Mitral regurgitation carries greater prognostic significance than mitral stenosis in patients undergoing transcatheter aortic valve replacement.

AIMS: This study assessed the outcomes of concomitant mitral valve disease and severe aortic stenosis in patients undergoing transcatheter aortic valve replacement (TAVR). METHODS: Echocardiographic data of 813 patients with severe aortic stenosis undergoing transfemoral TAVR were collected, and clinical outcomes were analyzed for individuals with mitral stenosis and mitral regurgitation. RESULTS: The final cohort includes 788 patients with severe calcific aortic stenosis. Among single parameters of mitral stenosis, a smaller baseline mitral valve area (MVA) by the continuity equation and higher postprocedural mean mitral gradients (MMG) were associated with an increased risk of death at 1 year (P-values 0.02 and <0.01, respectively), but no correlation with outcomes was demonstrated after multivariate adjustment for major prognosticators. Mitral stenosis (based on MVA + MMG) was not associated with complications or mortality. Mitral regurgitation was present in 94.6% of the population at baseline and regressed by at least one grade post-TAVR in 28% of the patients. The improvement in mitral regurgitation was associated with a greater prosthetic effective orifice area (P-value 0.03). Significant (at least moderate) residual mitral regurgitation was correlated with short-term complications and shown to be an independent predictor of 1-year mortality (P-value 0.02, odds ratio (OR) 5.37, confidence interval 1.34-21.5). CONCLUSION: Mitral regurgitation has a greater impact on TAVR patients than mitral stenosis as assessed by functional methods.

Correlation between circulating fibrosis biomarkers with left atrial function and left atrial volume index in rheumatic mitral stenosis.

Mitral stenosis is the most common rheumatic heart disease (RHD) disorder worldwide, including in Indonesia. This pathological condition causes left atrial pressure, leading to left atrial fibrosis that affects the structure and function of the left atrial as well as the clinical condition. The aim of this study was to assess the correlation between circulating fibrosis biomarkers with net atrioventricular compliance (Cn) as a parameter of left atrial function, and left atrial volume index (LAVI) as a parameter left atrium structure of changes. A cross-sectional study was conducted at Panti Rahayu Hospital and Permata Bunda Hospital, Purwodadi, Central Java, with a total of 40 RHD patients with severe mitral stenosis. The ELISA was used to measure the levels of carboxy-terminal propeptide of type I procollagen (PICP), matrix metalloproteinase I (MMP-1), tissue inhibitor matrix metalloproteinase 1 (TIMP-1), and transforming growth factor-ß1 (TGF-ß1). The left atrial function was assessed by measuring Cn, and the LAVI parameters were measured to assess left atrium structure/size. The mean levels of circulating fibrosis biomarkers were as follows: PICP 153.96±89.12 ng/mL; MMP-1 1.44±2.12 ng/mL; MMP-1/TIMP-1 ratio 0.38±0.54 and TGF-ß1 2.66±1.96 pg/mL. From the echocardiographic evaluation, the mean Cn was 5.24±1.93 mL/mmHg and the mean LAVI was 152.55±79.36 mL/m2. There were significant correlation between MMP-1 and MMP-1/TIMP-1 ratio with Cn (r=0.345 and r=0.333, respectively; both had p<0.05). PICP and TGF-ß1 biomarkers did not significantly correlate with Cn (p>0.05). Meanwhile, none of the biomarkers had a significant correlation with LAVI (p>0.05). This study highlights that MMP-1 and MMP-1/TIMP-1 ratio are potentially to be used as markers to determine the Cn in RHD patients with severe mitral stenosis. However, further studies with a higher sample size are needed to confirm this finding.

Left Atrial Enlargement as a Predictor of Atrial Fibrillation in Rheumatic Mitral Valve Disease: An Echocardiography-based Retrospective Cross-sectional Study.

BACKGROUND: Rheumatic heart disease is a major cause of cardiovascular morbidity and mortality in developing nations and is a leading cause of hospital admission due to cardiac problems in our country. This study will evaluate the association between left atrial size and the occurrence of atrial fibrillation and describe the clinical characteristics along with complications related to Rheumatic Mitral valve disease. METHODS: A retrospective cross-sectional study was conducted at a tertiary care center from January 2018 to December 2019. Reports of 207 patients admitted to medical and/or surgical wards with echocardiographic diagnosis of rheumatic mitral valve disease with or without atrial fibrillation were reviewed. Data were collected, entered, and analyzed using the Statistical Package for the Social Science version 25.0. RESULTS: Among 207 patients, atrial fibrillation was present in 90 (43.5%) patients. Atrial fibrillation was higher in patients with mixed mitral valvular lesions compared to isolated mitral stenosis or mitral regurgitation. Univariate and multivariate analysis revealed left atrial size [aOR=1.067, 95% CI: 1.023 - 1.113, P= 0.002] and age [aOR = 1.073, 95% CI: 1.042 - 1.105, P<0.001] as an independent predictor of atrial fibrillation. CONCLUSIONS: Larger left atrium was an independent predictor of atrial fibrillation. Besides this, atrial fibrillation was associated with increasing age, mixed mitral valvular lesion, and moderately reduced left ventricular ejection fraction, but not associated with gender and mitral stenosis severity. Left atrial clot was significantly higher in patients with atrial fibrillation than in sinus rhythm.

[Catheter-based and surgical treatment of mitral valve diseases]. / Katheterbasierte und operative Therapie bei Mitralklappenvitien.

There is a broad spectrum of mitral valve diseases ranging from young patients with rheumatic mitral valve stenosis up to older patients with secondary mitral valve regurgitation and numerous comorbidities. A profound understanding of the etiology, anatomical characteristics of mitral valve diseases and current treatment options is necessary to be able to prepare a patient-centered treatment approach. The interdisciplinary collaboration of referring physicians, interventional cardiologists, cardiac surgeons, heart failure and imaging specialists as well as anesthesiologists is a cornerstone of optimal patient treatment.

Bioprosthetic mitral valve thrombosis: the role of cardiac CT in diagnosis and guiding the management.

A patient in his 60s with a bioprosthetic aortic and mitral valve replacement presented with dyspnoea, tiredness and dizziness 2 years postoperatively. Transthoracic echocardiography showed mitral valve stenosis and increased pulmonary artery pressure suggesting bioprosthetic valve failure. Cardiac CT confirmed the diagnosis of bioprosthetic mitral valve thrombosis. Treatment with anticoagulation resulted in a remarkable improvement of the valve area and gradient and complete resolution of the thrombus. Herein, we report a case of rare bioprosthetic mitral valve thrombosis.

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.

Hypoplastic Left Heart Syndrome with Mitral Stenosis and Aortic Atresia-Echocardiographic Findings and Early Outcomes.

BACKGROUND: Mitral stenosis/aortic atresia (MS/AA) has been reported as a high-risk variant of hypoplastic left heart syndrome (HLHS), potentially related to ventriculocoronary connections (VCCs) or endocardial fibroelastosis (EFE) and myocardial hypoperfusion. We aimed to identify echocardiographic and clinical factors associated with early death or transplant in this group. METHODS: Patients with HLHS MS/AA treated at our center between 2000 and 2020 were included. Pre-stage I palliation echocardiograms were reviewed. Certain imaging factors, such as determination of VCC, EFE, and measurement of tricuspid annular plane systolic excursion were measured from retrospective review of preoperative images; others were derived from clinical reports. Groups were compared according to primary outcome of death or transplant prior to stage II palliation. RESULTS: Of 141 patients included, 39 (27.7%) experienced a primary outcome. Ventriculocoronary connections were identified in 103 (73.0%) patients and EFE in 95 (67.4%) patients. Among imaging variables, smaller ascending aorta size (median, 2.2 [interquartile range (IQR) 1.7-2.8] vs 2.6 [2.2-3.4] mm, P = .01) was associated with primary outcome. There was similar frequency of VCC (74.4% vs 72.5%, P = .83), EFE (59.0% vs 72.5%, P = .19), moderate or greater tricuspid regurgitation (5.1% vs 5.9%, P = 1.00), and similar right ventricular systolic function (indexed tricuspid annular plane systolic excursion 32.5 ± 7.3 vs 31.4 ± 7.2 mm/m2, P = .47) in the primary outcome group compared to other patients. Clinical factors associated with primary outcome included lower birth weight (mean, 2.8 ± SD 0.8 vs 3.3 ± 0.5 kg, P = .0003), gestational age <37 weeks (31.6% vs 4.9%, P < .0001), longer cardiopulmonary bypass time (median, 112 [IQR, 93-162] vs 82 [71-119] minutes, P = .001), longer intensive care unit length of stay (median, 19 [IQR, 10-30] vs 10 [7-15] days, P = .001), and extracorporeal membrane oxygenation following stage I palliation (43.6% vs 8.8%, P < .0001). Presence of VCCs and EFE was not associated with death or transplant after controlling for birth weight and era of stage I palliation. CONCLUSIONS: In one of the largest reported single-center cohorts of HLHS MS/AA, there were few pre-stage I palliation imaging characteristics associated with primary outcome. Imaging findings evaluated in this study, including the presence of VCC and/or EFE as determined using highly sensitive echocardiogram criteria, should not preclude intervention, although impact on long-term outcomes requires further evaluation.

Imaging of the Mitral Valve.

Echocardiographic imaging is the foundation for the evaluation of mitral valve dysfunction. Both transthoracic and transesophageal echocardiography provide insight into the anatomy, pathology, and classification mitral valve dysfunction. Echocardiography also provides a multi-parametric approach with semi-quantitative and quantitative parameters to assess the severity of mitral regurgitation and mitral stenosis. Transesophageal imaging is essential in the assessment of patients considered for surgical or transcatheter interventional strategies to treat mitral valve dysfunction. Cardiac computed tomography (CT) and cardiac MRI are useful adjunctive imaging techniques in mitral valve disease with CT providing detailed procedural specificity and MRI providing detailed ventricular and regurgitant flow analysis.

Assessment of suitability for percutaneous mitral commissurotomy: a contemporary review of key anatomical criteria and predictive models.

The immediate result of percutaneous balloon mitral commissurotomy is largely determined by the anatomy of the mitral valve complex. Several scores and models have been developed to assess anatomical suitability for percutaneous balloon mitral commissurotomy. Although none has an optimal predictive power, these models look at the valvular apparatus from different perspectives bearing the potential for a complementary role.

Differential Clubbing and a Triad of Patent Ductus Arteriosus, Ventricular Septal Defect and Supravalvular Ring Mitral Stenosis: A Case Report.

It is not uncommon for congenital heart defects to occur in clusters. Those involving a right to left heart shunt commonly cause cyanosis and finger clubbing. Differential clubbing involving only the lower limb digits is a strong pointer to the presence of patent ductus arteriosus with reversal of shunt. We report a case of 25-year-old man with effort intolerance and differential clubbing. He was found to have the uncommon triad of patent ductus arteriosus, ventricular septal defect and supravalvular ring mitral stenosis. The presence of differential clubbing on a background of patent ductus arteriosus usually indicates a reversal of shunt and negates surgical intervention. This general rule may however not apply with co-existing mitral stenosis as the elevated pulmonary pressure may be predominantly post-capillary. The finding of mitral stenosis in a patient with patent ductus arteriosus and differential limb clubbing may signify a good prognostic surgical outcome.

Il n'est pas rare que des malformations cardiaques congénitales surviennent en clusters. Celles impliquant un shunt cardiaque droitegauche provoquent souvent une cyanose et un hippocratisme digital. L'hippocratisme digital différentiel touchant uniquement les orteils des membres inférieurs est un indicateur fort de la présence d'un canal artériel persistant avec inversion du shunt. Nous rapportons le cas d'un homme de 25 ans présentant une intolérance à l'effort et un hippocratisme digital différentiel. Il a été diagnostiqué avec la triade peu commune de canal artériel persistant, de communication interventriculaire et de sténose mitrale à anneau supravalvulaire. La présence d'un hippocratisme digital différentiel sur un fond de canal artériel persistant indique généralement une inversion du shunt et exclut une intervention chirurgicale. Cependant, cette règle générale peut ne pas s'appliquer en présence d'une sténose mitrale concomitante, car la pression pulmonaire élevée peut être principalement post-capillaire. La découverte d'une sténose mitrale chez un patient atteint de canal artériel persistant et d'un hippocratisme digital différentiel peut indiquer un bon pronostic pour l'intervention chirurgicale.

Mitral leaflet separation index correlation with mitral stenosis severity, a reliable easy 2-d echocardiography technique.

Objectives: To evaluate accuracy of mitral leaflet separation index for the determination of mitral stenosis severity in patients with rheumatic mitral stenosis. METHODS: The prospective, cross-sectional study was conducted at the National Institute of Cardiovascular Diseases, Karachi, from March 2021 to February 2022, and comprised patients with rheumatic mitral stenosis detected on echocardiography. The best end-diastole parasternal long axis and apical four-chamber views were acquired and Mitral leaflet separation was measured as the distance between the inner edges of the tip of mitral leaflets. Pearson correlation coefficient was computed for mitral leaflet separation index and mitral valve area. Receiver operating characteristic curve was used to determine the cut-off value of the mitral leaflet separation indexto categorise mitral stenosis. Data was analysed using SPSS 19. RESULTS: Of the 277 patients, 205(74%) were females and 72(26%) were males. The overall mean age was 39.93±11.22 years. The mean mitral leaflet separation index value was 7.65±2.23. The correlation was significant and strong between mitral leaflet separation index and mitral valve area on planimetry (p<0.001), and was significant and moderate when measured by pressure half-time (p< 0.001). Mitral leaflet separation index cut-off value <8.625mm and <8.25mmcould predict severe mitral stenosis with 84% and 86.3% sensitivity and 84.6% and 78.3% specificity on planimetry and pressure half-time, respectively. CONCLUSIONS: The mitral leaflet separation index was found to be an independent, reliable and simple measure for assessing mitral stenosis severity.

[Association of a myxoma of the left atrium and a mitral stenosis : About a case]. / Association d'un myxome de l'oreillette gauche et d'un rétrécissement mitral : à propos d'un cas.

Atrial myxoma is a rare and benign clinical entity. It remains common in women and mainly affects the left atrium. Its clinical picture is polymorphic. We report the case of a 53-year-old woman who consulted for dyspnea with cardiac failure's picture. The diagnosis of myxoma of the left atrium was made on echocardiography which also objectified the existence of mitral stenosis. The patient underwent surgical excision and mitral valve replacement with good postoperative outcomes.

Percutaneous treatment of mechanical mitral valve thrombosis.

A 75-year-old female was found to have mechanical mitral valve thrombosis complicated by severe mitral stenosis, pulmonary edema, and right heart failure. She was at prohibitive risk for surgical intervention. She did not tolerate thrombolysis due to bleeding. We performed percutaneous intervention with cerebral protection with subsequent restoration of mechanical mitral valve function, resolution of the mitral valve stenosis, and no neurologic complications.

Relationship between echocardiographic parameters and ALBI score in patients with rheumatic mitral stenosis.

An increase in the volume and pressure of the heart chambers has been shown to increase liver stiffness. The Albumin-Bilirubin (ALBI) score is useful and easy-to-use for objectively assessing liver function. There is no information in the literature regarding changes in ALBI scores in patients with rheumatic mitral stenosis (MS). The aim of our study was to investigate changes in ALBI score and its clinical impact in patients with MS. Of the 247 patients analyzed, 54 were excluded from the study. The remaining 193 patients with MS were divided into two groups: Group I (64 patients with mitral valve area > 1.5 cm2 and mean transmitral gradient < 10 mmHg) and Group II (129 patients with mitral valve area ≤ 1.5 cm2 and mean transmitral gradient ≥ 10 mmHg). The ALBI score was calculated based on serum albumin and total bilirubin levels using the following formula: ALBI= (log10 bilirubin [µmol/L] × 0.66) + (albumin [g/L] × - 0.085). A significant correlation was found between the ALBI score and mitral valve area in patients with MS (r = - 0.479, p < 0.001*) (Table 4; Fig. 3A). An ALBI score greater than - 2.61 was associated with severe MS (mitral valve area < 1.5 cm2), with a sensitivity of 72% and a specificity of 69% (Area under the ROC curve = 0.726; p < 0.001; 95% CI 0.650-0.802) (Fig. 4A). A significant correlation was found between the ALBI score and mean transmitral gradient in patients with MS (r = 0.476; p < 0.001*) (Table 4; Fig. 3B). An ALBI score greater than - 2.57 was associated with severe MS (mean transmitral gradient < 10 mmHg), with a sensitivity of 65% and a specificity of 67% (Area under the ROC curve = 0.684; p < 0.001; 95% CI 0.608-0.759) (Fig. 4B). In multivariate linear regression analysis, mitral valve area and mean transmitral gradient were significantly associated with increased ALBI scores (p < 0.05). Mitral valve area, mean transmitral gradient, and NT-proBNP levels were significantly associated with the ALBI score. The ALBI score could provide an information about the severity of MS. The ALBI score is a simple, evidence-based, objective, and discriminatory method for assessing liver function in patients with MS.Please check and confirm that the authors and their respective affiliations have been correctly identified and amend if necessary.Authors and their respective affiliations are correctly identified.

Role of 3D transoesophageal echocardiography in correct diagnosis of congenital isolated double orifice mitral valve in a young adult misdiagnosed as rheumatic heart disease.

Double orifice mitral valve (DOMV) is an extremely rare congenital anomaly of the mitral valve (MV) wherein the MV orifice divides into two separate orifices by an accessory fibrous band.Isolated DOMV is a rarity and is often discovered incidentally. It may be associated with other congenital conditions wherein it is identified in early childhood. Its prevalence and prognostic relevance in adulthood remain unclear. DOMV patients may be asymptomatic or have symptoms due to mitral stenosis or regurgitation. We present a case of an asymptomatic young adult initially diagnosed with rheumatic mitral stenosis. However, after a thorough echocardiographic assessment, including three-dimensional transesophageal echocardiography, the accurate diagnosis of DOMV was made.

Left atrial Thrombus formation after discontinuation of anticoagulation in patient with severe bioprosthetic mitral stenosis.

BACKGROUND: Mitral valve stenosis can be a highly symptomatic condition with significant complications if left untreated. In such cases, mitral valve replacement with a bioprosthetic or mechanical valve may be a viable solution to prevent progressive disease. Current guidelines do not recommend continued anticoagulation beyond 6 months for patients who have undergone bioprosthetic valve replacement without a separate indication for anticoagulation. With this case discussion we aim to 1) Review the current indications for anticoagulation for bioprosthetic mitral valves in patients without atrial fibrillation and 2) Discuss the constellation of comorbidities that may affect the decision to begin anticoagulation therapy. CASE PRESENTATION: We present a case describing a 55-year-old male with end-stage renal disease, coronary artery disease with coronary artery bypass graft surgery, and bioprosthetic mitral valve replacement 2 years prior with rapid degeneration of the replaced valve and on warfarin without a clear indication for anticoagulation. The patient was admitted for symptomatic, severe mitral stenosis and consideration of transcatheter mitral valve-in-valve replacement. During hospital admission, warfarin was discontinued and replaced with prophylactic anticoagulation. However, 8 days after warfarin cessation an intraoperative transesophageal echocardiography revealed a newly developed large left atrial thrombus leading to cancellation of the planned operation. CONCLUSIONS: This patient developed a left atrial thrombus after discontinuing warfarin in the setting of rapidly deteriorating bioprosthetic valve stenosis and vascular comorbidities. The decision to discontinue warfarin was made in concordance with current guidelines, which do not indicate systemic anticoagulation post 3-6 months after bioprosthetic valve replacement without separate indication for anticoagulation. This case identifies the need to investigate rebound hypercoagulability and further risk stratify comorbidities which may independently increase the risk of clot formation in the setting of severe mitral valve stenosis.