Echocardiographic predictors of pulmonary hypertension in patients with severe aortic stenosis.

BACKGROUND: Pulmonary hypertension complicating severe aortic stenosis increases morbidity and mortality. Causes and mechanisms of this are unclear. METHODS: This is a retrospective observational study of 626 patients with severe aortic stenosis who had measurable pulmonary arterial pressure by Doppler echocardiography. Clinical, echocardiographic and pharmacological data were related to the presence of pulmonary hypertension. RESULTS: Of the 626 patients, 119 (19%) had severe pulmonary hypertension defined as pulmonary artery systolic pressure > or =60 mmHg. Patients with severe pulmonary hypertension had a smaller aortic valve area (P < 0.0001), a lower left ventricular ejection fraction (P < 0.0001), a higher mitral E/A velocity ratio (P < 0.0001) indicating a higher filling pressure and a higher prevalence of 3 or 4+ mitral regurgitation (P < 0.001). They were less likely to be on a beta blocker (P = 0.05) or a statin (P = 0.02). Smaller aortic valve area, left ventricular dysfunction, mitral regurgitation and lack of statin use were independent predictors of severe pulmonary hypertension. CONCLUSIONS: Severity of aortic stenosis, left ventricular dysfunction, and mitral regurgitation are risk factors for the genesis of pulmonary hypertension and statins may potentially be protective in patients with severe aortic stenosis.     

Hemoptysis,recurrent cerebrovascular accident,and emergency mitral valve replacement

Hemoptysis in mitral stenosis may occur frequently, but massive pulmonary hemorrhage is uncommon. We describe a patient with mitral stenosis who had severe hemoptysis and required anticoagulation for recurrent embolic cerebrovascular accidents. The patient underwent successful mitral valve replacement with a Hancock bioprosthesis. There was no evidence of pulmonary bleeding following operation. This case illustrated that mitral valve operation may be performed in acutely ill patients for the relief of hemoptysis.     

Severity of rheumatic mitral stenosis in children

Clinical, hemodynamic and operative findings of 125 children, up to the age of 12 years, were analysed to determine if the severity of pulmonary venous and arterial hypertension correlated with the severity of rheumatic mitral stenosis. Moderately severe to severe pulmonary venous and arterial hypertension was found in almost three-quarters of the patients. Operative findings indicated critical mitral stenosis in 69% of the cases. In India, following rheumatic fever, some patients follow an unusually rapid course in developing mitral stenosis severe enough to require operative treatment, even at the age of six years.     

Pulmonary hypertension in Takayasu arteritis

Takayasu arteritis (TA) is a rare chronic vasculitis primarily involving the aorta and its main branches. The disease affects women much more frequently than men, the ratio being 8:1. The onset occurs in the teenage years, always before age of 40. Aortic regurgitation is rare. The pulmonary artery stenosis may also rarely occur. We report the case of a 49-year old female patient with Takayasu arteritis who presented with severe left pulmonary trunk stenosis resulting in pulmonary hypertension, severe aortic regurgitation due to the dilatation of the ascending aorta, mitral insufficiency, critical left renal artery stenosis, and probably with left main coronary artery stenosis. No severe stenosis or occlusion in the mid portion of mid subclavian artery lesion were present. Because the patient presented with serious congestive heart failure, she underwent mitral valvuloplasty and aortic valve replacement. However, the patient died in early postoperative period due to pulmonary hypertension which failed to respond to pharmacotherapy.     

Fatal massive pulmonary hemorrhage complicating mitral stenosis

Mitral stenosis is a well known cause of hemoptysis; however, sudden death due to fatal massive pulmonary hemorrhage is an extremely rare complication. In this report, we describe a 28-year-old female with severe mitral stenosis who died suddenly due to such complication. A review of the literature shows such complication is extremely rare and unpredictable. We recommend that patients with severe mitral stenosis and history of hemoptysis be considered as candidates for early surgical intervention.     

Surgical tactics in pregnant women with mitral valve stenosis]

The rationale of undertaing operative interventions in pregnant women with mitral stenosis of the III and IV stages is analyzed. On the basis of his investigations the author thinks that in women with severe mitral stenosis of the II and IV stages and with the gestation term of up to 30 weeks mitral commissurotomy is indicated. In patients at these stages of the disease and with full-term pregnancy laparotomy may be performed when there is no pulmonary edema and no risk of its development. Simultaneous mitral commissurotomy and cesarian section are indicated in women with mitral stenosis of the III and IV stages and full-term pregnancy in cases of already existing pulmonary edema or when there is a danger of its development.     

Successful balloon mitral valvotomy in rheumatic mitral stenosis with Ebstein's anomaly

The association of Ebstein's anomaly of tricuspid valve with rheumatic mitral stenosis is extremely rare. The case is presented of a young female who had been admitted with progressive dyspnea secondary to severe rheumatic mitral stenosis with moderate pulmonary hypertension, along with Ebstein's anomaly of tricuspid valve. The patient underwent successful balloon mitral valvotomy, using the Inoue technique, with a marked improvement in her symptoms.     

Parachute mitral valve in a young adult with recurrent pulmonary oedema

A parachute mitral valve is a rare congenital malformation resulting from fusion of the mitral chordae tendineae and their attachment to the one prominent papillary muscle. It can be found either as an isolated lesion or, more often, associated with left heart obstructive lesions, patent ductus arteriosus or ventricular septal defect. Congenital mitral stenosis usually presents with severe symptoms in early childhood, otherwise remains stable and hardly ever requires surgical intervention. We present a case of a young adult with severe stenosis of a parachute mitral valve and history of recurrent pulmonary oedema treated by mitral commissurotomy.     

Commissurotomie mitrale percutanée associée à une communication interauriculaire type sinus venosus et un retour veineux anormal partiel : à propos d’un cas

Lutembacher's syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. It is rarely associated to partial anomalous pulmonary venous connection. This condition is treated surgically by mitral commissurotomy or mitral valve operation with concomitant closure of the atrial septal defect with correction of the abnormal pulmonary venous connection. Percutaneous mitral commissurotomy before surgery can be a therapeutic alternative when mitral valve stenosis is severe and valve anatomy is favourable. The authors bring back the case of a 24 years old man having mitral stenosis in sinus rhythm associated to sinus venosus septal defect and partial anomalous pulmonary venous connection. The diagnosis was made for the age of 17 years old on the occasion of dyspnea. He benefited in February 2003 of rescue percutaneous mitral commissurotomy because of pulmonary oedema. Mitral valve area increased from 0.7 cm² to 1.6 cm². The patient was clinically approved, so that he refused surgery and was lost sight. Seven years later (August 2010) he was taken back for a second rescue percutaneous mitral commissurotomy because of a very severe mitral stenosis (mitral valve area was 0.8 cm²), in pulmonary oedema with echocardiographic evaluated pulmonary hypertension at 68 mmHg. The trans-septal complicated of a false road from the right atrium, towards the pericardic cavity. The patient was operated as the matter of urgency, and benefited from a mitral valve replacement by mechanical prosthesis, of closure of sinus venosus septal defect by PTFE patch and correction of abnormal pulmonary venous connection. Operating suites were simple, and the postoperative echocardiography concludes to a good prosthesis profile, the absence of residual shunt and a decrease of pulmonary artery blood pressure from 68 to 40 mmHg. In conclusion, percutaneous mitral commissurotomy may be a waiting procedure for surgery of this disease or emergency treatment of it's valve anomaly, with regular monitoring while awaiting surgery faster and in better conditions.     

Pulmonary microvascular permeability in patients with severe mitral stenosis

Patients with rheumatic mitral stenosis often have no pulmonary oedema despite considerably increased pulmonary venous pressure. Pulmonary microvascular permeability was measured non-invasively by a previously validated method of double isotope scintigraphy with indium-113m and technetium-99m. This permits calculation of an index reflecting transferrin efflux and thus, indirectly, the microvascular permeability. Fifteen patients with severe mitral stenosis (defined as valve area less than 1.0 cm2) were compared with a control group of 11 patients with mild coronary artery disease. The permeability index was significantly lower in patients with mitral stenosis than in the control group. Furthermore, the extent of reduction of the permeability index correlated with the severity of mitral stenosis as reflected by the Gorlin valve area. This finding may account for the relative resistance of these patients to pulmonary oedema despite chronic pulmonary venous hypertension.     

Pulmonary microvascular permeability in patients with severe mitral stenosis.

Patients with rheumatic mitral stenosis often have no pulmonary oedema despite considerably increased pulmonary venous pressure. Pulmonary microvascular permeability was measured non-invasively by a previously validated method of double isotope scintigraphy with indium-113m and technetium-99m. This permits calculation of an index reflecting transferrin efflux and thus, indirectly, the microvascular permeability. Fifteen patients with severe mitral stenosis (defined as valve area less than 1.0 cm2) were compared with a control group of 11 patients with mild coronary artery disease. The permeability index was significantly lower in patients with mitral stenosis than in the control group. Furthermore, the extent of reduction of the permeability index correlated with the severity of mitral stenosis as reflected by the Gorlin valve area. This finding may account for the relative resistance of these patients to pulmonary oedema despite chronic pulmonary venous hypertension.     

Beneficial effect of sildenafil following surgery for mitral stenosis complicated by pre-capillary pulmonary hypertension: report of two cases

Pulmonary hypertension is a serious disorder, difficult to treat especially in the severe forms. The treatment consists mainly of calcium channel blockers, anti-coagulation, intravenous epoprostenol, inhaled nitric oxide and recent agents as bosentan and sildenafil. Sildenafil, a phosphodiesterase 5 specific inhibitor, has been largely evaluated in primary pulmonary hypertension, and in some cases of secondary pulmonary hypertension including parenchymal and thromboembolic diseases; it has not yet been evaluated in severe pulmonary hypertension with elevated pre-capillary resistance in operated mitral stenosis. We report the cases of two patients operated from mitral valve replacement for severe mitral stenosis with elevated pre-capillary resistance, where oral sildenafil, introduced empirically immediately after the surgical procedure at the dose of 50 mg/d, permitted a significant decrease in pulmonary pressures and resistances, allowing a rapid withdrawal of nitric oxide and reducing therefore hospitalization time in the intensive care unit. We think that this simple treatment, with or without association to nitric oxide, should be generalized to persistent pulmonary hypertension following cardiac surgery.     

Successful percutaneous balloon mitral valvuloplasty using left ventricular pressure as a guide to cross the mitral valve--a case report

Percutaneous balloon mitral valvuloplasty (PBMV) provides an effective alternative to surgery in a selective group of patients with symptomatic mitral stenosis. The Inoue balloon technique involves transseptal catheterization followed by catheter manipulation to cross the mitral valve. The authors describe a case of successful percutaneous balloon mitral valvuloplasty in a patient with severe mitral stenosis and pulmonary hypertension. Left ventricular systolic pressure was used as a guide to locate and to advance the balloon catheter across the mitral valve. This technique to cross the mitral valve has not been reported in the literature.     

A rare association of Ebstein's anomaly of tricuspid valve with rheumatic mitral stenosis

Mitral valve abnormalities have been described in Ebstein's anomaly, but acquired rheumatic mitral valve disease is an extremely rare association. We describe a classical case of Ebstein's anomaly of tricuspid valve with severe rheumatic mitral stenosis. This patient had mild mitral regurgitation, pulmonary hypertension and atrial fibrillation.     

Percutaneous transluminal balloon dilatation of the mitral valve in pregnancy

Pregnancy can cause life threatening complications in women with mitral stenosis, and there is a substantial risk of fetal death if valvotomy under cardiopulmonary bypass is required. A patient is described in whom pulmonary oedema developed after delivery of her first child by caesarean section 13 months previously. Subsequent cardiac catheterisation showed severe mitral stenosis (valve area 0.96 cm2, valve gradient 12 mm Hg, pulmonary artery pressure 30/16 mm Hg). Before valvotomy could be performed the patient again became pregnant and presented in pulmonary oedema at twenty two weeks' gestation. Medical treatment was unsuccessful and she underwent percutaneous transluminal balloon dilatation of the mitral valve. This increased the valve area to 1.78 cm2 and reduced the transmitral gradient to 6 mm Hg. The procedure was uncomplicated, and she remained symptom free on no medication. She delivered vaginally at 37 weeks' gestation. Percutaneous transluminal balloon dilatation of the mitral valve is a safe and effective alternative to mitral valvotomy in pregnancy.     

First report of a simultaneous transcatheter mitral valve‐in‐valve and aortic valve replacement in a left ventricular assist device patient

Transcatheter aortic valve replacement is standard of care for patients with severe aortic stenosis at high risk for surgical aortic valve replacement. Although not intended for treatment of primary aortic insufficiency, several transcatheter aortic valve prostheses have been used to treat patients with severe aortic insufficiency (AI), including patients with left ventricular assist devices (LVAD), in whom significant AI is not uncommon. Similarly, transcatheter valve replacements have been used for valve‐in‐valve treatment, in the pulmonary, aortic, and mitral positions, either via a retrograde femoral approach or antegrade transseptal approach (mitral valve‐in‐valve). In this case report, we report an LVAD patient with severe aortic insufficiency and severe bioprosthetic mitral prosthetic stenosis, in whom we successfully performed transfemoral aortic valve replacement and transfemoral mitral valve‐in‐valve replacement via a transseptal approach. © 2017 Wiley Periodicals, Inc.     

Percutaneous transluminal balloon dilatation of the mitral valve in pregnancy.

Pregnancy can cause life threatening complications in women with mitral stenosis, and there is a substantial risk of fetal death if valvotomy under cardiopulmonary bypass is required. A patient is described in whom pulmonary oedema developed after delivery of her first child by caesarean section 13 months previously. Subsequent cardiac catheterisation showed severe mitral stenosis (valve area 0.96 cm2, valve gradient 12 mm Hg, pulmonary artery pressure 30/16 mm Hg). Before valvotomy could be performed the patient again became pregnant and presented in pulmonary oedema at twenty two weeks' gestation. Medical treatment was unsuccessful and she underwent percutaneous transluminal balloon dilatation of the mitral valve. This increased the valve area to 1.78 cm2 and reduced the transmitral gradient to 6 mm Hg. The procedure was uncomplicated, and she remained symptom free on no medication. She delivered vaginally at 37 weeks' gestation. Percutaneous transluminal balloon dilatation of the mitral valve is a safe and effective alternative to mitral valvotomy in pregnancy.     

Percutaneous Mitral Commissurotomy in Acute Pulmonary Edema

From January 1994 to July 1998, percutaneous mitral commissurotomy was performed in 520 patients. Of these patients, 7 (4 men and 3 women aged 31 ± 5.6 years) were dilated in an emergency situation of intractable pulmonary edema caused by severe mitral stenosis. Three patients required mechanical ventilatory support. Percutaneous mitral commissurotomy was performed with the Inoue balloon. The dilatation of the valve was undertaken even though the echocardiographic score of the valve was high. Percutaneous mitral commissurotomy resulted in an increase in the mitral valve area from 0.72 ± 0.18 cm² to 1.95 ± 0.18 cm² (P = 0.011) with a concomitant reduction in pulmonary artery systolic pressure from 82.5 ± 16.4 mmHg to 46.7 ± 11.6 mmHg (P = 0.018). One patient died (he had two cardiac arrests before the dilatation). During follow-up (mean 18 months), one patient presented with a restenosis, one an aggravation of mitral insuflciency grade, and four were in NYHA functional Class II. Thus, percutaneous mitral commissurotomy can be considered as a treatment of choice in patients with intractable pulmonary edema caused by severe mitral stenosis.     

Life-saving balloon mitral valvuloplasty in patient with cardiogenic shock after cardiac arrest.

Balloon mitral valvuloplasty is the procedure of choice in a selected group of patients with significant mitral stenosis and suitable valve morphology. Experience in patients with cardiogenic shock is very limited. We report the case of a dying patient in cardiogenic shock, with pulmonary edema and severe hepatic damage after cardiac arrest caused by mitral restenosis. The patient was successfully treated by emergency balloon mitral valvuloplasty with a good result and complete recovery.     

The spectrum of pure mitral stenosis Hemodynamic studies in relation to clinical disability

The pathophysiology of mitral stenosis is reassessed, with special emphasis upon relation of physiologic variables to severity of symptoms and degree of disability. Data from 44 patients with pure mitral stenosis are presented. Cathetcrization of the left side of the heart was performed in all and catheterization of the right side of the heart in 25 patients.

Twenty-six patients were in Class I or II (American Heart Association Functional Classification) with mild symptoms or none at all, while 18 patients were in Class III with severe symptoms.

As expected, inverse relationships existed between left atrial pressure and mitral valve area (r = − 0.618), pulmonary arterial pressure and mitral valve area (r = − 0.575), and between mean mitral diastolic pressure gradient and mitral valve area (r = − 0.708). There was a positive relationship between cardiac index and mitral valve area (r = + 0.407). All correlation coefficients were significant to the 1 per cent level.

Seventeen of the 26 patients in Classes I and II had mitral valve areas of 1.5 cm², or less. This indicates that severe mitral stenosis can be found in a nearly asymptomatic state. All of the 18 Class III patients had valve areas of less than 1.5 cm². These two groups of patients with similar degree of valve narrowing were compared. Cardiac output was significantly (p < 0.01) reduced in both categories (2.81 L. min. M². for Classes I and II, and 2.82 L. min. M². for Class in patients). Left atrial pressure in the two groups, 18 and 19 mm. Hg, respectively, and mean diastolic pressure gradient, 11 and 13 mm. Hg, respectively, did not show significant differences. However, pulmonary arterial pressure, 22 mm. Hg in Classes I and II and 36 mm. Hg in Class II, as well as pulmonary arteriolar resistance, 105 compared to 425 dynes sec. cm. ⁻⁵, did allow a hemodynamic distinction between the two clinically different groups. These data suggest that the degree of pulmonary vascular disease is an important determinant of the symptoms of mitral stenosis.

For Class I and II patients, history, physical examination and radiographic studies did not allow an accurate prediction of the mitral valve size.

It is suggested that one of the earliest adaptive mechanisms to mitral blockade is a decrease in cardiac output and that this is not mediated, initially, through an elevated pulmonary vascular resistance, myocardial failure or atrial fibrillation. It is one of the means by which a patient with severe stenosis of the mitral valve may remain asymptomatic for prolonged periods of time.