Left ventricular long-axis function is reduced in patients with rheumatic mitral stenosis

Left ventricular long-axis function evaluated by M-mode or tissue Doppler echocardiography has been shown to be useful indexes of left ventricular systolic function; however it has not been evaluated in patients with mitral stenosis. We examined the left ventricular long-axis function of the patients with pure mitral stenosis and normal global systolic function as assessed by fractional shortening of the left ventricle (LV). Fifty-two patients with pure mitral stenosis and twenty-two healthy controls were evaluated by echocardiography. Although there was no statistically significant difference in global systolic function, M-mode derived systolic motion of the septal side and (12 +/- 3 vs 14.4 +/- 1.5 mm, P = 0.016) the lateral side of mitral annulus (13.2 +/- 3 vs 16.8 +/- 2 mm, P = 0.001) were both significantly lower in the patients with mitral stenosis than control subjects. Similarly tissue Doppler systolic velocity of the septal annulus (7.6 +/- 1.1 vs 10.4 +/- 3.2 cm/s, P = 0.03) and lateral mitral annulus (7.6 +/- 1.1 vs 10.4 +/- 3.2 cm/s, P = 0.003) were also significantly lower in patients with mitral stenosis than in controls. There was a statistically significant correlation between septal annular motion and annular velocity (r = 0.643, P = 0.002). Septal annular motion and annular velocity were also correlated with left atrial ejection fraction (r = 0.338, P = 0.005 and r = 0.676, P = 0.001, respectively). Thus, patients with mitral stenosis had significantly impaired long-axis function evaluated by M-mode or tissue Doppler echocardiography despite normal global systolic function.     

Determinants of left ventricular function in isolated rheumatic mitral stenosis

Left ventricular end-diastolic volume (preload), peak systolic wall stress (afterload), instant Emax (contractility index = peak systolic left ventricular pressure/end-systolic volume), left ventricular mass, left ventricular ejection fraction (LVEF) alone and normalised for mass index, were studied in 30 patients with isolated rheumatic mitral stenosis (group 1) and compared with 24 normal individuals (group II) who served as control. Preload was not different in the two groups (p = NS), afterload was increased in group I (p = 0.01), while LVEF, Emax, left ventricular mass and mass normalised LVEF were reduced in mitral stenosis as compared to normal control (p less than 0.01- less than 0.001). Comparison of patients with reduced ejection performance (LVEF less than 50%, n = 9, group IA) with those having normal LVEF (n = 21 group IB) revealed increased left ventricular end-diastolic volume and reduced left ventricular mass, mass normalised ejection fraction and Emax (in IA p less than 0.05). Peak systolic wall stress was comparable in these two subgroups. This study shows that the major determinant of left ventricular dysfunction in isolated rheumatic mitral stenosis is impaired contractility and not the loading factors.     

Echocardiographic evaluation of left ventricular function in pure mitral stenosis

Echocardiographic evaluation of left ventricular function was performed in 22 cases of pure rheumatic mitral stenosis and 22 age matched normal persons. Cases with any evidence of rheumatic activity in the preceding six months, those with gross tricuspid regurgitation and paradoxical movement of the interventricular septum and cases with atrial fibrillation were excluded. None of the patients showed systolic left ventricular dysfunction. Left ventricular end diastolic dimension was also not affected. Echocardiographic parameters did not have any relation for mitral valve area. Our observations show that mitral stenosis per se does not affect left ventricular function.     

Global left ventricular function and regional wall motion in pure mitral stenosis-Left ventricular function in pure mitral stenosis

Global left ventricular function (LVF) and scgmental wall motion of the left ventricle are registered in 113 patients presenting a pure mitral stenosis (MS) and in a control group of 50 individuals. The segmental wall motion is measured on the end-diastolic-end-systolic frames of the left ventricle, obtained from right anterior oblique (RAO) monoplane cineangiography. Measurement of the segmental wall shortening is performed using the Stanford method. Group 1 includes 68 patients (60% of the total number of patients studied). These patients show no pathological contraction abnormality. In this group, the global LVF is not different from the control group. Group 2 includes 45 patients (40% of the total) for whom contraction abnormalities are present: anterior hypokinesis in 20% of the cases (anterior area mean shortening (AAS) = 18±8%; p<0.001 vs. group 1 and control group), and posterior hypokinesis in 20% of the cases (posterior area mean shortening (PAS) = 9.8 ±5.8%, p<0.001 vs. group 1 and control group). In this group, global LVF is impaired; ejection fraction (EF) = 0.57±0.1% (p<0.001 vs. group 1); velocity of circumferential fiber shortening (Vcf) = l±0.3 circ/s (p<0.001 vs. group 1); end-diastolic pressure (EDP) = 11±5 mmHg (p<0.01 vs. group 1). Segmental contraction abnormalities appear to be the main factor involved in the global LVF impairment. Segmental wall motion abnormalities could be related to subvalvular fibrosis, or LV filling difficulties, or principally, to a possible interplay between the right and the left ventricles.     

Effect of balloon mitral valvotomy on left ventricular function in rheumatic mitral stenosis

AimMitral stenosis (MS) is found to produce left ventricular (LV) dysfunction in some studies. We sought to study the left ventricular function in patients with rheumatic MS undergoing balloon mitral valvotomy (BMV). Ours is the first study to analyze effect of BMV on mitral annular plane systolic excursion (MAPSE), and to quantify prevalence of longitudinal left ventricular dysfunction in rheumatic MS.MethodsIn this prospective cohort study, we included 43 patients with severe rheumatic mitral stenosis undergoing BMV. They were compared to twenty controls whose distribution of age and gender were similar to that of patients. The parameters compared were LV ejection fraction (EF) by modified Simpson's method, mitral annular systolic velocity (MASV), MAPSE, mitral annular early diastolic velocity (E′), and myocardial performance index (MPI). These parameters were reassessed immediately following BMV and after 3 months of procedure.ResultsMASV, MAPSE, E′, and EF were significantly lower and MPI was higher in mitral stenosis group compared to controls. Impaired longitudinal LV function was present in 77% of study group. MAPSE and EF did not show significant change after BMV while MPI, MASV, and E′ improved significantly. MASV and E′ showed improvement immediately after BMV, while MPI decreased only at 3 months follow-up.ConclusionsThere were significantly lower mitral annular motion parameters including MAPSE in patients with rheumatic mitral stenosis. Those with atrial fibrillation had higher MPI. Immediately after BMV, there was improvement in LV long axis function with a gradual improvement in global LV function. There was no significant change of MAPSE after BMV.     

Tei指数评价风湿性心脏病二尖瓣狭窄患者左心室功能

目的运用脉冲型组织多普勒技术(PW-TDI)测算左心室心肌综合指数(Tei指数),评价风湿性心脏病二尖瓣狭窄(MS)患者左心室功能,并探讨其与右心室功能的关系。方法测量30例MS患者及25例健康对照者的常规超声心动图指标,在PW-TDI条件下测算左心室二尖瓣环四个位点(后间隔、侧壁、前壁、下壁)的Tei值及其均值(t-Tei)以及三尖瓣环位点(右心室游离壁)的Tei值,对各组值进行对比分析。结果(1)与正常对照组相比,MS患者左、右心室的Tei值明显增大(P<0.001);左心室二尖瓣环四个位点t、-Tei、右心室三尖瓣环位点的等容舒张时间延长(P<0.001)、射血时间缩短(P<0.01或P<0.05),前壁、下壁及t-Tei等容收缩时间延长(P<0.05);(2)相关性分析表明MS患者左、右心室的Tei指数呈正相关关系(r=0.73,P<0.001)。结论MS患者左心室在收缩功能正常时舒张功能已减退,左、右心室功能状态可能相互影响,重视改善MS患者左心室功能具有重要的临床意义。     

Tissue Doppler assessment of left ventricular diastolic function in rheumatic mitral stenosis

BackgroundLeft ventricular systolic and diastolic functions are reported to be altered in mitral stenosis. Although conventional Doppler ultrasound recording of transmitral flow is used in the assessment of left ventricular diastolic function, yet, in patients with mitral stenosis, it is altered by mitral stenosis itself and thus precludes the proper assessment of LV diastolic function.Aim of the workThe aim of this work is to assess LV diastolic function using pulsed tissue Doppler interrogation of mitral annulus motion in patients with rheumatic mitral stenosis.Patients and methodsTwelve patients with established diagnosis of rheumatic mitral stenosis in normal sinus rhythm were obtained from outpatient clinic of Cardiology Department in Mansura specialized hospital. Thirteen age and sex matched controls with completely normal echo-Doppler study were taken for comparison. All patients were subjected to thorough history taking including dyspnea grading according to NYHA score, clinical examination, 12 lead surface electrocardiogram and most importantly echo-Doppler study.ResultsWe found statistically significant higher peak mitral annular E_a velocity from septal, anterior, inferior and lateral portions of the mitral annulus in controls compared with mitral stenosis patients as well as their averaged values. There is no statistically significant difference regarding peak mitral annular A_a velocity from septal, anterior, inferior and lateral portions of the mitral annulus between both groups as well as their averaged values. The ratio of early to late mitral annular velocities from all recorded sites was statistically significantly higher in the controls compared with mitral stenosis patients.ConclusionsTDI of mitral annulus may provide potential diagnostic role for assessment of LV diastolic function in patients with mitral stenosis.     

Isolated left ventricular noncompaction in association with rheumatic mitral stenosis

Fifty year old man with a known case of chronic rheumatic heart disease with atrial fibrillation was presented with severe mitral stenosis. He was incidentally detected to have noncompaction of left ventricle on echocardiography and Doppler examination. He underwent successful percutaneous trans-luminal mitral commissurotomy (PTMC) for severe mitral stenosis. This is the first reported case of isolated ventricular noncompaction (IVNC) associated with acquired chronic rheumatic mitral stenosis.     

风湿性二尖瓣狭窄伴心房颤动二尖瓣球囊扩张术疗效评价

对26例风湿性二尖瓣狭窄伴心房纤额（房颤二狭）与同期31例风湿性二尖瓣狭窄无房颤（窦律二狭）患者PBMV术后及随访结果进行比较，结果显示：虽然房颤二狭具有血栓发生率高、左房前后径大、瓣膜超声评分高等特殊性，但只要术前抗凝准备充分，操作仔细，房颤二狭接受PBMV治疗与窦律二狭一样具有良好的安全性和临床效果。     

Impaired fibrinolytic capacity in rheumatic mitral stenosis with or without atrial fibrillation and nonrheumatic atrial fibrillation

Chronic atrial fibrillation (AF) has often been associated with systemic embolization, and patients with mitral stenosis (MS) have the highest thromboembolic risk. Increased risk of thromboembolism could be in part due to impaired fibrinolytic function. Global fibrinolytic capacity (GFC) is an innovative technique for evaluating the entire fibrinolytic system.The aim of our study was to evaluate fibrinolytic activity in patients with rheumatic and nonrheumatic chronic AE To investigate fibrinolytic activity, we assessed GFC in peripheral blood samples of 32 patients with nonrheumatic AF (14 women; mean age, 56 +/- 1 years), 30 patients with rheumatic MS and AF (23 women; mean age, 35 +/- 9 years), and 32 patients with rheumatic MS and sinus rhythm (24 women; mean age, 36 +/- 8 years). The control group comprised 30 healthy adult subjects in normal sinus rhythm. Patients with chronic AF (rheumatic and nonrheumatic) had lower GFC than did the controls (P = .0001). The rheumatic AF group also showed decreased levels of GFC compared with the nonrheumatic AF group, with the rheumatic MS and sinus rhythm group, and with controls (P = .03, P = .02, P = .0001, respectively). GFC was lower in patients with rheumatic MS and sinus rhythm than in controls (P = .003). Although there were correlations between GFC and mitral valve area, transmitral mean gradient, left atrial diameter, and mitral calcification in patients with rheumatic MS, multivariate analysis showed only transmitral gradient as an independent factor affecting GFC. Patients with AF have decreased GFC, a finding that suggests the presence of a hypofibrinolytic state. Fibrinolytic dysfunction was more pronounced in rheumatic MS patients with AF than in those with nonrheumatic AF. Moreover, patients with rheumatic MS and sinus rhythm had decreased global fibrinolytic activity. Hypofibrinolysis documented by decreased GFC can be one of the important causes of increased risk of embolism in patients with AF and rheumatic MS.     

Combined percutaneous balloon mitral valvuloplasty and left atrial appendage occlusion device implantation for rheumatic mitral stenosis and atrial fibrillation

Rheumatic heart disease is a common cause of cardiovascular morbidity and mortality worldwide, mostly in developing countries. Mitral stenosis and atrial fibrillation often coexist, related to both structural and inflammatory changes of the mitral valve and left atrium. Both predispose to left atrial thrombus formation, commonly involving the left atrial appendage. Thromboembolism can occur, with devastating consequences. We report the case of a 62 year old woman with rheumatic heart disease resulting in mitral stenosis and atrial fibrillation. Previous treatment with warfarin resulted in life-threatening gastrointestinal bleeding and she refused further anticoagulant therapy. A combined procedure was performed, including percutaneous balloon mitral valvuloplasty and left atrial appendage occlusion device implantation with the Atritech® Watchman® device. No thromboembolic or bleeding complications were encountered at one year follow-up. Long-term follow-up in a cohort of patients will be required to evaluate the safety and efficacy of this strategy.     

风湿性心脏病二尖瓣狭窄左房血栓形成的相关因素

目的：探讨风湿性心脏病二尖瓣狭窄(风心二狭)患考左房血栓形成的相关因素。方法：162例风心二狭并行心脏外科手术治疗患，术前常规做经胸心脏彩超检查，术中仔细寻找左房血栓。结果：房颤、二尖瓣返流是风心二狭思考左房血栓形成的相关因素，其相对危险度分别是17．744、0．468。年龄、左室舒张末期内径、左室射血分数、二尖瓣口面积在单因素分析中表现出一定的相关性，但在逐步logistic回归分析中并无统计学意义。在二尖瓣返流患中，随着返流的加重，左房血栓发生率下降。结论：风心二狭病人，房颤患易形成左房血栓。二尖瓣返流对血栓形成起保护作用，二尖瓣口面积与血栓形成的关系尚需进一步明确。     

Effects of left atrial compliance on left atrial pressure in pure mitral stenosis.

In mitral stenosis (MS), left atrial (LA) pressure is commonly elevated because of increased LA afterload. There is a wide spectrum of LA pressure in patients with MS, however, despite a similar mitral valve orifice area. LA compliance is an important determinant of both cardiovascular performance and pathological physiology. Few data are available, however, regarding the effects of LA compliance on LA pressure. We hypothesized that LA pressure may be higher in patients with decreased LA compliance. We analyzed the right heart and transseptal catheterization data in 47 patients (41 female, mean age 40 +/- 10 years) with pure MS and sinus rhythm. The magnitude of LA a and v waves was measured from transseptal catheterization. Fick's method was used to determine cardiac output. LA compliance was calculated by dividing the systolic rise in LA pressure (DeltaP(LA) = P(LA(v)) - P(LA(x))) into the stroke volume. LA size, mitral valve area (MVA), mean diastolic pressure gradient (MG), left ventricular (LV) end-diastolic and end-systolic dimensions were obtained by using two-dimensional and Doppler echocardiography. Multiple regression analysis was performed to identify independent factors determining LA pressure. The mean MVA was 0.95 +/- 0.22 cm(2). MG and LA dimension were 11.2 +/- 5.2 mm Hg and 50.6 +/- 5.2 mm, respectively. The mean LA pressure and cardiac output obtained by cardiac catheterization were 23.4 +/- 8.4 mm Hg and 4.3 +/- 1.5 L/min, respectively. The calculated LA compliance was 4.9 +/- 2.8 cm(3)/mm Hg. Univariate analysis showed that factors associated with increased LA pressure were smaller MVA (r = -0.33, P < 0.05), higher MG (r = 0.69, P < 0.01) and lower LA compliance (r = -0.55, P < 0.01); among them, MG (beta coefficient 0.59, SE 0.19, P < 0.01) and LA compliance (beta coefficient -0.26, standard error 0.34, P < 0.05) were the strongest predictors of LA pressure. In conclusion, LA compliance, along with MG that reflects the severity of MS, is an important contributing factor determining LA pressure in patients with pure MS and sinus rhythm.     

风湿性心脏病二尖瓣狭窄患者左房血栓形成的多因素回归分析

目的 :探讨风湿性心脏病二尖瓣狭窄 (风心二狭 )患者左房血栓形成的临床相关因素。方法 :6 9例风心二狭患者行经胸及食管超声心动图检查 ,并用发色底物显色法测定血浆组织型纤溶酶原激活物 (t PA )、组织型纤溶酶原激活物抑制物 1(PAI- 1)及抗凝血酶 (AT- )活性。结果 :33例风心二狭左房血栓形成组与 36例无血栓组比较 ,年龄偏大 ,症状持续时间较长 ,心房颤动发生率高 ;超声心动图显示左房内径较大 ,左室射血分数较低 ,二尖瓣口面积较小 ,明显二尖瓣关闭不全少见 ,左房自发性回声 (SEC)发生率明显增高 ;血液学检查显示红细胞压积较高 ,AT- 活性较低 t PA活性较高 ,PAI- 1活性较低。多元回归分析表明左房 SEC、AT- 活性、年龄、二尖瓣口面积大小是左房血栓形成的独立相关因素。结论 :风心二狭患者左房血栓的形成不仅与血流的局部机械性梗阻淤滞 ,而且与机体抗栓能力的下降有关。     

风湿性二尖瓣狭窄伴心房纤颤患者在经皮球囊二尖瓣成形术后的心房纤颤电复律治疗(附538例报告)

探讨风湿性二尖瓣狭窄伴心房纤颤（房颤）球囊二尖瓣成形术（PBMV）后房颤复律治疗的方法及复律后影响维持窦性心律的因素。方法：PBMV术后4～6周仍不能转复为窦性心律的房颤患者538例进行电复律治疗，转复后随诊3～6个月，动态观察房颤复发情况。结果：538例行体表电复律者，恢复窦性心律。     

风湿性二尖瓣狭窄伴心房颤动患者血栓前状态的研究

目的 :观察风湿性二尖瓣狭窄伴心房颤动 (房颤 )的血栓前状态。方法 :使用酶联免疫法和凝固法测量 2 4例风湿性心脏病 (风心病 )伴窦性心律患者 (窦律组 )、2 5例风心病伴房颤患者 (房颤组 )和 2 0例对照者 (对照组 )的外周血浆因子Ⅷ相关抗原 (VWFAg)、血小板α颗粒膜蛋白 14 0 (GMP 14 0 )、D 二聚体 (D dimer)和纤维蛋白原 (Fg)的水平变化 ,进行统计学分析。 结果 :与对照组比 ,窦律组血浆VWFAg、D dimer和Fg水平均显著升高(P <0 .0 5 ) ,而血浆GMP 14 0水平无显著性改变 (P >0 .0 5 ) ;房颤组血浆GMP 14 0、D dimer和Fg水平也明显升高 (P <0 .0 5 )。房颤组与窦律组相比血浆GMP 14 0、VWFAg、D dimer水平更高 (P <0 .0 5 ) ,而Fg水平在二者之间无明显变化 (P >0 .0 5 )。结论 :风湿性二尖瓣狭窄伴房颤患者外周血存在血栓前状态。     

Relationship between inflammation and atrial fibrillation in patients with isolated rheumatic mitral stenosis

BACKGROUND AND AIM OF THE STUDY: Atrial fibrillation (AF) is the most common arrhythmia in patients with rheumatic mitral stenosis (MS), with an increased risk of mortality and morbidity. Although recent data have suggested that the inflammatory process is associated with non-valvular AF, the relationship between inflammation and AF occurrence in MS patients remains unknown. The study aim was to determine whether plasma levels of high-sensitivity C-reactive protein (hs-CRP), as a marker of inflammation, are elevated in patients with isolated rheumatic MS and AF compared to patients with MS but without AF. METHODS: The study population comprised 89 patients with isolated rheumatic MS (57 patients in sinus rhythm and 32 in AF) and 35 healthy controls. Patients with MS were categorized into subgroups in terms of their mitral valve area (MVA). Mean transmitral diastolic gradients and pulmonary artery pressure were monitored, and morphologic features of the mitral valve classified using an echocardiographic scoring system. Plasma levels of hs-CRP were monitored in all patients and control subjects, using a commercially available analytical kit. RESULTS: Patients with AF were shown to have significantly higher plasma levels of hs-CRP compared to those in sinus rhythm and controls (p < 0.001). In general, patients with AF were older (p < 0.001) and had a larger left atrial diameter (LAD) (p < 0.001). Plasma levels of hs-CRP were associated with LAD only in the AF group (rho = 0.437; p = 0.012). Multivariate logistic regression analysis revealed a significant independent relationship between AF and hs-CRP plasma level (odds ratio (OR) 3.57; 95% confidence interval (CI) 1.2-10.5; p = 0.021), age (OR 1.08; 95% CI 1.03-1.14; p = 0.003), and LAD (OR 1.2; 95% CI 1.02-1.4; p = 0.023). CONCLUSION: The study results indicated that hs-CRP plasma levels are associated with the presence of AF in patients with MS. This finding may have important implications for the development of new therapeutic and preventive approaches of AF in the setting of MS.