Stenosis In Sinus Rhythm Research Articles

Transesophageal Echocardiographic Evaluation of Pulmonary Venous Flow before, after and One-year after Percutaneous Mitral Valvulopasty in Patients with Mitral Stenosis in Sinus Rhythm

Background:To evaluate the influence of changes in mitral valve area (MVA and left atrial pressure on pulmonary vein flow (PVF we analyzed PVF with transesophageal echocardiography (TEE before, after and one-year after percutaneous mitral valvuloplasty (PMV in patients with mitral stenosis (MS in sinus rhythm. Methods:PMV was guided with TEE. Follow-up TEE was done about one year after PMV. MVA and transmitral mean gradient (TMG were measured. Systolic velocity (S, diastolic velocity (D, atrial reversal velocity (AR, their time-velocity integral (S-TVI, D-TVI, AR-TVI and their ratio (S/D ratio, S-TVI/D-TVI ratio were evaluated. Results:The number of patients was twenty-two (F:20. The age was 39±9 years (range:26-64. Follow-up duration was 16±6 months (range:7-28. MVA increased from 0.9±0.2 cm 2 to 1.9±0.3 cm 2 after PMV and decreased to 1.7±0.3 cm 2 on follow-up TEE significantly. TMG decreased from 15.4±4.3 mmHg to 5.5±1.9 mmHg after PMV and was 6.2±2.4 mmHg on follow-up. S increased significantly on follow-up at both pulmonary vein (PV. D increased on follow-up at left PV. S/D ratio increased on follow-up at both PV. AR increased on follow-up at both PV. S-TVI increased after PMV at left PV and increased on follow-up at both PV. D-TVI had no change. S-TVI/D-TVI ratio increased on follow-up at left PV. AR-TVI increased on follow-up at right PV. Conclusions:The main changes after PMV in patients with MS in sinus rhythm were increasing tendency in S, S-TVI, S/D ratio, S-TVI/D-TVI ratio and AR. And these changes were statistically significant on follow-up TEE rather than immediately after PMV. (Korean Circulation J 2000;30(2 :134-140

Prothrombotic state and elevated levels of plasminogen activator inhibitor-1 in mitral stenosis with and without atrial fibrillation

Patients with mitral stenosis in sinus rhythm are in a prothrombotic state and have fibrinolytic dysfunction, shown by an increase in levels of the inhibitor of tissue plasminogen activator, D-dimer, and modified antithrombin III. This state may be observed even in patients without dilated left atria (diameter < or =45 mm).

Left atrial appendage function in mitral stenosis: is a group in sinus rhythm at risk of thromboembolism?

Objective: To study the left atrial appendage (LAA) function and potential for embolization in severe mitral stenosis (MS). Background: Patients with MS and atrial fibrillation or in sinus rhythm develop systemic emboli. LAA function has not been well studied in sinus rhythm. Methods: Forty consecutive patients with MS (valve area ≤0.7 cm 2/m 2) were studied. LAA ejection fraction and peak emptying velocity were measured along with other data. Results: Patients were subgrouped according to LAA Doppler flow pattern. Group I ( n=13) in sinus rhythm had biphasic high velocity ≥25 cm/s. Group II ( n=13) in sinus rhythm had biphasic low velocity <25 cm/s. Group III ( n=14) in atrial fibrillation had multiphasic irregular flow <25 cm/s or no definite flow. The LAA ejection fraction and peak emptying velocity were strikingly different in all groups. They were lower in group II when compared to group I. Group II had intermediate risk for thromboembolism compared to Group I and III as judged by systemic embolization, spontaneous echo contrast, thrombus in left atrium and LAA. Conclusion: A subset of mitral stenosis in sinus rhythm at increased risk of embolization can be suspected by Doppler transesophageal echocardiographic LAA flow profile.

Left Atrial Contribution to Left Ventricular Filling in Patients with Mitral Stenosis: Combined Analysis of Transmitral and Pulmonary Venous Flow Velocities.

We recorded transmitral and pulmonary venous flow velocities using transthoracic continuous-wave and transesophageal pulsed Doppler echocardiography, respectively, in 36 patients with mitral stenosis who were in sinus rhythm to investigate the left atrial contribution to left ventricular filling in mitral stenosis. The mitral valve area was determined by transthoracic two-dimensional short-axis echocardiography. Patients were classified as having mild stenosis (>/=1.5 cm(2), n = 17) or moderate stenosis (<1.5 cm(2), n = 19). The mean pulmonary capillary wedge pressure and left atrial maximal diameter were significantly larger, and left atrial volume change during atrial contraction was significantly smaller in the moderate group than in the mild group. The percent left atrial contribution to left ventricular filling, estimated from the transmitral flow velocity, the peak atrial systolic velocity, and the percent ratio of left atrial systolic regurgitation to left atrial filling, estimated from the pulmonary venous flow velocity, were significantly lower in the moderate group than in the mild group. The percent left atrial contribution to left ventricular filling, the peak atrial systolic velocity, and the percent ratio of left atrial systolic regurgitation to left atrial filling were positively correlated with the mitral valve area and negatively correlated with the mean pulmonary capillary wedge pressure. These results suggest that the left atrial contribution to left ventricular filling in patients with mitral stenosis in sinus rhythm decreases as the severity of valve stenosis increases, and that analysis of the atrial systolic waves of the transmitral and pulmonary venous flow velocities provides important information for evaluation of left atrial systolic performance in patients with mitral stenosis.

Beta adrenergic blockade does not improve effort tolerance in patients with mitral stenosis in sinus rhythm

This study was designed to assess the effects of beta-blockade on cardiopulmonary exercise performance in symptomatic patients with tight mitral stenosis in sinus rhythm. The role of beta-blockers in these patients has been controversial and assessment of effort tolerance using treadmill exercise time has produced conflicting results. Nineteen patients with isolated symptomatic (New York Heart Association class II or III) mitral stenosis received a beta-blocker (acebutalol or atenolol) or matching placebo for one week each in a randomized double-blind crossover fashion. Exercise on a treadmill with real time gas exchange analysis was performed six times over 4 weeks in each patient. The test was further repeated once within a week of percutaneous mitral valvotomy. Heart rate at rest and during peak exercise was significantly lower with beta-blockade compared to control state or placebo treatment. Mean peak oxygen consumption did not differ significantly between treatment groups. When patients were arbitrarily classified into those with (group I, heart rate < or = 130.min-1) and those without (group II, heart rate > or = 131.min-1) adequate beta-blockade, there was a significant difference in peak VO2. The peak VO2 for group I: 14.0 +/- 3.2 vs 17.5 +/- 4.0 ml.min-1.kg-1; peak VO2 for group II: 17.2 +/- 2.4 vs 18.0 +/- 2.4 ml.min-1.kg-1 (beta-blockade vs control state respectively). Treadmill exercise time did not differ between treatment groups. The slope of minute ventilation (MV) and carbon dioxide (CO2) excretion, and instantaneous carbon dioxide ventilatory equivalent (MV/VCO2) was unchanged with beta-blocker therapy indicating no improvement in ventilatory performance. Beta-blocker therapy in tight mitral stenosis appears to have no beneficial effect on aerobic capacity, nor does it improve ventilatory performance. Adequate beta-blockade may adversely effect peak oxygen consumption.

Hemodynamic Evaluation and Exercise Tolerance Comparison before and after Operation in Closed versus Open Mitral Valvotomy in Pure Mitral Stenosis

The relative merits and efficacy of open versus closed mitral valvotomy remains controversial. The purpose of this study was to compare improvement of the hemodynamic parameters and exercise tolerance capacity of the 2 operations in 59 patients with pure mitral stenosis in sinus rhythm. Patients were randomly assigned to 1 of 2 groups: 29 patients in group 1 were operated on with the closed technique and 30 patients in group 2 were operated by the open technique. Preoperatively, the hemodynamic parameters and exercise capacity were similar in the two groups. Cardiac catheterization and exercise treadmill test were performed on all patients before and 3 months after each operation. Hemodynamic parameters as well as exercise tolerance capacity were significantly improved by both open and closed valvotomy ( p &lt; 0.0001). However, postoperatively the improvement in exercise capacity was similar in both groups ( p = NS) and there was no significant difference in hemodynamic parameters in both groups, except for reduction in pulmonary artery pressure and increment in cardiac output. Complication rates were similar in both groups, except for atrial arrhythmias, which were more common in group 2. This study suggested that the closed technique, when performed by experienced surgeons, achieved similar hemodynamic and functional results as the open method. It also has the potential advantage of cost savings in addition to avoiding the complications of cardiopulmonary bypass. It clearly has a place in properly selected patients with mitral stenosis.

Usefulness of carotid sinus massage in the quantification of mitral stenosis in sinus rhythm by Doppler pressure halftime

A lthough it has limitations,i4 the pressure halftime concept has gained widespread acceptance since Hatle et a15Jj used this method for quantification of mitral valve area by Doppler ultrasound. One limitation is a high heart rate that shortens the early diastolic interval before atria1 contraction and may prevent a clear delineation of the spectral velocity decay.&* Carotid sinus massage is a well-known maneuver in the evaluation and management of some cardiac arrhythmias. By increasing vagal tone, this technique reduces sinus nodal discharge, leading to longer diastolic intervals among other effects. In the present noninvasive study, we report the effects and practical usefulness of this maneuver in the determination of pressure halftime in patients with mitral stenosis who maintain sinus rhythm. The study cohort comprised 87 consecutive patients (mean age 49.0 f 12.5 years; 62 women and 25 men) with mitral stenosis in sinus rhythm without significant aortic valve disease. No patient underwent previous commissurotomy or valvuloplasty. Mitral regurgitation was detected in 26 patients (mild in 17, moderate in 6, and severe in 3) and mild aortic insu&iency was found in 21. All patients underwent complete 2-dimensional and Doppler echocardiographic studies. The ultrasound examinations were pet$ormed with a Doppler echocardio-

Pulmonary venous flow pattern studied by transoesophageal pulsed Doppler echocardiography in mitral stenosis in sinus rhythm: effect of atrial systole.

In 13 patients with isolated mitral stenosis in sinus rhythm the pulmonary venous flow was evaluated by transoesophageal pulsed Doppler echocardiography. The patients were divided into two groups according to their mitral valve area (MVA); Group I (MVA < 1.5 cm2, n = 7 patients); and Group II (MVA > 1.5 cm2, n = 6). The patients in group I with haemodynamically significant mitral stenosis had lower velocities of systolic (S), diastolic (D) and atrial retrograde (A) waves of pulmonary venous flow (PVF) compared to milder stenosis (P < 0.05). The peak velocity of pulmonary retrograde venous flow at atrial contraction (A) primarily depends on the relative amplitude of the atrial transmitral wave (RA), which is measured from the onset of atrial systole to its peak velocity. We found a highly positive correlation between RA of mitral valve flow (MVF) and A wave of PVF (r = 0.87, P < 0.0001). There was also a highly negative correlation (r = 0.80, P < 0.001) between A of PVF and ratio of early (PE) to late (PA) velocities of MVF. Therefore, the retrograde A wave of PVF is related to the pressure generated in the left atrium during atrial systole. Use of pulmonary vein velocities in conjunction with mitral flow velocities can increase our understanding of the haemodynamics of mitral stenosis and provide a new insight into left atrial performance.

Pulmonary venous flow dynamics before and after balloon mitral valvuloplasty as determined by transesophageal Doppler echocardiography

The pattern of left atrial filling was studied in 14 patients with severe mitral stenosis in sinus rhythm before and immediately after successful balloon mitral valvuloplasty by transesophageal pulsed Doppler echocardiography of the left superior pulmonary vein. Mean mitral valve orifice area increased from 0.8 ± 0.1 to 2.2 ± 0.3 cm 2 (p < 0.0001), and left atrial mean pressure decreased from 30 ± 5 to 12 ± 4 mm Hg (p < 0.0001) after the procedure. After balloon mitral valvuloplasty, significant increases in peak systolic pulmonary velocity (35 ± 16 to 44 ± 10 cm/s; p < 0.01), systolic flow velocity time integral (3.3 ± 1.5 to 5.9 ±2.0 cm; p < 0.001) and the ratio of systolic/diastolic pulmonary venous flow velocity time integrals (0.8 ± 0.4 to 1.4 ± 0.5; p < 0.001) were observed. An acute increase in mitral valve orifice area caused no significant changes in peak diastolic forward flow velocity (40 ± 7 to 41 ± 9 cm/s; p = not significant [NS]), diastolic forward flow velocity time integral (4.3 ± 1.7 to 4.6 ± 1.8 cm; p = NS) and atrial flow reversal velocity (30 ±3 to 35 ± 3 cm/s; p = NS) compared with at baseline. The results suggest that in patients with severe mitral stenosis and sinus rhythm, left atrial filling is biphasic with a diastolic preponderance, and successful mitral valvuloplasty is associated with an immediate increase in pulmonary venous systolic forward flow.

Cardiovascular Diseases: An Annotated Bibliography of Recent Literature

Cardiovascular Diseases: An Annotated Bibliography of Recent Literature

Propranolol in mitral stenosis during sinus rhythm

Patients with early symptomatic mitral stenosis usually suffer from pulmonary congestion on the basis of left atrial and pulmonary venous hypertension. They are often in sinus rhythm, and cardiac output is usually well maintained. Symptoms occur most often when heart rate, cardiac output, or both are increased. In this study, intravenous propranolol administered to patients with pure mitral stenosis in sinus rhythm resulted in significant reductions in mitral diastolic gradient (-7.1 mm. Hg +/- 1.6 SED), mean pulmonary wedge pressure (--6.9 mm. Hg +/- 1.2) and mean pulmonary artery pressures (--9.0 mm. Hg +/- 1.2). This was due to simultaneous reduction of heart rate (--13.0 beats/minute +/- 2.6 and cardiac output (--0.5 L./minute +/- 0.2). A small associated reduction of left ventricular systolic pressure (--5.1 mm. Hg +/- 2.6) was not accompanied by adverse clinical effects. A potential role for propranolol in medical management of pure mitral stenosis in the presence of sinus rhythm is suggested.

The left atrial pressure pulse of mitral stenosis in sinus rhythm

The left atrial pressure pulse of isolated, severe mitral stenosis (sinus rhythm, noncalcified valve) is compared with the normal left atrial pressure pulse (indirect, esophageal); the left atrial sound and pressure relations are described in both groups. Micromanometers mounted on cardiac catheters and nasogastric tubes were used for recording. The left atrial pressure pulse of noncalcified mitral stenosis in sinus rhythm differs from the normal in several important respects. Fusion of the a - c waves in mitral stenosis reflects the overlap of atrial contraction with initial ventricular contraction. The delayed left atrial a wave peak is consistent with prolonged atrial systole. The c wave occurs during the ascent or eversion phase of the mitral complex and terminates abruptly with the initial vibrations of the delayed, accentuated first heart sound. The initial y descent reflects descent or inversion of the mitral complex toward the ventricle and terminates abruptly at the opening snap notch with the mitral opening snap occurring before mitral valve diastolic flow.

Left atrial and left ventricular sound and pressure in mitral stenosis.

Left atrial and left ventricular pressure and sound were recorded at the time of mitral commissurotomy in 18 patients with severe, isolated, noncalcific mitral stenosis and sinus rhythm. Catheter tip micromanometers were used, and in eight studies, two equisensitive micromanometers were employed to examine pressure crossover relationships. Analysis of the left atrial and left ventricular sound and pressure crossover relationships is presented; viewed in the perspective provided by cineangiographic studies and surgical observations, a unifying concept of the auscultatory events in mitral stenosis is proposed. Beginning with left ventricular pressure rise, the left ventricle drives the mitral complex through its ascent (or eversion) phase toward the left atrium, clearing the anterior leaflet from the left ventricular outflow tract. The ascent (eversion) terminates abruptly at the first heart sound (S 1 ). Following systole, left ventricular and left atrial pressure fall together after v peak, during and after pressure crossover, until the point where left atrial pressure fall ceases abruptly (opening snap notch), left atrial pressure exceeding that in the left ventricle, and the mitral opening snap occurs. During this interval, the mitral valve complex descends or inverts toward the left ventricle and terminates abruptly with the mitral opening snap. Thus, the mitral opening snap may be considered as the reciprocal of the delayed, accentuated S 1 , in noncalcific mitral stenosis in sinus rhythm.

Effects of atrial fibrillation upon the circulation in patients with mitral stenosis

Atrial fibrillation is known to occur in approximately 40 per cent of the cases of mitral stenosis. 1,2 Uncontrolled atrial fibrillation often causes disabling cardiac symptoms, which may disappear when the ventricular rate is slowed by the administration of digitalis. However, even adequately controlled atrial fibrillation is considered a highly undesirable complication of mitral stenosis, primarily because it enhances the formation of mural thrombi, providing a threat of embolic phenomena. Furthermore, it is generally believed that controlled atrial fibrillation may affect adversely circulatory dynamics by exaggerating the circulatory embarrassment that may be caused by stenosis of the mitral orifice. It was noted 2–4 that patients with atrial fibrillation have, on the average, lower cardiac output, higher pulmonary vascular resistance, and higher left atrial and pulmonary arterial pressures than do patients with mitral stenosis in sinus rhythm. However, it has not been hitherto ascertained whether these differences reflect merely the well-known fact that atrial fibrillation is apt to appear in more advanced cases of mitral stenosis and in patients of more advanced age, or whether such differences are genuinely related to the effects of the arrhythmia per se. The purpose of this investigation was to examine hemodynamic differences between patients with mitral stenosis in sinus rhythm and those in atrial fibrillation, attempting to eliminate all factors that affect the circulation except for the presence or the absence of atrial fibrillation.