Mitral stenosis – ABC CARDIOL

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Case Report

Giant Atrial Thrombus in a Patient with Mitral Stenosis: A Case Report

Julia Garcia Leal Elias et al. Maurício Marson Lopes Fernanda Betanho Mori Luana Monferdini … Maria Ligia Ciscon Guilherme Viana Barbosa

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Artigo Original

Changes in P-wave after percutaneous mitral valvuloplasty in patients with mitral stenosis and left atrial enlargement

José Carlos Estival Tarastchuk et al. Ênio Eduardo Guérios Sônia Perreto Ronaldo da Rocha Loures Bueno … Paulo Maurício Piá de Andrade Deborah Cristina Nercolini Álvaro Luiz Aranha Pacheco Frederico Thomaz Ultramari Alisson Moço Faidiga

OBJECTIVE: To investigate potential clinical, echocardiographic and/or hemodynamic predictors of the regression of electrocardiographic (ECG) signs of left atrial enlargement (LAE) after successful percutaneous mitral valvuloplasty (PMV). METHODS: We studied 24 patients (75% female, mean age =37.1 ± 11.9 years) with moderate to severe mitral stenosis (MS), sinus rhythm (SR) and ECG signs of LAE who underwent successful PMV between 2002 and 2004. At least 6 months after the procedure (388.2 ± 192.9 days), the patients returned for clinical, ECG and echocardiographic follow-up. They were then divided in 2 groups: patients of group 1 (n = 8; 33.3%) still had ECG signs of LAE, and patients of group 2 (n = 16; 66.6%), had normal P wave. A multivariate analysis of clinical, ECG, echocardiographic and hemodynamic variables was performed. RESULTS: The mitral valve area (MVA) increased from 1.12 ± 0.15 cm2 to 1.9 ± 0.35 cm² immediately after the procedure (p 1.7 cm² at follow-up was the only independent predictor of a normal P-wave after PMV (p=0.02). CONCLUSION: ECG changes suggestive of LAE regress in the majority of patients with MS and sinus rhythm that undergo a successful PMV. An MVA>1.7 cm² at late follow-up was found to be an independent predictor of such normalization.

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Vascular reactivity response to mental stress in pregnant women with mitral stenosis

Walkiria Samuel Avila et al. Osmar Araújo Calil Ivani C. Trombetta Carlos Eduardo Negrão … Max Grinberg Marcelo Zugaib José Antonio Franchini Ramires

OBJECTIVE: To study vascular reactivity according to the analysis of blood flow and peripheral vascular resistance at rest and during mental stress in pregnant women with mitral stenosis. METHODS: Twenty two women with mitral stenosis, 13 of whom were pregnant (PS) and 9 were non-pregnant (MIS), and 9 healthy pregnant women (NP) were studied. During gestation, 9 out of the 13 patients of the PS group required a beta-blocker (PSB) and the remaining 4 progressed without medication (PSWB). Plethysmography at rest and during mental stress analyzed muscle blood flow, peripheral vascular resistance (PVR), mean arterial pressure (MAP) and heart rate (HR) during gestation and puerperium. RESULTS: During gestation of PSWB, muscle blood flow and HR were higher in 1.6% and 20.5% (p = 0.05), and PVR and MAP were lower in 19.3% and 4.4%, respectively, in comparison to the puerperium; during mental stress, the muscle blood flow increased by 55.9%, HR decreased by 30.2% and PVR and MAP were similar. In PSB, muscle blood muscle blood flow and HR were greater in 5.9% and 14.9% (p= 0.001) and MAP and PVR were lower in 10.3% and 9.1%, respectively, when compared to the puerperium. During mental stress, muscle blood flow and MAP increased by 69.8% and 174.1%, respectively. HR was similar and PVR decreased by 53.7%. The comparative study showed that in the NP group the muscle blood flow was higher, PVR was lower, and MAP and HR were similar in relation to the PS group, and that the PS, NP, MIS groups had a similar response to mental stress. CONCLUSIONS: Vascular reactivity in pregnant women with mitral stenosis was preserved and the analysis of measurements showed lower values of muscle blood flow and higher values of PVR when compared to those of healthy pregnant women.

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Artigo Original

Balloon valvuloplasty outcome of a group previously submitted to mitral percutaneous or surgical valve repair versus first-time valvuloplasty patients: evolution of the group previously submitted to valve repair procedures

Edison Carvalho S. Peixoto et al. Rodrigo Trajano S. Peixoto Ivana Picone Borges Paulo Sergio de Oliveira … Mario Salles Netto Ronaldo Amorim Villela Marta Labrunie Pierre Labrunie Ricardo Trajano S. Peixoto

OBJECTIVE: To evaluate 501 procedures of mitral balloon valvuloplasty and the differences among the group already submitted the prior surgical or balloon valvuloplasty, with 59 procedures and the group without previous intervention, with 442 procedures. METHODS: It was used the single balloon in 403, Inoue balloon in 89 and a double balloon in six, with no difference between the 2 groups (p=0.6610). RESULTS: The prior surgical or balloon valvuloplasty group was older, with higher echo score and higher atrial fibrillation rate and of its 59 patients, 48 had been submitted only to mitral surgical commissurotomy, 8 only to mitral balloon valvuloplasty and 3 to surgical commissurotomy and after submitted to balloon valvuloplasty because of restenosis. In prior surgical or balloon valvuloplasty and mitral balloon valvuloplasty without previous intervention groups pre valvuloplasty there were respectively: echo mitral valve area 0.99±0.21 and 0.94±0.21 cm² (p=0.0802) and mitral valve area (Gorlin) 0.94±0.18 and 0.91±0.21 cm² (p=0.2518) and post mitral valvuloplasty 1.95±0.44 and 2.05±0.42 cm² (p=0.1059). CONCLUSIONS: The hemodynamic and angiographic outcome of the prior surgical or balloon valvuloplasty group were similar to the group without previous intervention. The evolution was satisfactory in the prior valvuloplasty subgroup with long-term follow-up.

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Functional assessment of the left atrial appendage at transesophageal echocardiography before and after percutaneous valvotomy in the mitral stenosis

Solange Bernardes Tatani et al. Orlando Campos Filho Claudio Henrique Fischer Valdir Ambrósio Moisés … José Augusto Marcondes de Souza Cláudia Maria Rodrigues Alves Angelo Amato Vincenzo de Paola Antonio Carlos C. Carvalho

OBJECTIVE: To assess the effects of the relief of the mitral stenosis by percutaneous ballon valvotomy in the function of the left atrial appendage. METHODS: Twelve patients with symptomatic mitral stenosis, in sinus rhythm, were studied. They were submitted to the transesophageal echocardiogram before and after effective percutaneous ballon valvotomy. Concerning the left atrial appendage, the peak flow velocities and the respective integral of the anterograde and retrograde flow, in addition to the ejection fraction calculated through the planimetry of the area of that structure, were analyzed at the pulsatile Doppler. RESULTS: There was a significant increase of the anterograde flow velocity of the left atrial appendage after percutaneous ballon valvotomy (pre: mean of 0.30 m/s; post: mean of 0.47 m/s; p<0.05) and their respective integrals. The same happened with the retrograde flow velocity (pre: mean of 0.35 m/s, post: mean of 0.53 m/s; p<0.05). There was a tendency of increase of the ejection fraction of the left atrial appendage after the procedure (pre: mean of 20%, post: mean of 31%; p=0.08). CONCLUSION: The effective opening of the stenosed mitral orifice resulting from the percutaneous ballon valvotomy determined an improvement of the flow pattern of the left atrial appendage, which can potentially contribute for the reduction of the embolic risk.

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Percutaneous mitral balloon valvotomy: long-term outcome and assessment of risk factors for death and major events

Ivana Picone Borges et al. Edison Carvalho Sandoval Peixoto Rodrigo Trajano Sandoval Peixoto Paulo Sergio de Oliveira … Mario Salles Netto Pierre Labrunie Marta Labrunie Ricardo Trajano Sandoval Peixoto Ronaldo de Amorim Villela

OBJECTIVE: To identify the factors that predict death and combined events, (death, new mitral balloon valvotomy, or mitral valve surgery) in long-term follow-up of patients undergoing percutaneous mitral balloon valvotomy. METHODS: Follow-up was 49.0±31.0 (1 to 122) months. Techniques used were the single-balloon (84.4%), Inoue-balloon (13.8%), and double-balloon techniques (1.7%). RESULTS: Included in the study were 289 patients 38.0±12.6 years of age (range, 13 to 83). Before the procedure, 244 patients had echocardiographic score 8. Females comprised 85%, and 84% patients were in sinus rhythm. During follow-up, survival of the total group was 95.5%, that of the group with 8 was 82.2% (P<0.0001), whereas combined event-free survival was 83.4%, 86.1%, and 68.9%, respectively (P 8 and the presence of severe valvular mitral regurgitation during the procedure. The events that predicted combined events were a previous history of mitral valvular commissurotomy and atrial fibrillation and the presence of severe mitral valvular regurgitation during the procedure, and postprocedure mitral valvular area < 1.5 m² (failure). CONCLUSION: Percutaneous mitral balloon valvotomy is an effective procedure, and over 2/3 of the patients were event-free at the end of follow-up. Survival in the group was high, even higher in the group with lower echocardiographic scores.

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Original Article

Prognostic factors of rheumatic mitral stenosis during pregnancy and puerperium

Paulo José Bastos Barbosa et al. Antônio Alberto Lopes Gilson Soares Feitosa Rosângela Vasconcelos de Almeida … Rosenbert Mamédio da Silva José Carlos Brito Maria Lúcia Duarte Augusto José Gonçalves Almeida

OBJECTIVE: To identifity characteristics associated with complications during pregnancy and puerperium in patients with rheumatic mitral stenosis. METHODS: Forty-one pregnant women (forty-five pregnancies) with mitral stenosis, followed-up from 1991 to 1999 were retrospectively evaluated. Predictor variables: the mitral valve area (MVA), measured by echocardiogram, and functional class (FC) before pregnancy (NYHA criteria).Maternal events: progression of heart failure, need for cardiac surgery or balloon mitral valvulotomy, death, and thromboembolism. Fetal/neonatal events: abortion, fetal or neonatal death, prematurity or low birth weight ( or = II and III versus I) was also associated with a risk for maternal events (RR=2.7; 95% CI=1.4-5.3).MVA and FC were not importantly associated with these events, although a smaller frequency of fetal/neonatal events was observed in patients who had undergone balloon valvulotomy. CONCLUSION: In pregnant women with mitral stenosis, the MVA and the FC are strongly associated with maternal complications but are not associated with fetal/neonatal events. Balloon mitral valvulotomy could have contributed to reducing the risks of fetal/neonatal events in the more symptomatic patients who had to undergo this procedure during pregnancy.

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Early and late physiological effects of balloon mitral valvuloplasty

Japy Angelini Oliveira Fº et al. Marcelo Regazzini Orlando Campos Fº Ana Fátima Salles … Turíbio Leite Barros Neto Neil Ferreira Novo José Bocanegra Eulógio Martinez Fº Dirceu Vieira Santos Fº

PURPOSE: To evaluate the early and late cardiorespiratory responses after balloon mitral valvuloplasty. METHODS: Nine female patients aged 35±9 years, with mitral stenosis, in class II or III (NYHA) underwent upright ergoespirometric test, resting electrocardiogram and echocardiogram before, 3 to 5 days (early evaluation) and 8 to 12 months (late evaluation) after mitral valvuloplasty. All patients were treated with digitalis and diuretics. RESULTS: During late evaluation, 44% patients were in class II and 56% were in class I (NYHA). The resting heart rate decreased (87±11bpm vs 85±7bpm vs 75±9bpm) and the number of steps increased (4±1 steps vs 5±2 steps vs 6±1 steps); the peak oxygen uptake improved only in the late evaluation (16±3mL/kg/min vs 18±4mL/kg/min vs 22±7mL/kg/min). The anaerobic threshold, minute ventilation (VE) and ventilatory equivalent for oxygen showed no change. The heart rate (1st step: 124±18bpm vs 112±13bpm vs 87±15bpm), O2 uptake (1st step: 10±2mL/kg/min vs 8±2mL/kg/min vs 8±2mL/kg/min) and VE decreased during submaximal exercise in early and late phases. The mitral valve area decreased in the late evaluation (0.94cm² vs 1.66cm² vs 1.20cm²). CONCLUSION: Although partial restenosis tended to occur in these patients, they improved the functional class and cardiorespiratory performance and cardiocirculatory load during submaximal exercise.

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Original Article

Influence of the echocardiographic score and not of the previous surgical mitral commissurotomy on the outcome of percutaneous mitral balloon valvuloplasty

Edison C. Sandoval Peixoto et al. Rodrigo T. Sandoval Peixoto Ivana Picone Borges Paulo Sérgio de Oliveira … Marta Labrunie Mário Salles Netto Ronaldo A. Villela Pierre Labrunie Guilherme A. Xavier de Brito Ricardo T. Sandoval Peixoto

OBJECTIVE: To evaluate prior mitral surgical commissurotomy and echocardiographic score influence on the outcomes and complications of percutaneous mitral balloon valvuloplasty. METHODS: We performed 459 complete mitral valvuloplasty procedures. Four hundred thirteen were primary valvuloplasty and 46 were in patients who had undergone prior surgical commissurotomy. The prior commissurotomy group was older, had higher echo scores, and a tendency toward a higher percentage of atrial fibrillation. RESULTS: When the groups were compared with each other, no differences were found in pre- and postprocedure mean pulmonary artery pressure, mean mitral gradient, mitral valve area, and mitral regurgitation . Because we found no significant differences, we subdivided the entire group based on echo scores, those with echo scores 8 the mitral valve area being higher in the 8 echo score group. CONCLUSION: Dividing the groups based on echo score revealed that the higher echo score group had smaller mitral valve areas postvalvuloplasty.

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