Severe rheumatic mitral stenosis: a 21st century medusa

Although the prevalence of rheumatic fever has greatly decreased in developed countries, rheumatic mitral stenosis still causes significant morbidity and mortality. Symptomatic patients have a poor prognosis, with a 0 to 15% 10-year survival rate, particularly if percutaneous or surgical intervention are contraindicated or considered high risk. We present a case of severe rheumatic mitral stenosis with an evolution over 4 decades, in which exceptional venous distention has established.     

The vectorcardiographic quantitation of pulmonary hypertension in mitral stenosis

Hemodynamic data and vectorcardiographic (VCG) parameters were correlated in ninety-nine patients with mitral stenosis in order to quantitate the severity of pulmonary hypertension. Using spherical coordinate representation of VCG parameters as independent variables, multi-parameter regression equations were derived for estimating mean pulmonary artery pressure (PAm) and total pulmonary vascular resistance (TPR). The regression equations of this group of ninety-nine patients performed well when the patients were divided into specific subgroups based on horizontal plane morphology. The correlation co-efficients between estimated and measured values ranged from 0.71 to 0.81 for PAm and 0.68 to 0.80 for TPR. These regression equations were used to predict the PAm and TPR in a second set of 11 patients. The correlation co-efficients between the measured and predicted values for this group were 0.54 for PAm and 0.64 for TPR.     

Role of closed mitral commissurotomy in mitral stenosis with severe pulmonary hypertension

BACKGROUND AND AIMS OF THE STUDY: Closed mitral commissurotomy (CMC) is a well-established method for treatment of rheumatic mitral stenosis, but outcome in patients with severe pulmonary arterial hypertension (PAH) has not been clearly documented. METHODS: Between April 1996 and October 1999, among 61 patients who underwent CMC, 27 had severe PAH (systolic pressure > 100 mmHg). Of these patients, 11 were in NYHA class III, and 16 were in class IV. Preoperatively, the mean pulmonary artery (PA) pressure was 107.85 +/- 5.74 mmHg (range: 100-118 mmHg), mitral valve area (MVA) 0.704 +/- 0.106 cm2 (range: 0.5-0.91 cm2), and transmitral gradient 11.93 +/- 1.54 mmHg (range: 10-15 mmHg). The echocardiographic mitral valve score was 6.37 +/- 1.11 (range: 6-10). RESULTS: There was no operative mortality or incidence of significant (> or = 2+) post-CMC mitral regurgitation or cerebrovascular accident. The MVA increased to 2.385 +/- 0.248 cm2 (range: 1.9-2.8 cm2), the transmitral gradient fell to 2.44 +/- 0.51 mmHg (range: 2-3 mmHg), and postoperative PA systolic pressure fell to 33.33 +/- 8.20 mmHg (range: 30-60 mmHg). During a mean follow up of 26.9 months (range: 11-51 months), 23 patients were in NYHA class I and four were in class II. There were no significant differences in parameters between sexes, but mean male age was five years less than mean female age. CONCLUSION: In the subset of patients with severe PAH, surgical CMC is a safe and effective procedure that results in greater MVA and a more significant and sustained fall in PA pressure compared with reported series of percutaneous balloon mitral valvuloplasty.     

Influence of pulmonary hypertension on pulmonary diffusing capacity in patients with mitral stenosis

The pulmonary diffusing capacity (DLCO--steady state method according to Bates and coworkers) was measured at the time of heart catheterization in 12 patients with mitral stenosis without mitral incompetence. DLCO correlates with the tidal volume at rest and during exercise and with pulmonary vascular resistance during exercise only. DLCO and left atrial pressure exhibit a positive correlation up to 22.5 mm Hg only. In patients with mitral stenosis DLCO depends on the alveolar surface area and DLCO is influenced by regional changes in the pulmonary vascular resistance.     

Extreme pulmonary hypertension caused by mitral valve disease. Natural history and results of surgery.

Five hundred and eighty six patients with mitral valve disease were studied with cardiac catheterization between 1961 and 1972; 48 (8.2%) had extreme pulmonary hypertension (resting systolic pulmonary artery pressure of 80 mmHg or above and pulmonary vascular resistance of 10 units or greater) and of these patients, 27 underwent cardiac surgery. The operative mortality for mitral valvotomy was 11 per cent and for mitral valve replacement 56 per cent. The overall mortality was 31 per cent. The risks of operation were increased in those with a long history of cardiac symptoms, those over 50 years of age, and in the presence of associated aortic valve disease. The mean survival for those patients not having operation was only 2.4 plus or minus 0.5 years. The mean follow-up period for those surviving operation has been 5.8 plus or minus 0.6 years, and symptomatic improvement has been good.     

Acquired pulmonary artery branch stenosis caused by pulmonary thromboembolism.

We present a case of acquired pulmonary artery branch stenosis caused by pulmonary thromboembolism. The patient presented with symptoms mimicking aortic dissection. An emergent transesophageal echocardiogram showed a high gradient across the right pulmonary artery along with mobile thrombi. The vital importance making an accurate diagnosis and ruling out aortic dissection is emphasized in view of the need for urgent heparinization or thrombolysis for pulmonary thromboembolism as this is contraindicated in aortic dissection.