Initial experience of using intracardiac echocardiography (ICE) for guiding balloon mitral valvuloplasty (BMV)

Background and aimsBMV is an established treatment for rheumatic mitral valve stenosis. The procedure is historically guided by fluoroscopy, and the role of intracardiac echocardiogram (ICE) guidance is not well defined. We report our initial experience of using ICE to guide BMV procedures.MethodsDuring BMV procedure, ICE catheter was inserted into the right atrium from the right femoral vein, and the septal puncture was monitored by ICE, as well as positioning of the balloon in the mitral valve. Comparisons were made between ICE, transthoracic echocardiography (TTE), and catheterization derived hemodynamic measurements (cath).ResultsSeventeen patients with mitral stenosis underwent the procedure. The mean age was 44.4 ± 21 years. The mean MV area increased from 0.9 ± 0.1 cm² to 1.7 ± 0.2 cm², P < 0.0001 and the mean gradient decreased from 12.6 ± 5.8 mmHg to 4.9 ± 1.8 mmHg, P < 0.001. Atrial septum puncture and guidance of the balloon into the MV apparatus were obtained in all patients under ICE guidance. Severe MR developed in one patient and was readily detected by ICE. ICE derived gradient measurements were comparable to those obtained by TTE, and cath.ConclusionICE guidance of BMV is feasible, and useful in monitoring safe septal puncture, optimizing balloon positioning, and in detecting complications. The hemodynamic measurements obtained were comparable to those obtained by TTE, and cath.     

Percutaneous transvenous mitral commissurotomy in mitral stenosis and left atrial appendage clot patients in special conditions: Hospital-based study

BackgroundThe percutaneous transvenous mitral commissurotomy is an important procedure for the treatment of mitral stenosis. A lot of mitral stenosis cases have left atrial appendage clot which precludes the patient from the benefit of this procedure.The aim of the study was to study the feasibility and safety of the procedure in a patient with appendage clot in the setup of certain urgent conditions.MethodAll cases of mitral stenosis with significant dyspnea and mitral valve area <1.5 cm² with left atrial appendage clot and a condition which would preclude the patient from continuing on anticoagulation and needed urgent intervention were included in the study. From January 2011 to December 2013, twenty patients coming to Shahid Gangalal National Heart Centre, Kathmandu were selected for the procedure with conventional sampling technique. Informed written consent was obtained from the patients explaining all possible complications. The approval of the study was taken from the ethical committee of the hospital.ResultMean mitral valve area increased from 0.90 cm² (SD ± 0.14) to 1.5 cm² (SD ± 0.21) (p = 0.02). Left atrial mean pressure decreased from mean of 20 to 10 mmHg. Subjective improvement was reported in all. All of the patients had fulfilled criteria for successful PTMC. There was no mortality during hospital stay or in one-week follow-up period. There were no neurological complications or any need for emergency surgery.ConclusionThe immediate result of percutaneous transvenous mitral commissurotomy in selected cases of mitral stenosis with left atrial appendage clot is safe and acceptable in certain urgent situations in experienced hands.     

The impact of commissural morphology on clinical outcome in patients undergoing percutaneous balloon mitral valvuloplasty

AimWe aimed to evaluate the prognostic value of commissural morphology on immediate and short term outcome after Percutaneous balloon mitral valvuloplasty (PBMV).MethodsThe study included 30 patients with symptomatic mitral stenosis (MS) scheduled for PBMV with these exclusion criteria: left atrial thrombi, High echocardiography score, Moderate to severe mitral regurgitation (MR), Atrial fibrillation (AF) or Calcification. After PBMV, they were randomized into 2 groups: Group I: 12 patients with only opened one commissure and group II: 18 patients with bilateral opened commissures.ResultsFollowing PBMV, the mean mitral valve area (MVA) increased from 0.94 ± 0.19 to 1.86 ± 0.27 cm² in group I & from 0.91 ± 0.18 to 2.29 ± 0.33 cm² in group II (p = 0.001). The mean transmitral gradient (MG) decreased from 21.83 ± 4.1 to 8.08 ± 2.9 mmHg in group I and from 18.28 ± 5 to 5.2 ± 1.76 mmHg in group II (p = 0.003). The MVA was 1.85 ± 0.23 cm² in group I and 2.25 ± 0.31 cm² in group II (p = 0.001) and MG was 8.09 ± 2.90 mmHg in group I and 5.47 ± 1.79 mmHg in group II (p = 0.001). Three month follow-up: there was no patient developed AF, embolization or severe MR. Also, there was no mortality, redo, or surgery.ConclusionWe concluded that degree of commissural opening and MVA are closely related. The complete bilateral commissural opening is associated with better sustained MVA and functional status. Thus, evaluation of the degree of commissural opening can be considered as a complementary measure of the procedural success in PBMV.     

Comparison of left and right atrial appendages anatomy and function in patients with mitral stenosis and sinus rhythm

BackgroundThe left atrial appendage (LAA) has been considered a relatively significant portion of the cardiac anatomy. Transesophageal echocardiography (TEE) is a technique that makes clear imaging of the LAA possible, so that its shape and function can be assessed. Tissue Doppler imaging (TDI) was used recently for the assessment of the contractile function of the left atrial appendage (LAA) and right atrial appendage (RAA).Patients and methodsForty-three patients with pure mitral stenosis (MS) in sinus rhythm were compared to 12 normal individuals only patients with mild and severe mitral stenosis were included. Patients with moderate mitral stenosis were excluded. A transthoracic and a transesophageal echo were performed in all patients. We assessed the LAA anatomy (neck width, length, area). Assessment of LAA function was done by the recording of LAA emptying velocity. Pulsed-wave tissue Doppler imaging (TDI) was positioned at the tip of the LAA and the tip of the RAA to obtain atrial peak systolic (Sm) and diastolic myocardial velocities.ResultsPatients with MS (severe and mild) had a larger left atrial diameter and area than the control {50.5 ± 3.8 & 46.2 ± 4.5 vs 35.4 ± 1.8, and 31.2 ± 3.3 & 26 ± 2.3 vs 19.9 ± 1.4} P-value 0.0001 & 0.0001, respectively and patients with MS (severe and mild) had a higher PASP than the control {50.9 ± 10.5 & 30 ± 7 vs 25.2 ± 1.6} P-value 0.0001. TEE data of patients with MS (severe and mild) had a larger left atrial appendage length, base, and area than the control {(49.8 ± 6.38 & 42 ± 2.5 vs 37.8 ± 2.2), (27.7 ± 3.8 & 23.2 ± 3.1 vs 18 ± 2.5), and (7.6 ± 0.6 & 6.5 ± 0.5 vs 4.6 ± 0.7} P-value 0.0001. Patients with MS (severe and mild) had a significant decrease in atrial peak systolic flow velocities (S wave) than the control (16.1 ± 3.7 & 26.5 ± 0.7 vs 70 ± 13), P-value 0.0001.Also patients with MS (severe and mild) had significant decrease in atrial peak systolic myocardial velocities (Sm wave) of the LAA compared with the control (6.1 ± 1.7 & 12.6 ± 0.3 vs 18.8 ± 1.9), P-value 0.0001. (TDI) flow of the RAA myocardial velocity, patients with mitral stenosis (severe and mild) had a significant decrease in atrial peak systolic myocardial velocities (Sm wave) of the RAA compared with the control (16.5 ± 2.9 & 17.7 ± 1.6 vs 20.1 ± 2.6), P-value 0.0001. SEC was detected in the LAA in 17 patients of the 43 patients with mitral stenosis which represents 39.5% of the patients. All patients with SEC were with severe MS. Patients with SEC had a significant increase in Fc, mean transmitral gradient, PASP, Sm LAA, Sm RAA, LAA area and peak S velocity LAA than patients without SEC. No patient had SEC in the RAA cavity.ConclusionLAA and RAA dysfunction occurred in patients with MS and sinus rhythm due to increase of atrial afterload presented by a decrease in atrial myocardial velocities.     

A comparative study of ivabradine and atenolol in patients with moderate mitral stenosis in sinus rhythm

BackgroundBeta-blockers are frequently used in patients with mitral stenosis to control the heart rate and alleviate exercise-related symptoms. The objective of our study was to examine whether ivabradine was superior to atenolol for achieving higher exercise capacity in patients with moderate mitral stenosis in sinus rhythm. We also evaluated their effects on left ventricular myocardial performance index (MPI).Methods and resultsEighty-two patients with moderate mitral stenosis in sinus rhythm were randomized to receive ivabradine (n = 42) 5 mg twice daily or atenolol (n = 40) 50 mg daily for 6 weeks. Transthoracic echocardiography and treadmill test were performed at baseline and after completion of 6 weeks of treatment. Mean total exercise duration in seconds markedly improved in both study groups at 6 weeks (298.57 ± 99.05 s vs. 349.12 ± 103.53 s; p = 0.0001 in ivabradine group, 290.90 ± 92.42 s vs. 339.90 ± 99.84 s; p = 0.0001 in atenolol group). On head-to-head comparison, there was no significant change in improvement of exercise time between ivabradine and atenolol group (p = 0.847). Left ventricular MPI did not show any significant change from baseline and at 6 weeks in both drug groups (49.8% ± 8% vs. 48.3% ± 7% in ivabradine group, 52.9% ± 10% vs. 50.9% ± 10% in atenolol groups; p = 0.602).ConclusionIvabradine or atenolol can be used for heart rate control in patients with moderate mitral stenosis in sinus rhythm. Ivabradine is not superior to atenolol for controlling heart rate or exercise capacity. Left ventricular MPI was unaffected by either of the drugs.     

Résultats de la dilatation mitrale percutanée chez la femme enceinte à propos de 12 cas

IntroductionMitral stenosis (MS) is the most common valvular heart disease revealed or exacerbated by pregnancy. Percutaneous mitral balloon commissurotomy (PMC) is currently the treatment of choice when mitral valve morphology is favorable.Aim of the studyThe purpose of this study is to evaluate the immediate, medium and long term results of percutaneous mitral balloon commissurotomy in pregnant women with a severe symptomatic mitral stenosis despite medical treatment.Patients and methodsIt is a retrospective study including 12 pregnant patients diagnosed with severe mitral stenosis and hospitalized in the cardiology department of Habib Thameur hospital between 1994 and 2014. A clinical and ultrasonographic monitoring was performed for over 15 years.ResultsMean patients age was 31.5 ± 4.4 years. All patients were in NYHA class III or IV despite medical treatment. Mitral regurgitation was rated as moderate in four cases. Functional improvement was observed in all cases immediately after the procedure. Mitral valve area increased from 1.02 ± 0.5 cm² averaged to 2 ± 0.35 cm². Mitral regurgitation increased in three cases and appeared in two cases. All patients delivered at term. Newborns were all healthy. Two of them had a low birth weight. On the long term follow-up (95.58 ± 64.1 months), five patients had mitral restenosis: two had a surgical valve replacement and three underwent a second percutaneous mitral balloon commissurotomy.ConclusionThe effectiveness of the percutaneous mitral balloon commissurotomy is clearly documented by clinical and echocardiographic evaluation. In the case of pregnancy, the goal is not so much to obtain an optimal result but to cause hemodynamic improvement authorizing the continuation of pregnancy and childbirth.     

Correlation of pulmonary capillary wedge pressure with left atrial pressure in patients with mitral stenosis undergoing balloon valvotomy

AimsWe sought to evaluate the correlation between PCWP and LAP and to compare transmitral gradients obtained with LAP and PCWP in MS, before and after balloon mitral valvotomy (BMV).MethodsConsecutive patients with MS for BMV were included in this prospective cohort study. Simultaneous PCWP and LAP were recorded followed by simultaneous left atrium–left ventricular (LA–LV) and pulmonary capillary wedge pressure–left ventricular (PCWP–LV) gradients before and after BMV.ResultsThere were 30 patients with a mean age of 41 yrs (males 10 (33.3%), females 20 (66.7%)). There was no significant difference between mean LAP and mean PCWP before BMV (21.3 mmHg and 22.3 mmHg, respectively) or after BMV (15.3 mmHg and 17.3 mmHg, respectively). There was excellent correlation between mean PCWP and mean LAP before BMV (r = 0.95) (p < 0.001) and after BMV (r = 0.85) (p < 0.001). The phasic components of the pressures (a and v waves) of LAP and PCWP also showed good correlation before and after BMV. Further, transmitral gradients assessed by LA–LV and PCWP–LV pressures showed excellent correlation before BMV (r = 0.95) (p < 0.001) and after BMV (r = 0.95) (p < 0.001).ConclusionIn patients with MS undergoing balloon valvotomy, PCWP shows good correlation with LAP. Transmitral gradients obtained with PCWP and LAP also correlate well after correction of phase lag in PCWP tracing. Hence, PCWP can be used for reliable measurement of transmitral gradient.     

Potential use of Brain Natriuretic Peptide in patients with asymptomatic significant mitral stenosis

ObjectiveTo evaluate the ability of BNP to identify a subset of patients with asymptomatic significant rheumatic MS, who get symptoms on stress exercise testing.MethodsSeventy asymptomatic patients with significant rheumatic MS (MVA ⩽1.5 cm²) were included in the study. All patients underwent resting echo-Doppler study, exercise echocardiography and BNP level assessment pre- and one week post-balloon dilatation (for group I patients who had PMC).Patients were divided into two groups. Group I included 33 patients who became symptomatic on exercise and had low exercise capacity. Group II included 37 patients who were asymptomatic on exercise and had reasonable exercise capacity.ResultsBNP level in group I was 92 ± 12 compared to 40 ± 10 pg/ml in group II, P < 0.001. Post PMC, BNP in group I significantly decreased (92 ± 12, compared to 31 ± 9 pg/dl, P < 0.001). LA dimension was significantly different between both groups (50 ± 2.9 in group I compared to 46 ± 3.1 mm in group II, P < 0.001). Post-exercise SPAP was 72 ± 12 in group I compared to 46 ± 13 mmHg in group II, P < 0.001. Post-exercise MV gradient was 28 ± 9 compared to 20 ± 12 mmHg, P = 0.002. BNP significantly correlated with post-exercise SPAP (r = 0.635; P < 0.001). Area under the ROC curve for BNP as a predictor of low exercise capacity and development of symptoms on exercise was 0.98 [CI 95% 0.96–1.0]. When using a cutoff value of 55 pg/mL for BNP, sensitivity was 93.9% and specificity was 91.9%.ConclusionBNP may be used to approach asymptomatic patients with significant MS. BNP may identify a subset of patients with exercise-induced clinical and echo-Doppler criteria that meet the contemporary guidelines for intervention.     

Prise en charge du rétrécissement mitral durant la grossesse au centre hospitalo-universitaire d’Oran : à propos de 83 cas

IntroductionThe management of pregnancy in patients with mitral valve stenosis disease continues to pose a challenge to the clinician.ObjectiveThe aim of study was to evaluate the association between mitral valve stenosis and maternal and fetal out come.Materiel and methodEighty-three pregnant women with mitral valve disease, followed-up from 2009 to 2012, were prospectively evaluated medical history, NYHA class assessment, ECG and echocardiography were performed during pregnancy and after delivery.ResultsWomen with mitral stenosis had significantly clinical higher incidence of complications deterioration of clinical status was observed (44.57%, P = 0.0001) congestive heart failure had observed (27.71%, P = 0.0001), hospitalization (33.73%, P = 0.0001), need of cardiac medications (53.75%, P = 0.009), arrhythmias (16%, P < 0.05), New born outcome, mitral stenosis had an effect on fetal outcome. We had increasing preterm, delivery (17.50%, P = 0.018), hypotrophy (20.48%, P = 0.001), intra-uterine growth retardation (12.04%, P = 0.011) new born hospitalizations (13.25%, P = 0.03) Increased maternal morbidity and unfavorable fetal outcome was seen mostly in patients with moderate and severe mitral stenosis.ConclusionPregnant with critical mitral stenosis form a high-risk groups of life-threatening complications. There is need for close maternal follow-up and fetal surveillance and repair of mitral stenosis should be performed before pregnancy.     

Balloon atrial septostomy: The oldest cardiac interventional procedure in Mansoura

BackgroundBalloon atrial septostomy (BAS) was first described by Rashkind and Miller in 1966 and remains an important interventional procedure in the palliation of certain forms of congenital heart disease (CHD). Creating an atrial septa1 defect in patients with transposition of the great arteries (d-TGA) will enhance bidirectional mixing of the pulmonary and systemic venous blood, hence improving oxygen saturation. The aim of the work is to review and report our experience using balloon atrial septostomy in different CHD.MethodWe retrospectively reviewed the hospital records, echocardiographic and cardiac catheterization reports of patients subjected for BAS during the period from January 2001 till January 2010. One hundred and ninety two patients with CHD (78.5% d-TGA, 10% mitral atresia, 7.5% tricuspid atresia, and 4% hypoplastic left heart syndrome) underwent BAS. Their gestational age was 38.63 ± 1.48 weeks, postnatal age (median 3.5 days, range 1–54) and weight 3.08 ± 0.37 kg, 57.5% was male and 42.5% was female. All patients received PGE1 infusion before the procedure to maintain the ductal patency in a dose of 0.05–0.1 μg/kg/min.ResultsOne hundred twenty two procedures (63.5%) were done in neonatal intensive care at bedside and 70 procedures (36.5%) in the catheterization laboratory. General anesthesia was used in 31.3% of patients whereas conscious sedation was used in 68.7% of patients. Femoral access in 78% while umbilical access in 22%. Seven F sheath was used in 100% of case. The Miller catheter was used in 75% and a Z-5 septostomy catheter in 25% of cases. The diameter of the atrial communication increased from 2.75 ± 0.97 mm to 7.07 ± 0.79 mm (p < 0.0001). Oxygen saturations increased significantly from 65.38 ± 9.59% to 88.62 ± 3.13% (p < 0.0001). Mean pressure gradient for patients done in catheterization laboratory decreased from 4.1 ± 2.4 to 0.5 ± 1.1 mmHg (p < 0.0001). The number of septostomies required to achieve good results was 5.23 ± 1.20. No significant difference in oxygen saturation or the size of inter-atrial communication was observed between the two used balloons (p = 0.6).ConclusionBAS is safe and an effective palliative procedure for different CHD with good immediate results in our institution.     

Progresión de la enfermedad renal crónica en pacientes con hipertensión resistente sometidos a 2 estrategias terapéuticas: intensificación con diuréticos de asa vs. antagonistas de la aldosterona

IntroductionActualy, there are few data about glomerular filtration rate (eGFR) drop in patients with resistant hypertension and how diferent therapies can modify chronic kidney disease progression (CKD).ObjectiveTo evaluate CKD progression in patients with resistant hypertension undergoing 2 diferent therapies: treatment with spironolactone or furosemide.MethodsWe included 30 patients (21 M, 9 W) with a mean age of 66.3 ± 9.1 years, eGFR 55.8 ± 16.5 ml/min/1.73 m², SBP 162.8 ± 8.2 and DBP 90.2 ± 6.2 mmHg: 15 patients received spironolactone and 15 furosemide and we followed up them a median of 32 months (28-41).ResultsThe mean annual eGFR decrease was -2.8 ± 5.4 ml/min/1.73 m². In spironolactone group was –2.1 ± 4.8 ml/min/1.73 m² and in furosemide group was -3.2 ± 5.6 ml/min/1.73 m², P<0.01. In patients received spironolactone, SBP decreased 23 ± 9 mmHg and in furosemide group decreased 16 ± 3 mmHg, P<.01. DBP decreased 10 ± 8 mmHg and 6 ± 2 mmHg, respectively (P<.01). Treatment with spironolactone reduced albuminuria from a serum albumin/creatine ratio of 210 (121-385) mg/g to 65 (45-120) mg/g at the end of follow-up, P<.01. There were no significant changes in the albumin/creatinine ratio in the furosemide group. The slower drop in kidney function was associated with lower SBP (P=.04), higher GFR (P=.01), lower albuminuria (P=.01), not diabetes mellitus (P=.01) and treatment with spironolactone (P=.02). Treatment with spironolactone (OR 2.13, IC 1.89-2.29) and lower albuminuria (OR 0.98, CI 0.97-0.99) maintain their independent predictive power in a multivariate model.ConclusionTreatment with spironolactone is more effective reducing BP and albuminuria in patients with resistant hypertension compared with furosemide and it is associated with a slower progression of CKD in the long term follow up.     

Safety and efficacy of percutaneous balloon mitral valvotomy in severe mitral stenosis with moderate mitral regurgitation – A prospective study

BackgroundPercutaneous balloon mitral valvotomy (PBMV) is generally considered as a contraindication in patients with mitral stenosis (MS) associated with moderate to severe mitral regurgitation (MR). We sought to compare the safety and efficacy of PBMV in patients with severe MS and with moderate MR with those with less than moderate or no MR.Materials and methodsSymptomatic patients of MS with mitral valve area ≤1.5 cm² were screened into two groups: Group I with moderate MR and Group II with less than moderate or no MR. Clinical and echocardiographic assessments were done at 24 h, 1 month, and 6 months post-procedure. A treadmill testing was done prior to PBMV and at 6 months.Primary safety outcome was a composite of cardiovascular death and development of severe MR with or without requirement for mitral valve replacement at 30 days of procedure. Efficacy of the procedure was measured as improvement in functional class, treadmill time, and mitral valve area (MVA) at 6 months.ResultsSeventeen patients with moderate MR and 208 patients with less than moderate MR underwent PBMV. Primary outcome showed no significant difference [2 (11.7%) in Group I vs. 8 (3.85%) in Group II, p = 0.36]; occurrence of severe MR was higher in Group I [RR = 4.87, 95% C.I. = 1.42–16.69]. In Group I patients, improvement in treadmill time was seen in 12 (70.59%), functional class in 13 (76.47%), and MVA in all patients.ConclusionIn patients having severe MS associated with moderate MR, PBMV may be a safe option and provides sustained symptomatic benefit.     

Mitral balloon valvotomy,long-term results,its impact on severe pulmonary hypertension,severe tricuspid regurgitation,atrial fibrillation,left atrial size,left ventricular function

Percutaneous mitral balloon valvotomy (MBV) was introduced in 1984 by Inoue who developed the procedure as a logical extension of surgical closed commissurotomy. Since then, MBV has emerged as the treatment of choice for severe pliable rheumatic mitral stenosis (MS). With increasing experience and better selection of patient, the immediate results of the procedure have improved and the rate of complications declined. When the reported complications of MBV are viewed in aggregate, complications occur at approximately the following rates: mortality (0–0.5%), cerebral accident (1–2%), mitral regurgitation (MR) requiring surgery (0.9–2%). These complication rates compare favorably to those reported after surgical commissurotomy. Several randomized trials reported similar hemodynamic results with MBV and surgical commissurotomy. Restenosis after MBV ranges from 4% to 70% depending on the patient selection, valve morphology, and duration of follow-up. Restenosis was encountered in 31% of the author’s series at mean follow-up of 9 ± 5.2 years (range 1.5–19 years) and the 10, 15, and 19 years restenosis-free survival rates were (78 ± 2%) (52 ± 3%) and (26 ± 4%), respectively, and were significantly higher for patients with favorable mitral morphology (MES ⩽ 8) at 88 ± 2%, 67 ± 4% and 40 ± 6%, respectively (P < 0.0001). The 10, 15, and 19 years event-free survival rates were 88 ± 2%, 60 ± 4% and 28 ± 7%, respectively, and were significantly higher for patients with favorable mitral morphology 92 ± 2%, 70 ± 4% and 42 ± 7%, respectively (P < 0.0001). The effect of MBV on severe pulmonary hypertension, concomitant severe tricuspid regurgitation, left ventricular function, left atrial size, and atrial fibrillation is addressed in this review.     

Mean pulmonary arterial pressure after percutaneous mitral valvuloplasty predicts long-term adverse outcomes

Introduction and aimPercutaneous mitral valvuloplasty (PMV) is an effective treatment option for mitral stenosis (MS), but its success is assessed on the basis of clinical and echocardiographic outcomes in studies with relatively short follow-up. We aimed to characterize a cohort of patients undergoing PMV with long-term follow-up and to determine independent predictors of post-PMV mitral re-intervention and event-free survival.MethodsWe studied 91 consecutive patients with MS who underwent PMV with a median clinical follow-up duration of 99 months. Two endpoints were considered: post-PMV mitral re-intervention (PMV or mitral surgery) and a composite clinical events endpoint including cardiovascular death, mitral valve re-intervention and hospital admission due to decompensated heart failure. We compared patients who required post-PMV mitral re-intervention with those who did not during follow-up.ResultsThe study population included 83.5% females and mean age was 48.9 ± 13.9 years. The 1-, 3-, 5-, 7- and 9-year rates of clinical event-free survival were 93.0 ± 2.8%, 86.0 ± 3.9%, 81.0 ± 4.4%, 70.6 ± 5.6%, and 68.4 ± 5.8%, respectively. The 1-, 3-, 5-, 7- and 9-year rates of mitral re-intervention-free survival were 98.8 ± 1.2%, 97.5 ± 1.7%, 92.1 ± 3.1%, 85.5 ± 4.5%, and 85.5 ± 4.5%, respectively. The median time to mitral re-intervention was 6.2 years. Patients who required mitral re-intervention during follow-up were younger (43.3 vs. 51.2 years, p=0.04) and had higher pre- and post-PMV mitral gradient (14.9 vs. 11.5 mmHg, p=0.02 and 6.4 vs. 2.1 mmHg, p<0.001) and higher post-PMV mean pulmonary artery pressure (mPAP) (30.0 vs. 23.2 mmHg, p=0.01). In a Cox proportional hazards model, mPAP ≥25 mmHg was the sole predictor of both mitral re-intervention (HR 5.639 [1.246–25.528], p=0.025) and clinical events (HR 3.622 [1.070–12.260], p=0.039).ConclusionIn our population, immediate post-PMV mPAP was the sole predictor of post-PMV mitral intervention. These findings may help identify patients in need of closer post-PMV follow-up.     

Comparison of determinations of left atrial volume by the biplane area-length and Simpson's methods using 64-slice computed tomography

ObjectivesThere is increasing evidence that left atrial (LA) size is an important predictor of adverse cardiovascular outcomes such as atrial fibrillation, stroke, and congestive heart failure. The aim of this study was to determine whether there is a difference in results of quantification of LA volume by the area-length and Simpson's methods using multislice computed tomography (MSCT).Methods and resultsThe study population consisted of 51 patients with sinus rhythm (sinus group) and 20 patients with atrial fibrillation (af group) clinically indicated for MSCT angiography for evaluation of coronary arteries. Maximum LA volume, obtained at end-systole from the phase immediately preceding mitral valve opening, was measured using the area-length and Simpson's methods. In the sinus group, the mean LA volumes, indexed to body surface area, were 48.4 ± 17.9 ml/m² with the area-length method and 48.3 ± 17.0 ml/m² with the Simpson's method. In the af group, the mean indexed LA volumes with the area-length method and the Simposon's method were 91.5 ± 47.5 ml/m² and 90.3 ± 45.9 ml/m², respectively. LA volumes calculated by the area-length method exhibited a strong linear relationship and agreement with those calculated using Simpson's method in both the groups (sinus group: r = 0.99, P < 0.0001, af group: r = 0.99, P < 0.0001).ConclusionsThe area-length method is a simple and reproducible means of assessment of LA volume. Standardization of LA volume assessment using MSCT is important for serial follow-up and meaningful communication of results of testing among institutions and physicians.     

Transcatheter edge-to-edge repair following surgical valve repair with ring implantation: Results from the multicentre “Clip-in-Ring” registry

BackgroundManagement of mitral regurgitation recurrence after failed surgical valve repair with ring implantation is controversial.AimTo describe the French experience regarding midterm safety and efficacy of transcatheter edge-to-edge mitral valve repair (TEER) in patients with failed surgical valve repair with ring implantation.MethodsThe “Clip-in-Ring” registry is a multicentre registry conducted in 11 centres in France, approved by local institutional review boards, of consecutive TEER following surgical valve repair with ring implantation. Outcomes were Mitral Valve Academic Research Consortium (MVARC) technical success, modified 30-day device and procedural success (where 10 mmHg is considered as a cut-off for significant mitral stenosis) and MVARC complications.ResultsTwenty-three patients were studied: mean age, 69 ± 10 years; male sex, 74%; EuroSCORE II, 16 ± 17; left ventricular ejection fraction, 53 ± 12%; mitral regurgitation grade 3+/4+, 17%/78%; New York Heart Association class III/IV, 47%/22%; median surgery to TEER delay, 23 (6–94) months. Technical success was 100%. At discharge, residual mitral regurgitation grade was ≤ 2+ in 87% and median transmitral gradient was 4 (3–5) mmHg. Thirty-day modified MVARC device and procedural success was 82%: four patients (17%) had residual mitral regurgitation grade > 2+, including two patients who needed complementary surgery. No patient had a 30-day transmitral gradient > 7 mmHg. No patient died or had a stroke or any life-threatening complications. One patient presented a vascular access complication requiring transfusion. No other MVARC-2 adverse event was reported.ConclusionsTEER in patients with failed mitral ring is feasible and safe. Further studies should delineate its exact role in the therapeutic armamentarium for this medical issue.     

Echocardiographic variables associated with mitral regurgitation after aortic valve replacement for aortic valve stenosis

BackgroundMitral regurgitation (MR) is frequently associated with aortic stenosis. Previous reports have shown that coexisting mitral insufficiency can regress after aortic valve replacement (AVR) while others recommend dealing with examination.AimThe study aimed to assess the severity of MR before and after aortic valve replacement for aortic stenosis and to define the determinants of its postoperative evolution.MethodsFor this purpose, 30 adult patients referred for aortic valve surgery underwent pre- and 1 month postoperative transthoracic echocardiography including 2D, MM, PW, CW and color Doppler examination.ResultsPostoperative MR improved in 68.4% of the 19 patients (63.3%) who had preoperative moderate MR (p = 0.002). The effect of the valve size on the postoperative MR was statistically insignificant (0.059) but was significant on regression of the mass (p = 0.001) and drop in mean PG (p = 0.04) across AV. Patients with persistent moderate MR after surgery were all in AF and had significantly larger left atrial size (45 ± 26 mm), compared to none and a smaller left atrial (37 ± 19 mm) in patients in whom MR regressed or disappeared after surgery; respectively, p < 0.05. The postoperative variables associated with moderate MR were peak PG across AV (29.4 ± 5.1 vs 38.0 ± 5.7 p = 0.004), mean PG (15.04 ± 4.4 vs 22.8 ± 5.8 p = 0.009) and LVMI (124.7 ± 19.3 vs 147.2 ± 31.6 p = 0.065).ConclusionPreoperative predictors of residual postoperative MR were large LA and AF while the postoperative variables were high peak and mean pressure gradient across the aortic valve and high LVMI.     

Validity of the distance between mitral leaflets coaptation point and annular plane in differentiation between ischemic and dilated cardiomyopathy

Background: Identification of patients with ischemic cardiomyopathy (ICM) from those with idiopathic dilated cardiomyopathy (DCM) is important therapeutically and prognostically.Objective: To assess the validity of the distance between the mitral leaflets coaptation point and the mitral annular plane (CPMA) at low dose dobutamine stress echocardiography (DSE) for differentiation between ICM and DCM.Patients and methods: Echocardiographic indices and CPMA were measured at baseline and during dobutamine infusion for 50 patients who were presenting with heart failure and reduced ejection fraction (EF). Patients were divided into two groups depending on coronary angiographic findings, group I (ICM with significant coronary artery disease) and group II (DCM with normal coronary arteries).Results: Compared with baseline values, the CPMA at low dose DSE decreased significantly in ICM patients (11.8 ± 2.2 vs 8 ± 1.2 mm, P < 0.01) while it showed non-significant change in patients with DCM (11.66 ± 2.3 vs 11.99 ± 2.22 mm, P > 0.05). At low dose DSE ICM group showed a high statistically significant negative correlation between CPMA and both EF (r = ?0.749, P < 0.0001) and viability index (r = ?0.782, P < 0.0001) and significant positive correlation with WMSI (r = 0.79, P < 0.0001). Receiver operating characteristic (ROC) CPMA cut-off value ? 9 mm at low dose DSE, had sensitivity of 76.92%, specificity of 85.71% in detecting patients with ICM.Conclusion: Measurement of CPMA at low dose DSE might help in identifying patients with ICM from those with DCM.     

Immediate impact of successful percutaneous balloon mitral valvuloplasty on right and left ventricular functions: An echocardiographic study using load independent tissue velocity imaging indices

BackgroundThe impact of successful percutaneous balloon mitral valvuloplasty (PBMV) on left ventricular (LV) function has been a controversial subject. This study aimed to determine the immediate impact of PBMV on biventricular function using recent Tissue Velocity Imaging (TVI) derived load-independent indices.Methods and resultsA total of 30 patients with severe mitral stenosis (MS) who underwent PBMV at a tertiary center of India from August 2012 to December 2013 were included in the study. Thirty age-matched and gender-matched healthy controls were also enrolled.Out of 30 patients, 27(90%) were female. Mean mitral valve area (MVA) of patients before and after PBMV was 0.78 and 1.82 cm² (p < 0.001), respectively. All TVI-derived LV and RV basal systolic (IVCV, Sm and the relatively load independent IVA) and diastolic velocities (Em, Em/Am) were significantly decreased in patients with MS compared to controls (p < 0.001 for all) which improved significantly after PBMV (6.4 ± 0.7 vs 11 ± 1.6; 5.8 ± 0.7 vs 9.9 ± 1.6; 1.5 ± 0.3 vs 4.2 ± 0.6; 6.4 ± 0.6 vs 13.1 ± 2.1; 0.7 ± 0.1 vs 1.7 ± 0.2 for mitral annulus respectively, p < 0.001 for all). Increment in MVA positively correlated with Tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular Sm and isovolumic contraction velocity (IVCV) and inversely with left atrium (LA) size and Pulmonary arterial systolic pressure (PASP) (p = 0.01 for LA size; p < 0.001 for others) while no such correlation was found with mitral annulus isovolumic acceleration (IVA) (r = −0.078; p = 0.679).ConclusionThe improved right ventricular (RV) function appears to be predominantly due to afterload reduction, while that of LV appears to be more due to the acute relief of mechanical restraint.