Rheumatic mitral stenosis: cross-sectional echocardiographic analysis

Twenty-one patients with rheumatic mitral stenosis diagnosed by both M-mode echocardiography and hemodynamic findings were subjected to detailed cross-sectional echocardiographic studies. The age of the patients ranged from 27 to 79 years with 76% females. Left ventricular longitudinal, short axis, and apical four-chamber cross-sectional echocardiographic views were obtained in each patient. Three predominant patterns of anterior mitral leaflet motion on left ventricular longitudinal view were observed and correlated with the severity of mitral stenosis: Pattern A (eight patients) with diastolic leaflet doming and restricted leaflet tip motion, Pattern B (eight patients) with restricted tip and body leaflet motion, and Pattern C (five patients) with the entire leaflet motion restricted. Mitral valve prolapse as a rebound phenomenon was observed in three patients who had marked leaflet doming in Pattern A and two had severe obstruction. The longitudinal cross-sectional echocardiography was superior to the apical view in assessing the diastolic doming motion of the anterior mitral leaflet. Thus, longitudinal cross-sectional echocardiographic analysis of the pliability and degree of doming of the anterior mitral leaflet is valuable in estimating the severity of mitral stenosis.     

Rheumatic mitral valve stenosis mimicking advanced lung cancer

This report describes a patient with a perihilar mass and mediastinal lymphadenopathy mimicking advanced lung cancer. The patient, a 45-year old regular smoker, was admitted to hospital for dyspnea and tachyarrhythmia, and during hospitalization he was diagnosed with severe rheumatic mitral valve stenosis (MVS) and aortic regurgitation as well as pulmonary venous hypertension. Surgical valve replacement and removal of an atrial thrombus was delayed considerably by diagnostic work-up for suspected malignancy. After cardiac surgery had been performed, recovery was uneventful. On follow-up 1 year later, echocardiography showed well-functioning prosthetic mitral and aortic valves, and normal findings on chest X-ray. Perihilar masses and mediastinal lymphadenopathy presented in this case constitute infrequent yet established findings in MVS, resulting from pulmonary venous congestion and hypertension, and focal lymphedema.     

Rheumatic tricuspid stenosis without involvement of the mitral valve

We describe a case of rheumatic tricuspid stenosis without involvement of the mitral valve. Rheumatic disease of the tricuspid valve is very rare in the absence of concomitant mitral valvar disease. We suggest that the closing pressure at the valve is not the only factor governing localization of the rheumatic process.     

Rheumatic mitral valve stenosis is associated with impaired flow-mediated dilatation

Isolated pulmonary hypertension with clinical implication is rare in rheumatoid arthritis. We sought to study the prevalence of pulmonary arterial hypertension in an unselected population of 45 patients with rheumatoid arthritis (classified according to the ARA criteria) without cardiac disease and corresponding age and sex matched controls by Doppler echocardiography. The pulmonary artery systolic pressure was higher in patients with Rheumatoid Arthritis (27.49+/-12.66 mm Hg) than in controls (20.40+/-8.88) (p=0.003). Incidence of pulmonary artery systolic pressure>30 mm Hg suggesting pulmonary hypertension was significantly higher in patients with RA (26.7% versus 4.5% in controls; p=0.03) and 20% of patients had pulmonary hypertension without lung disease or cardiac disease evident on pulmonary function testing, and echocardiogram respectively. There was also a strong correlation between the pulmonary artery pressure and the disease duration (r=0.68, p<0.0001) suggesting a subclinical involvement of the pulmonary vasculature with disease progression and may be relevant to the high incidence of cardiovascular deaths observed in patients with Rheumatoid Arthritis.     

Rheumatic aortic stenosis in young patients presenting with combined aortic and mitral stenosis.

This report describes 30 patients under the age of 30 years with rheumatic aortic stenosis, presenting with combined aortic and mitral stenosis. Three patients had additional tricuspid stenosis. Twenty-eight patients gave a history of rheumatic polyarthritis. The diagnosis was confirmed by right and left heart catheterisation in all. The murmur of aortic stenosis was not initially present in 8 out of 10 patients in congestive heart failure. Aortic valve calcification was not seen. Cineangiography showed a tricuspid aortic valve in all, unlike congenital aortic stenosis. A unique feature of this group was the raised pulmonary vascular resistance in 87 per cent of the patients. The present study shows that patients in India developing aortic stenosis after rheumatic fever do so early in the natural history of the disease.     

Unsuspected mitral stenosis

PURPOSE AND PATIENTS AND METHODS: We observed a series of patients in whom the diagnosis of mitral stenosis was first discovered in the echocardiography laboratory. Because of this experience, we examined the records of 152 patients with echocardiographic evidence of rheumatic mitral stenosis to determine the clinical characteristics and course of patients with unsuspected mitral stenosis as well as those factors that may have obscured the diagnosis. RESULTS: Of these 152 patients, 18 had mitral stenosis that was unsuspected clinically until the echocardiogram. These patients were elderly, with a median age of 72 years. They were all referred for echocardiography because of cardiac symptoms. Eight patients were referred for evaluation of congestive heart failure. Five patients were referred for evaluation of aortic valve disease. Three patients were referred because of cerebrovascular accidents and atrial fibrillation. The Doppler-determined mean diastolic mitral gradient ranged from 4 to 15 mm Hg (mean: 7 mm Hg). Mitral stenosis ranged in severity from trivial to very severe. Eight patients had moderate to severe mitral stenosis with estimated mitral valve areas less than or equal to 1.5 cm2. Seven had mild or trivial mitral stenosis with estimated mitral valve areas greater than 1.5 cm2. After further evaluation, two patients underwent mitral valve surgery with improvement of congestive failure. In three patients, warfarin therapy was begun to prevent emboli. Thus, five of 18 patients had a significant immediate change in therapy because of the discovery of mitral stenosis. CONCLUSION: The diagnosis of mitral stenosis may not be suspected in the presence of advanced age, other serious cardiac and medical conditions, or mechanical factors that complicate the physical examination. In these patients, mitral stenosis may be hemodynamically significant and may cause significant symptoms.     

Congenital mitral stenosis

This study consists of a detailed analysis of the clinical, hemodynamic, surgical and pathologic findings of 23 children with congenital mitral stenosis and 99 additional cases from the literature. These cases were grouped into three major pathologic complexes: (1) the isolated form; (2) the form associated with other obstructive left-sided heart lesions (coarctation of the aorta, aortic stenosis) and a patent ductus arteriosus, or both; and (3) the type associated with a ventricular septal defect. Clinical observations indicate a high mortality rate in infancy secondary to early and refractory cardiac decompensation. In the majority of instances there is severe pulmonary hypertension which approaches systemic levels when the mean left atrial pressure reaches 20 mm. Hg. The surgical mortality is still high, and an objective assessment of the operative results is not yet available.     

Inoue-balloon mitral valvuloplasty in double-orifice mitral stenosis

We report 7 symptomatic patients with stenotic double-orifice mitral valve of incomplete bridge type. In each patient, the fibrous bridge tissue between the valve leaflets was successfully split using an Inoue balloon valvuloplasty technique with stepwise dilations applied only to the posteromedial orifice.     

Non-surgical mitral valvuloplasty for rheumatic mitral stenosis

One hundred and twenty-six patients of rheumatic mitral stenosis (MS), aged 10-30 (mean 19.5 +/- 5.9) years underwent balloon mitral valvuloplasty (BMV). All valvuloplasties were done by the anterograde transvenous, transatrial route. The procedure was successful in 120 (95%) cases. Single balloon was used in 10 patients early in the series and double balloon was used in the other 110 patients. BMV resulted in a significant increase in the mitral valve area (MVA) from 0.96 +/- 0.35 to 2.3 +/- 0.8 cm2 (p less than 0.0001) and a significant fall in the transmitral pressure gradient (TMG) from 28.2 +/- 3.2 to 7.4 +/- 4.8 mmHg (p less than 0.001). The MVA achieved by BMV was found to have a significant positive correlation with the balloon diameter to body surface area ratio (BD/BSA) (r = 0.69, p less than 0.001). New mitral regurgitation (MR) developed in 15 patients--trivial in 11, 2+ in 2 and 3+ in 2. One patient required emergency mitral valve replacement. Procedure induced MR did not have a significant relation to the balloon size, degree of mitral sub-valvular pathology or the severity of mitral stenosis. Iatrogenic atrial septal defect was detected by oximetry in none, by angiography in one patient, and by Doppler color flow imaging in 5 patients. Cardiac tamponade was the most frequent serious complication, occurring in 6 patients, 4 of whom died following emergency surgery. Sixty-five patients have been followed up for at least 6 months (range 6-30, mean 16.3 +/- 6.3 months) following BMV.(ABSTRACT TRUNCATED AT 250 WORDS)