitic fluid analysis revealed a high serum ascites albumin gradient with low ascitic protein levels. The patient responded well to treatment and was discharged with appropriate medications. He was referred to a higher centre with cardiothoracic surgical facilities for mitral valve replacement and tricuspid annuloplasty. The present case report highlights the uniqueness of the combination of severe rheumatic mitral stenosis and ascites.

Immediate, short-term, and long-term effects of balloon mitral valvuloplasty on the left atrial global longitudinal strain and its correlation to the outcomes in patients with severe rheumatic mitral stenosis

BackgroundLeft atrial global longitudinal strain (LA GLS) has been used as a new assessment tool for left atrial function. This article aims to investigate the effect of balloon mitral valvuloplasty (BMV) in patients with severe rheumatic mitral stenosis on LA GLS and its relation to the mitral valve area achieved after the procedure. The study included 95 patients with severe mitral stenosis who fulfilled the criteria for BMV (case group) and 80 normal healthy subjects (control group). All included participants underwent complete echocardiographic examinations. For the case group, LA GLS was assessed by 2D speckle-tracking Echocardiography before valvuloplasty, immediately after, within 24 h, at 6 months, and at 12 months, and the results were compared.ResultsThe impaired left-atrium strain in patients with severe mitral stenosis was improved immediately after BMV, and the improvement continued at 6 and 12 months post-BMV (23.1% ± 4.2 vs. 36.0% ± 4.9, 36.2% ± 4.5, and 40.1% ± 9.5, respectively p < 0.01). After BMV, there was a significant decrease in left atrial volume (76.3 ± 12.4 ml/m2 vs. 68.6 ± 10.4 ml/m2, p < 0.01) and a significant increase in the area occupied by the mitral valve (1.02 ± 0.18 cm2 vs. 1.60 ± 0.31 cm, p < 0.01). The immediate LA GLS and the mitral valve area were positively correlated (r = 0.64, p < 0.01). Furthermore, the immediate LA GLS was associated with significantly improved function class (p < 0.01).ConclusionsLA GLS can indicate left atrial (mainly reservoir) function. The improvement observed in patients after BMV may indicate that LA GLS can be used to evaluate the progress after BMV.Trial registration: The study was approved by the local ethics committee of the Faculty of Medicine in Minia University (Registration No. MUFMIRB 324-4-2022). Institutional Review Board, Faculty of Medicine, Minia University, Egypt. 324-4-2022, 24 18 April, 2022.

Segmental and global longitudinal strain measurement by 2-dimensional speckle tracking echocardiography in severe rheumatic mitral stenosis.

The present study aimed to detect subtle left ventricular (LV) dysfunction in patients with severe rheumatic mitral stenosis (MS) by measuring global and segmental longitudinal strain with a two-dimensional speckle tracking echocardiography (2D-STE) method. In this case-control study, 65 patients with severe rheumatic MS and preserved ejection fraction (EF ≥ 50% measured by conventional echocardiographic methods) were compared with 31 otherwise healthy control subjects. All patients underwent LV strain measurement by the 2D-STE method in addition to conventional echocardiography using a VIVID S60 echocardiography device. Absolute strain values in myocardial segments 1-8, 10, and 12 (all basal, mid anterior, mid anteroseptal, mid inferior, and mid anterolateral segments) were significantly lower in patients with severe MS compared with the control group (P < 0.05 for all). The absolute global longitudinal strain (GLS) value was higher in the control group (-19.56 vs. -18.25; P = 0.006). After adjustment for age, gender, and systolic blood pressure, the difference in GLS between the two groups was as follows: mean difference=-1.16; 95% CI: -2.58-0.25; P = 0.110. In patients with severe rheumatic MS and preserved EF, the absolute GLS tended to be lower than healthy controls. Furthermore, the segmental strain values of LV were significantly lower in most of the basal and some mid-myocardial segments. Further studies are warranted to investigate the underlying pathophysiology and clinical implications of this subclinical dysfunction in certain segments of patients with severe rheumatic MS.

Thirty-year follow-up of patients submitted to percutaneous balloon mitral valvuloplasty for severe rheumatic mitral stenosis

Abstract Background Percutaneous balloon mitral valvuloplasty (PBMV) remains the mainstay of treatment for patients with severe rheumatic mitral stenosis (MS) and a favorable anatomy. Aim The present study aimed to assess very long-term outcomes after PBMV. Methods A retrospective analysis of PBMV performed at a single tertiary center between August 1991 and September 2022 was conducted. Successful PBMV was defined as a post-procedural functional mitral valve area (MVA) ≥1.5 cm2, mitral regurgitation less than moderate, and absence of in-hospital major cardiac or cerebrovascular events. The primary endpoint was composed of overall mortality and need for mitral reintervention (percutaneous and/or surgical). Results A total of 238 PBMV for severe rheumatic MS were conducted in our center during the specified timeframe (88.7% [n=211] female gender; mean age 48 ± 16 years; 48.6% [n=108] had atrial fibrillation [AFib]; 78.8% [n=149] had a Wilkins score ≤8). Acute success was achieved in 88% (n=198) procedures. Acute complications were present in 10.2% (n=23), mainly severe mitral regurgitation (n=10) and acute cerebrovascular events (n=5). During a mean follow-up of 15.3 ± 9.4 years, the incidence of the primary endpoint was 55% (n=131) (overall mortality 32.9% [n=77] and mitral valve reintervention 22.1% [n=54]). On bivariate analysis, higher age (p=0.042), presence of AFib (p=0.002), unsuccess of the procedure (p&amp;lt;0.001), acute complications (p=0.001) and larger left atrial (LA) diameter (p=0.05) were statistically significant for the occurrence of the primary endpoint. On multivariate analysis, larger LA diameter (hazard ratio [HR]: 1.03; 95% CI: 1.00-1.06; p=0.022), unsuccessful procedure (HR: 3.30; 95% CI: 1.56-7.01; p=0.002) and presence of complications (HR: 0.37; 95% CI: 0.17-0.84; p=0.017) were the only independent predictors of the primary endpoint. Conclusion In a large registry of patients submitted to PBMV for severe rheumatic MS, more than half met the primary endpoint for overall mortality or need for reintervention, up to 30 years after the procedure. This supports the dismal prognosis of this pathology. Prediction of late favorable results is multifactorial and appears to be determined by smaller LA diameter, absence of complications and acute success of the procedure.Event-free survival after PBMV

Abstract 15170: Prognostic Implication of Left Atrial Reservoir Strain in Severe Mitral Stenosis With Low Transmitral Diastolic Pressure Gradient: Result From Long-Term Follow-Up Registry

Background: Prognosis of severe mitral stenosis (MS) with low transmitral mean diastolic pressure gradient (MDPG) has not been fully understood with lack of long-term follow-up study. Aims: We investigated the prognostic implication in severe MS with low MDPG. Methods: We included patients with severe rheumatic MS (mitral valve area [MVA] &lt; 1.5 cm 2 ) from the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry. Patients with severe MS were categorized into high (≥ 5 mmHg) or low (&lt; 5 mmHg) MDPG groups. The primary outcome was a composite of all-cause mortality and stroke. Among 1,248 patients with severe MS, 322 (25.8%) had low and 926 (74.2%) had high MDPG. Results: Their mean age was 59±13 years, 25% were men, and 74% had atrial fibrillation. Patients with low MDPG were older and had a higher prevalence of atrial fibrillation. During a mean follow-up of 6.8±5.9 years, 194 patients (15.5%) experienced composite events. Patients with severe MS and low MDPG had a higher risk of experiencing composite events compared to those with high MDPG (hazard ratio [HR]: 1.56, 95% CI: 1.15-2.12; p=0.004). Subgroup analysis with low MDPG revealed that decreased left atrial reservoir strain (LARs) was independently associated with poorer outcome (HR, 2.58, 95% CI: 1.08-6.20; p=0.034). Conclusion: Severe MS patients with low MDPG are at higher risk of adverse events compared to those with high MDPG. The assessment of LARs can be useful in identifying subgroups of low MDPG severe MS patients with poor prognosis.

Abstract 14880: Optimizing Percutaneous Mitral Valvuloplasty for Rheumatic Mitral Stenosis: Clinical Significance of Mitral Valve Area Changes

Introduction: Percutaneous mitral valvuloplasty (PMV) is an established treatment for severe rheumatic mitral stenosis (RMS). However, there is limited data on the clinical significance of mitral valve area change (ΔMVA) during PMV on prognosis. Hypothesis: The prognosis improves with greater post-procedure ΔMVA. Methods: Data from the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, which included 3,140 patients with at least moderate RMS were analyzed. Out of those, patients with severe RMS (MVA &lt; 1.5 cm 2 ) who underwent their first PMV were included for analysis. Changes in echocardiographic parameters before and after PMV were calculated, and composite outcomes including all-cause death, heart failure admission, stroke, and mitral valve re-intervention were evaluated. Results: A total of 295 patients were included, and during the median follow-up of 91.1 months, composite outcomes occurred in 76 patients (16.5% in optimal and ΔMVA &gt; 0.5 cm2 group vs. 27.7% in optimal but ΔMVA ≤ 0.5 cm2 group vs. 35.7% in suboptimal group, respectively). Patients who achieved optimal results with ΔMVA &gt; 0.5 cm 2 had a better prognosis compared to other groups. (log-rank p=0.002). The group with optimal result but ΔMVA ≤ 0.5 cm2 had a higher risk for composite outcomes compared to the group with ΔMVA &gt; 0.5 cm2 (Hazard’s Ratio: 2.29, 95% confidence interval: 1.11-4.72, p=0.024). Conclusions: Achieving a significant increase in ΔMVA of at least 0.5 cm 2 can improve prognosis, and this could be recommended as an additional objective during PMV, in addition to the traditional optimal targets.

Left atrial size predicts long-term outcome after balloon mitral valvuloplasty.

The treatment of choice for severe rheumatic mitral stenosis is balloon mitral valvuloplasty (BMV). Numerous predictors of immediate and long-term procedural success have been described. The aims of this study were to describe our experience with BMV over the last decade and to evaluate predictors of long-term event-free survival. Medical records were retrospectively analyzed of patients who underwent BMV between 2009 and 2021. The primary outcome was a composite endpoint of all-cause mortality, mitral valve replacement (MVR), and repeat BMV. Long-term event-free survival was estimated using Kaplan-Meier curves. Logistic regression was used to create a multivariate model to assess pre-procedural predictors of the primary outcome. A total of 96 patients underwent BMV during the study period. The primary outcome occurred in 36 patients during 12-year follow-up: one (1%) patient underwent re-BMV, 28 (29%) underwent MVR, and eight (8%) died. Overall, event-free survival was 62% at 12 years. On multivariate analysis, pre-procedural left atrial volume index (LAVI) > 80 mL/m2 had a significant independent influence on event-free survival, as did previous mitral valve procedure and systolic pulmonary arterial pressure above 50 mmHg. Despite being a relatively low-volume center, excellent short and long-term results were demonstrated, with event-free survival rates consistent with previous studies from high-volume centers. LAVI independently predicted long-term event-free survival.

Immediate, short-term, and long-term effects of balloon mitral valvuloplasty on the left atrial global longitudinal strain and its correlation to the outcomes in patients with severe rheumatic mitral stenosis

Abstract Background Global longitudinal left atrial strain (GLS) has been used as a new assessment tool for left atrial function. Aim To investigate the effect of balloon mitral valvuloplasty (BMV) in patients with severe rheumatic mitral stenosis on GLS and its relation to the mitral valve area achieved after the procedure. Methods The study included 95 patients with severe mitral stenosis who fulfilled the criteria for BMV (case group) and 80 normal healthy subjects (control group). All included participants underwent complete echocardiographic examinations. For the case group, GLS was assessed by 2D speckle-tracking Echocardiography before valvuloplasty, immediately after, within 24 h, at 6 months, and at 12 months, and the results were compared. Results The impaired left-atrium strain in patients with severe mitral stenosis was improved immediately after BMV, and the improvement continued at 6 and 12 months post-BMV (23.1% ± 4.2 vs. 36.0 % ± 4.9, 36.2% ± 4.5, and 40.1% ± 9.5, respectively P &amp;lt; 0.01). After BMV, there was a significant decrease in left atrial volume (76.3 ± 12.4 mL/m2 vs. 68.6 ± 10.4 mL/m2, P &amp;lt; 0.01) and a significant increase in the area occupied by the mitral valve (1.02 ± 0.18 cm2 vs. 1.60 ± 0.31 cm, P &amp;lt; 0.01).The immediate GLS and the mitral valve area were positively correlated (r = 0.64, P &amp;lt; 0.01). Furthermore, the immediate GLS was associated with significantly improved function class (P &amp;lt; 0.01). Conclusion GLS can indicate left atrial function (mainly reservoir function). The improvement observed in patients after BMV may indicate that GLS can be used to evaluate the progress after BMV. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

An Unusual Presentation of a Rare Case of Rhabdomyosarcoma of the Left Atrium as Severe Rheumatic Mitral Stenosis with Atrial Fibrillation, Fast Ventricular Rate, and Left Atrial Failure

It is extremely rare to encounter primary malignant tumors of the heart. Rhabdomyoma constitutes approximately 20% of all primary malignant tumors of the heart. Rhabdomyoma commonly arises from the ventricular wall, and rarely, they arise from the atrial wall and mimic symptomatic atrioventricular valve stenosis. We describe an extremely rare case of left atrial (LA) rhabdomyosarcoma detected during the transesophageal echocardiography arising from the posterior wall of the left atrium protruding into the left ventricle causing obstruction of the mitral valve. Our case is a rare case of LA rhabdomyosarcoma presenting with mitral inflow obstruction and symptomatically mimicking severe rheumatic mitral stenosis with atrial fibrillation and fast ventricular rate with orthopnea secondary to LA failure and passive pulmonary venous congestion.

Predictive Value of D-dimer Levels for Detection of Left Atrial Thrombus in Patients with Rheumatic Severe Mitral Stenosis

Background: Systemic embolism is one of the most common complications of mitral stenosis (MS). Systemic embolism in patients with MS is caused by left atrial (LA) thrombus. Trans Esophageal Echocardiography (TEE) is considered the most reliable in ruling out LA thrombus, however, it is semi-invasive, operator-dependent, and not widely available. On the other hand, D-dimer is an indirect marker of fibrin formation. It reflects the activation of coagulation system. Objective: To measure D-dimer levels in patients with and without LA thrombus and find out predictive value of D-dimer levels to detect LA thrombus. Methods: In this cross-sectional observational study 50 patients with rheumatic severe mitral stenosis have been assessed. Patients underwent Trans Thoracic Echocardiography (TTE) and TEE to rule out LA thrombus. If TTE showed LA thrombus, TEE was not done. Patients were divided into two groups based on presence of LA thrombus; group I- patients with LA thrombus, and group II- patients without LA thrombus. D-dimer level was measured in two groups and comparison was done. Results: D-dimer was significantly elevated in group I compared to group II (2.8±1.9 µg/ml vs. 0.43±0.13µg/ml, p&lt;0.001). Receiver Operator Characteristic (ROC) Curve showed D-dimer level &gt; 0.6 µg/ml can predict LA thrombus with sensitivity of 84% &amp; specificity of 88%. Conclusion: A higher level of D-dimer can predict LA thrombus in patients with rheumatic severe MS, and can be used as a noninvasive marker to rule out LA thrombus in patients with rheumatic severe MS. Bangladesh Medical Res Counc Bull 2022; 48(3): 231-235

Left Atrial Remodeling in Patients With Severe Rheumatic Mitral Stenosis and Sinus Rhythm Using Two-Dimensional and Three-Dimensional Speckle Tracking Echocardiography

In mitral stenosis (MS), the combination of an increase in left atrium (LA) pressure and atrial inflammatory response is accompanied by increase in interstitial fibrosis of the atrial wall with disorganization of atrial muscle bundles, LA dysfunction and subsequently LA dilatation. We aimed to assess the effect of severe rheumatic MS on LA volumes and mechanics. We enrolled 40 patients with pure severe rheumatic MS and sinus rhythm as a patient group and 30 healthy subjects as a control group. All patient and control groups underwent two-dimensional (2D) transthoracic echo to measure left ventricle (LV) dimensions, function, LA deformations, estimated systolic pulmonary artery pressure (EPAP), and left ventricle global longitudinal strain (LV GLS). Also LA volumes and mechanics (LA strain during LV systole (reservoir function) and LV diastole (early = conduit, and late = booster pump = atrial contraction)) were measured by three-dimensional (3D) transthoracic echo; mitral valve (MV) area was measured by 3D transesophageal echo (as routine pre-percutaneous MV commissurotomy using multiplanar reconstruction in mid-esophageal apical long-axis view from LA prospective). By 2D transthoracic echo, patient group revealed significantly lower all LA function vs. control group including LA strain during reservoir (24 ± 6 vs. 43 ± 3, P < 0.001), LA strain during conduit (-11 ± 3 vs. -25 ± 2, P < 0.001), and during booster pump (-13 ± 4 vs. -18 ± 1, P < 0.001). EPAP was significantly higher in patient group (48 ± 7 vs. 27 ± 4 in control group). LV GLS was significantly lower in patient group (-16±2% vs. -23±2% in control group). All 3D LA volumes were significantly higher in patient group than control group including maximum LA volume (LAVmax) (76 ± 18 vs. 50 ± 5, P < 0.001), indexed LA volume (LAVi) (44.6 ± 10.1 vs. 28.7 ± 3.7, P < 0.001), LV minimum volume (LAVmin) (51 ± 15 vs. 30 ± 4, P < 0.001), and LA volume pre atrial contraction (LAVpre A) (63 ± 15 vs. 41 ± 6, P < 0.001). Also, there was significantly decreased LA strain using 3D speckle tracking echo in patient group including systolic deformation of LA (reservoir function) (23 ± 6 vs. 41 ± 3, P < 0.001) and diastolic deformation, early diastole (conduit function) (-10 ± 2 vs. -24 ± 2, P < 0.001), and late diastole (booster pump function) (-13 ± 4 vs. -18 ± 1, P < 0.001). All LA function markedly reduced in pure severe rheumatic MS. The reduction of LA mechanics is directly related to the degree of reduction of the stenotic MV area. LV GLS significantly reduced in severe MS and its reduction is directly related to the degree of reduction of the stenotic MV area and the LAVi by 3D echo.

Appropriate Use Criteria for the Management of Aortic Stenosis: Insight From the Japanese Expert Panel

BackgroundThe indication for transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) significantly varies among physicians and institutions. ObjectivesThis study aims to develop a set of appropriate use criteria for AS management to assist physicians in decision-making. MethodsThe RAND-modified Delphi panel method was used. A total of >250 common clinical scenarios were identified in terms of whether to perform the intervention for AS and the mode of intervention (surgical aortic valve replacement vs TAVR). Eleven nationally representative expert panelists independently rated the clinical scenario appropriateness on a scale of 1-9, as “appropriate” (7-9), “may be appropriate” (4-6), or “rarely appropriate” (1-3); the median score of the 11 experts was then assigned to an appropriate-use category. ResultsThe panel identified 3 factors that were associated with a rarely appropriate rating in terms of performing the intervention: 1) limited life expectancy; 2) frailty; and 3) pseudo-severe AS on dobutamine stress echocardiography. Clinical scenarios that were deemed rarely appropriate for TAVR were also identified: 1) patients with low surgical risk and high TAVR procedural risk; 2) patients with coexistent severe primary mitral regurgitation or rheumatic mitral stenosis; and 3) bicuspid aortic valve that was not suitable for TAVR. Importantly, any TAVRs for patients who were older than 75 years of age were not rated as rarely appropriate. ConclusionsThese appropriate use criteria provide a practical guide for physicians regarding clinical situations commonly encountered in daily practice and elucidates scenarios deemed rarely appropriate that are clinical challenges for TAVR.

A Rare Case of Cor Triatriatum Dexter With Severe Rheumatic Mitral Stenosis With Severe Organic Tricuspid Valve Regurgitation Masquerading as Acute Pulmonary Embolism in a Young

A Rare Case of Cor Triatriatum Dexter With Severe Rheumatic Mitral Stenosis With Severe Organic Tricuspid Valve Regurgitation Masquerading as Acute Pulmonary Embolism in a Young

Anesthetic Management of Pericardial Tamponade During Percutaneous Mitral Balloon Valvuloplasty - A Case Report

Percutaneous mitral balloon valvuloplasty (PMV) is the treatment of choice for symptomatic mitral valve stenosis. Most common complication of this procedure is pericardial tamponade. Early diagnosis and immediate management are essential and lifesaving as it determines the clinical outcome. Hereby a case report of successful management of pericardial tamponade following PMV in a middle-aged female patient with severe rheumatic mitral stenosis by multidisciplinary team approach with a focus on Anesthesia care and management.

Global Left Ventricular Myocardial Work Efficiency in Patients With Severe Rheumatic Mitral Stenosis and Preserved Left Ventricular Ejection Fraction.

Assessment of left ventricular (LV) function plays a pivotal role in the management of patients with valvular heart disease, including those caused by rheumatic heart disease. Noninvasive LV pressure-strain loop analysis is emerging as a new echocardiographic method to evaluate global LV systolic function, integrating longitudinal strain by speckle-tracking analysis and noninvasively measured blood pressure to estimate myocardial work. The aim of this study was to characterize global LV myocardial work efficiency in patients with severe rheumatic mitral stenosis (MS) with preserved ejection fraction (EF). We retrospectively included adult patients with severe rheumatic MS with preserved EF (> 50%) and sinus rhythm. Healthy individuals without structural heart disease were included as a control group. Global LV myocardial work efficiency was estimated with a proprietary algorithm from speckle-tracking strain analyses, as well as noninvasive blood pressure measurements. A total of 45 individuals with isolated severe rheumatic MS with sinus rhythm and 45 healthy individuals were included. In healthy individuals without structural heart disease, the mean global LV myocardial work efficiency was 96% (standard deviation [SD], 2), Compared with healthy individuals, median global LV myocardial work efficiency was significantly worse in MS patients (89%; SD, 4; p < 0.001) although the LVEF was similar. Individuals with isolated severe rheumatic MS and preserved EF, had global LV myocardial work efficiencies lower than normal controls.

Assessment of Right Ventricular Systolic Function with 3-Dimensional Speckle Tracking Echocardiography in Isolated Mild Mitral Stenosis.

In rheumatic severe mitral stenosis, right ventricular mechanics deteriorate with the increasing severity of mitral stenosis. Therefore, we aimed to investigate right ventricular mechanics in patients with mild mitral stenosis using 3-dimensional speckle tracking echocardiography. In total, 40 patients with mild mitral stenosis and 36 age- and gender-matched healthy controls were included. Conventional echocardiographic examination was performed and 3-dimensional data sets were acquired for strain analysis. Besides conventional echocardiographic parameters, right ventricular volume and function and 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain were compared between patients with mild mitral stenosis and healthy controls. Although 3-dimensional right ventricular volumes and ejection fraction were similar between the groups, 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain was significantly lower in patients with mild mitral stenosis than in controls (25.57 ± 4.39% vs. 27.90 ± 4.71%, P =.028). Significant correlations were observed between right ventricular free wall longitudinal strain and mitral valve area and estimated systolic pulmonary artery pressure (r = 0.597, P <.001; r = -0.508, P =.003, respectively). Another significant positive correlation was observed between planimetric mitral valve area and 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain (r = 0.597, P <.001). The degree of severity of mild mitral stenosis in terms of mitral valve area can help in the early detection of subclinical right ventricular systolic function impairment which can be easily detected by 3-dimensional speckle tracking echocardiography. Right ventricular contractile performance could decrease even in mild mitral stenosis.

Rare case of hereditary spherocytosis with rheumatic mitral stenosis

A rare case of hereditary spherocytosis (HS) and rheumatic mitral stenosis coexisting in a patient having severe stenosis, atrial fibrillation, and symptoms of the left ventricular dysfunction, along with hemolytic anemia attributed to HS. We present the case of a 58-year-old lady who presented to the emergency department with complaints of increasing shortness of breath for the past week. She was examined to have atrial fibrillation with a fast ventricular rate. On investigations, she was found to have severe rheumatic mitral stenosis with evidence of hemolytic anemia. Further, evaluation of the cause of her anemia revealed HS. This case highlights the importance of the evaluation of anemia in patients with valvular heart diseases. If a treatable cause is found, anemia can be treated to reduce the cardiac burden. Abstract: Background- A rare case of Hereditary Spherocytosis and Rheumatic Mitral Stenosis coexisting in a patient having severe stenosis, atrial fibrillation and symptoms of left ventricular function, along with hemolytic anemia attributed to HS. . Case presentation- We present a case of a 58-year-old lady presented to the Emergency Department with complaints of increasing shortness of breath in the last one week. She was examined to have Atrial Fibrillation with a Fast Ventricular Rate. Upon Investigations, she was found to have severe Rheumatic Mitral Stenosis with evidence of Hemolytic anemia. Further evaluation of the cause of her anemia revealed Hereditary Spherocytosis. Conclusion- This case highlights the importance of evaluation of anemia inpatients with valvular heart diseases. If a treatable cause is found, anemia can be treated to reduce the cardiac burden.

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

Comparison Between Isovolumic Acceleration and Conventional Echocardiograhic Parameters in Detecting Early Right Ventricular Systolic Dysfunction in Patients with Mitral Stenosis

Aim: The aim of the study was to determine if the tissue Doppler imaging (TDI)-derived myocardial acceleration during isovolumic contraction (IVA) of tricuspid lateral annulus could be used in early detection of RV systolic dysfunction in patients with mitral stenosis (MS), before the clinical signs of systemic venous congestion occur and to compare between IVA and conventional echocardiographic parameters in detecting early RV systolic dysfunction in patients with MS .&#x0D; Methods: Ninety-six patients with severe rheumatic MS without relevant regurgitation were enrolled in the study. Conventional echocardiographic parameters (mitral valve area, transmitral diastolic gradients, pulmonary artery pressure, RV fractional area change, pulmonary flow acceleration time, tricuspid annular plane systolic excursion) and TDI-derived systolic velocities of tricuspid annulus (isovolumic myocardial acceleration: IVA, peak myocardial velocity during isovolumic contraction: IVV, peak systolic velocity during ejection period: Sa and RV MPI) were recorded from all patients.&#x0D; Results: TDI-derived IVA, IVV, Sa were significantly decreased in patients with MS and RV MPI is increased in patients with MS. IVA was the only parameter which had a significant negative correlation with the traditional echocardiographic parameters and RV Tei index in patients with MS.&#x0D; Conclusion: TDI-derived right ventricular IVA may be used as an adjunctive, reliable, noninvasive parameter for the early detection of right ventricular systolic dysfunction in patients with MS but without signs of systemic venous congestion. RV IVA negatively correlate with RV MPI, positively correlate with IVV and Sa. RV IVA shows positive correlation with RVFAC and negative correlation with PAP, LA size. IVA shows no correlation with TAPSE.&#x0D; University Heart Journal 2022; 18(2): 80-86