Factors responsible for left atrial clot formation in patients with mitral stenosis and normal sinus rhythm

Background: The objective of the study was to investigate the factors responsible for left atrial (LA) clot formation in patients with mitral valve stenosis in normal sinus rhythm.Methods: 79 patients (43 males and 36 females) were included in the study. 9 patients with mitral stenosis in normal sinus rhythm had LA clot or LA smoke in echocardiography included in Group A and rest of 70 patients in Group B. LA size, gradient across mitral valve and mitral valve surface area was studied and compared in patients with or without LA clot/smoke.Results: Mean LA size was 4.8 (±0.5) and 4.6 (±0.7) in group A and B respectively with (p=0.304) and mean valve gradient was 11.6 (±2.8) and 10.6 (±3.5) in group A and B respectively with (p=0.507), the difference was not significant in both. Mean mitral valve area was 1.01 (±0.3) and 1.12 (±0.5) in group A and B (p=0.36), the difference was not significant.Conclusions: Study concluded that there was no significant difference in LA size, valve gradient and mitral valve area in patients with or without LA clot having mitral valve stenosis in normal sinus rhythm. Patients with LA clot warrant measures to prevent thromboembolic episodes.

Quality of life assessment after successful percutaneous transmitral commissurotomy and ascertain its relationship with gender / Evaluación de la calidad de vida tras comisurotomía mitral percutánea exitosa y determinación de su relación con el sexo

Abstract Background: percutaneous transmitral commissurotomy has become an ideal treatment option for mitral stenosis due to its less adverse events and more favorable outcomes. Patients improve symptomatically after percutaneous transmitral commissurotomy but we have minimal available data about the quality of life after percutaneous transmitral commissurotomy. Objective: to assess the quality of life after percutaneous transmitral commissurotomy through WHOQol scoring covering different aspects of life, to determine its correlation with a net gain in mitral valve area (MVA) and to ascertain its association with gender. Methods: it was a prospective cohort study carried out for a period of 15 months. A total of 100 patients with mitral stenosis who had successful percutaneous transmitral commissurotomy done were enrolled in the study. Among the total included, 4 patients were lost to follow up and data were collected from 96 patients. Quality of life was assessed before the procedure, at 1 month and 3 months follow up after percutaneous transmitral commissurotomy using WHOQol scoring questionnaire. Results: among 96 patients, 64 (67%) were females and 32 (33%) were males. WHOQol scoring improved significantly after percutaneous transmitral commissurotomy from 32.8±8.9 to 54.6±11.2 and 62.8± 9.7, after one month and 3 months respectively. There was a significant association between net gain of MVA and WHOQol scoring with an R value of 0.46 and p value of 0.03. There was no difference in group comparison of all the six domains between male and female patients. Conclusion: successful percutaneous transmitral commissurotomy improves the quality of life in mitral stenosis patients regardless of their gender and has a positive correlation with a net gain in mitral valve area.

Resumen Antecedentes: La comisurotomía mitral percutánea se ha convertido en una opción terapéutica ideal para la estenosis mitral, debido a efectos menos adversos y a resultados más favorables. Los pacientes mejoran sintomáticamente tras la realización de esta técnica, aunque se dispone de escasos datos acerca de la calidad de vida tras su puesta en práctica. Objetivo: Evaluar la calidad de vida tras la comisurotomía mitral percutánea mediante la puntuación WHOQol, que cubre diferentes aspectos de la vida, para determinar su correlación con la ganancia neta del área valvular mitral (AVM), y determinar su asociación con el sexo. Métodos: Estudio prospectivo de cohorte durante un periodo de 15 meses, en el que se incluyeron 100 pacientes con estenosis mitral a quienes se les practicó con éxito comisurotomía mitral percutánea. De entre el total incluido, se perdieron 4 pacientes durante el estudio, por lo que se recolectaron datos de los 96 pacientes restantes. La calidad de vida se evaluó antes del procedimiento, y transcurridos un mes y tres meses de seguimiento, utilizando el cuestionario de puntuación WHOQol. Resultados: De los 96 pacientes, 64 (67%) eran mujeres y 32 (33%) varones. La puntuación WHOQol mejoró considerablemente tras la realización de la comisurotomía mitral percutánea, con valores de 32,8±8,9 a 54,6±11,2 y 62,8± 9,7, transcurridos uno y 3 meses, respectivamente. Se produjo una asociación significativa entre la ganancia neta de AVM y la puntuación WHOQol, con un valor R de 0,46 y un valor p de 0,03. No se produjo diferencia alguna en cuanto a la comparación grupal de los seis dominios entre varones y mujeres. Conclusión: La comisurotomía mitral percutánea exitosa mejora la calidad de vida de los pacientes de estenosis mitral, independientemente del sexo, y tiene una correlación positiva con la ganancia neta del área valvular mitral.

Accuracy of mitral valve area in patients with mitral stenosis measured by echocardiography : Compared with operative mitral valve area

BACKGROUND: Measurement of echocardiographic mitral valve area (MVA) is an useful noninvasive method of estimating the stenotic mitral valve area. This study was undertaken to evaluate the accuracy of echocardiographic MVA measurement by comparing MVAs measured by the planimetric and pressure half-time method versus direct MVA measurement by using a cone shaped device specifically made for direct measurement of MVA. METHODS AND RESULTS: The study population consisted of 22 consecutive patients from August 1993 to February 1996. All the patients underwent 2D planimetry and Doppler echocardiographic MVA measurement before and after valve replacement surgery ; direct measurement also was performed after surgery. Five patients (22.7%) had normal sinus rhythm, and the rest of the patients had atrial fibrillation. Two-dimensional echocardiographic examinations were attempted in 22 patients, and adequate measurements were obtained in 21 of the patients studied. Mean mitral valve area were 0.99+/-0.32cm (2) ranged from 0.42 to 1.68cm (2) on 2D planimetry method, 0.93+/-0.32cm (2) ranged from 0.42 to 1.68cm (2) on Doppler pressure half-time method, 1.17+/-0.20cm (2) ranged from 0.93 to1.68cm (2) on direct measurement of mitral valve area after surgery. 2D planimetry method (r=0.621, p=0.003, SE=0.165), pressure half-time method (r=0.454, p=0.003, SE=0.187), and transmitral peak velocity (r=-0.480, p=0.026, SE=0.189) was relatively well correlate with operative mitral valve area. There was relatively good agreement between direct and 2D planimetric measurement and between direct and Dopler pressure-half time method. CONCLUSION: 2D planimetry and Doppler pressure half-time method on echocardiography are useful, noninvasive measurement method in patients with mitral stenosis.

Assessment of Mitral Valve Area in Patients with Mitral Stenosis and Atrial Fibrillation

BACKGROUND: In mitral stenosis with atial fibrillation, it is known that there is a significant linear correlation between end-diastolic mitral pressure gradient(EDMG) in cardiac catheterization and the corresponding RR interval. And using this, the equations to calculate the mitral valve area(MVA) in several heart retes has been inducing. However, as cardiac catheterization has a limitation not to be practiced repeatedly in all patients due to invasive procedure. In this study, using transthoracic doppler echocardiography, we tried to investigate the correlation of EDMG, RR interval and MVA and we tried to get the nomogram to predict MVA in different heart rates using it. METHODS: We made 9 patients an abject of this study whose measured MVA is from 0.5cm2 to 1.55cm2 by pressure half time(PHT) method among patients who have no any valvular heart disease except mitral stenosis with atrial fibrillation and whose condition is stable. We investigated the linear correlation between EDMG and RR interval, RR interval=a×EDMG+b(a ; slope, b ; intercept), using doppler echocardiography. We got the equation and nomogram to make an estimate of MVA with multiple regression analysis using the relation of measured MVA, slope and intercept. RESULTS: There was a linear correlation between EDMG and RR interval in all the patients. There was a mutual correlation of slope=53.0×(measured MVA)−101.2 between measured MVA and slope. There was a negative correlation of intercept=1,497−470×(measured MVA) between measured MVA and intercept. Using these, we could get multiple regression analysis equation, estimated MVA=0.0113×slope−0.0007×intercept+2.2497 and nomogram to estimate MVA. CONCLUSION: We could get the nomogram to estimate MVA easily using doppler echocardiography in mitral stenosis with atrial fibrillation.

A Comparative Study of the echocardiographic Methods Assessing Severity of Stenosis in Pateints with mitral Stenosis

BACKGROUND: Determination of mitral valve area (MVA) in patients with mitral stenosis is very important in clinical practice. Therefore, the ability to assess accurately MVA by noninvasive technique is of great meaning to the management of patients with mitral stenosis. Echo-Doppler(ED) method was derived from the study of fluid dynamics that the flow volume is proportional to orifice area, velocity of flow which shows period requird by the flow. It has been proposed recently that measuring the flow convergence region proximal to an orifice by Doppler flow mapping can be used to derive cardiac output or flow rate proximal to stenotic orifices and therefore to calculate their areas by the continuity equation (area=flow rate/velocity). Applying these methods in mitral stenosis would provide a unique way of validating the underlying concept because the predicted areas could be compared with those measured directly by planimetry and pressure half-time method. Valve resistance has been proposed as an alternative hemodynamic indicator, but initially this index was not used because it was unlikely to remain constant at different flow rates. Recently valve resistance provided a better indices of hemodynamic obstruction than mitral valve area, and these indices usually estimated by invasive method, but it is able to calculate from Doppler echocardiography and compared to the results of invasive method. METHODS: The mitral inflow volume can be obtained by estimating the stroke volume (SV) by Teichholz's method from M-mode echocardiogram of the left ventricle, and the mean diastolic velocity(MDV) and diastolic filling period (DFP) by mitral inflow continuous-wave Dopler echocardiogram. Therefore, Echo-Doppler method is MVA=SV/MDV×DFP. Doppler color flow recordings of mitral inflow were obtained from the apex, and the radius of the proximal flow convergence region was measured at its peak diastolic value from the calculated assuming uniform radial flow convergence toward the orifice, modified by a factor that accounted for the inflow funnel angle formed by the mitral leaflets. Mitral valve area was then calculated as peak flow rate divided by peak velocity by continuous-wave Doppler. To Compare the stenotic indices from noninvasive method and invasive method, cardiac catheterization was performed. RESULTS: 1) ED-MVA of these 28 patients with mitral stenosis correlated well at a coeffitient of 0.867 than PHT-MVA(r=0.513) or 2DE(r=0.513) in comparison with Cath-MVA. 2) Excluding 4 patients with mitral regurgitation, the ED-MVA of 24 patients with isolated mitral stenosis showed a better correlation with r=0.944 than with PHT-MVA(r=0.642) or 2DE-MVA(r=0.647) in comparison with Cath-MVA. 3) MVA determined by PISA method were correlated with planimetry method on 2DE(r=0.51, p < 0.001). 4) MVA determined by PISA method were correlated with PTH method(r=0.44, p=0.002). 5) Agreement with planimetrymethod was similar for 26 patients with mitral regurgitation and 24 without it, as well as for 34 in atrial fibrillation. 6) The correlation coefficient of mitral valve area and mitral valve resistance between echocardiography(r=0.87) and cardiac catheterization(r=0.82) showed positive correlation(p < 0.001). 7) Linear regression analysis showed a negative correlation of mitral valve resistance and Gorlin mitral valve area between echocardiography (r=−0.84) and cardiac catheterization(r=−0.84). CONCLUSION: Echocardiographic evaluation of mitral valve stenosis by planimetry, pressur half-time method, Echo-Doppler method, PISA method, and mitral valve resistance were useful noninvasive methods in assessing the severity of mitral stenosis. In mitral stenosis patients with mitral regurgitation and/or aortic regurgitation, PISA and mitral valve resistance methods were also reliable. In conclusion, these results suggested that the echocardiographic methods could be sufficient for assessing the severity of mitral stenosis without the necessity of invasive technique.

Dissociação clínico-morfológica em portadores de estenose mitral / Clinico-morphological dissociation in patients with mitral valve stenosis

PURPOSE--To study characteristics of the natural history of mitral stenosis (MS) in patients that have no correlation between mitral valve areas (MVA) and symptoms. METHODS--We studied 18 patients with MS, that presented no correlation between MVA and functional class (FC), 16 (89) were female and two (11) men, with age ranging from 16 to 54 (mean 33) years. Patients assigned to group A (8 cases) had FC III and MVA > or = 1.5 cm2 and group B (10 cases) FC I/II and MVA < 1.1 cm2. FC and MVA at the start (initial time-It) and after 12 months or before surgical correction (SC) or percutaneous mitral balloon valvuloplasty (PBV) (final time-Ft) were compared. All patients with predict O2 uptake (PRED VO2) at It were evaluated. RESULTS--Five (63) patients of group A, that maintained MVA > or = 1.5 cm2, changed to FC I/II but three (38) needed a SC or PBV (2 with lesser MVA at Ft). At group B, six (60) patients needed SC or PBV. CONCLUSION--MS patients with MVA > or = 1.5 and FC III, providing MVA do not decrease, improves their FC, becoming it more compatible with MVA PRED VO2. The cases of group B presented the greatest probability of needing SC or PVB.

Mitral Valve Area and Resistance in Mitral Stenosis: Comparison of Cardiac Catheterization and Doppler Echocardiography

BACKGROUND: The valve area derived from the Gorlin formula has been used clinically for decades as an index of severity on the assessiment of valve stenosis, in spite of some limitations on Gorlin formula studied in aortic stenosis and mitral bioprostheses. It had been shown that Gorlin valve area varied if the hemodynamic conditions during measurement are changed. Valve resistance has been proposed as an alternative hemodynamic indicator, but initially this index was not used because it was unlikely to remain constant at different flow rates. Recently valve resistance provided a better indices of hemodynamic obstruction than mitral valve area, and these stenotic indices usually estimated by angiographic method and we studied the valve resistance by Doppler echocardiographic measurement. METHOD AND RESULT: To compare the clinical implication about these stenotic indices measured by echcoardiography and cardiac catheterization, we studied 41 patients of mitral stenosis with normal sinus rhythm. The results were as follows ; 1) In catheterization, increased heart rate, mean pressure gradient and decreased diastolic time was observed, but mitral area, resistance, cardiac output and mitral flow was not different. 2) Linear regression analysis showed negative correlation of mitral valve resistance and Gorlin mitral area(echocardiography r=-0.84, catheterization r=-0.84)(p<0.001). 3) Correlation coefficeint of mitral valve area and mitral valve resistance between echocardiography(r=0.87) and catheterization(r=0.82) showed positive correlation(p<0.001). CONCLUSION: These results suggest that mitral valve resistance by echocardiography is a useful method in the evaluation of the severity of mitral stenosis.