Usefulness of three-dimensionally guided assessment of mitral stenosis using matrix-array ultrasound.

Two-dimensional (2-D) planimetry is limited by the technical demands, time, and observer variability required to locate the minimal orifice area, limiting the confident clinical reporting of mitral valve area (MVA). In 27 consecutive patients, MVA was determined independently by 2 observers using the conventional 2-D method and a new 3-D-guided method. Using a matrix-array probe, the valve was visualized in a long-axis view and a cursor steered to intersect the leaflet tips and provide a perpendicular short-axis plane viewed side-by-side. Two-dimensional and 3-D-guided methods allowed planimetry in 24 patients. Consistent with better orifice localization, 3-D guidance eliminated the overestimation of internal orifice diameters in the planimetered short-axis view relative to the limiting diameter defined by the long-axis view (for 3-D guidance, 0.73 +/- 0.20 vs 0.73 +/- 0.21 cm, p = 0.98, vs 0.90 +/- 0.27 cm in the 2-D short-axis view, p <0.01). Accordingly, mean values for the smallest orifice area by 3-D guidance were less than by 2-D imaging (1.4 +/- 0.5 vs 1.5 +/- 0.5 cm(2), p <0.01), changing the clinical severity classification in 11 of 24 patients (46%). The 2-D method also overestimated MVA relative to 3-D guidance compared with Doppler pressure halftime and (n = 6) Gorlin areas. Phantom studies verified no differences in resolution for the 2 acquisition modes. Three-dimensional guidance reduced intraobserver variability from 9.8% to 3.8% (SEE 0.14 to 0.06 cm(2), p <0.01) and interobserver variability from 10.6% to 6.1% (SEE 0.15 to 0.09 cm(2), p <0.02). In conclusion, matrix-array technology provides a feasible and highly reproducible direct 3-D-guided method for measuring the limiting mitral orifice area.

Impact of tissue harmonic imaging on the assessment of rheumatic mitral stenosis.

We examined the effect of tissue harmonic imaging on the echocardiographic splitability score and valve area measurement of 40 patients with rheumatic mitral stenosis. Planimetered valve areas were unaffected by the use of harmonic imaging, but valve scores were increased, particularly in patients with scores <10.

[General surgery and closed mitral commissurotomy: when necessity makes the rules]. / Chirurgien généraliste et commissurotomie mitrale à coeur fermé: ou quand la nécessité fait loi.

Since emergency transfer of patients from Africa to European cardiovascular facilities is difficult, surgeons at the Principal Hospital in Dakar, Senegal, have reevaluated closed mitral commissurotomy. The purpose of this study was to ascertain patient selection criteria, optimal operative conditions, immediate and middle-term outcome, and cost of closed mitral commissurotomy. From June 1995 to March 1998, closed mitral commissurotomy was carried out on 21 patients (13 women and 8 men). Inclusion criteria were symptomatic mitral stenosis with a mitral surface less than 1.5 square centimeters. Exclusion criteria were associated valve disease, Wilkins score higher than 8, severe pulmonary artery hypertension, and evidence of mitral thrombus. One patient died on the fourth postoperative day and one patient developed transient hemiparesis. Twenty patients showed significant functional improvement. Mean mitral surface increased from 0.87 to 1.8 square centimeters. Follow-up at one-year confirmed stable results. Only one patient developed grade 3 mitral insufficiency but it was well tolerated and did not require valve replacement. The cost of the procedure was 1,000,000 F CFA in second category and 820,000 F CFA in third category. The findings of this study show that closed mitral commissurotomy can be performed without circulatory assistance equipment in African facilities such as the Principal Hospital in Dakar, that immediate and middle-term results are excellent, and that African surgeons should continue to learn the technique.

Preoperative invasive testing in mitral stenosis: indications based on assessment of diagnostic yield.

The role of preoperative invasive testing in mitral stenosis was assessed in 82 patients undergoing cardiac catheterization for isolated mitral stenosis. The patients were diagnosed by physical examination and echocardiography and were considered for surgical treatment primarily to relieve dyspnea. They had no precordial murmur attributable to an aortic valvular lesion and had no history of chest pain. The presence of mitral stenosis was confirmed at catheterization in all patients. All 38 patients in New York Heart Association functional class III and 8 of 9 patients in class IV had hemodynamic confirmation of mitral disease warranting operation. Although a mitral gradient was present in all 35 patients in class II, operation was not recommended in 9 (26%) of 35 with normal or mildly elevated pulmonary arterial wedge pressure. Invasive testing did not increase preoperative knowledge of aortic. tricuspid, or pulmonary valvular lesions which required surgical treatment. Coronary arteriography was performed in 44 patients (54%) and identified 4 patients with luminal narrowing (greater than 70% diameter reduction) affecting 1 or 2 arteries. These results suggest that preoperative invasive testing in patients with mitral stenosis is unnecessary when symptoms are moderate to severe and clinical evidence of aortic valvular or coronary artery disease is absent. However, preoperative cardiac catheterization is indicated in patients with mild symptoms to avoid unnecessary or premature mitral valve operations.

Echocardiographic assessment of mitral stenosis by the left atrial emptying index.

Echocardiograms were performed in 35 patients prospectively with mitral stenosis to determine the usefulness of the left atrial emptying index (AEI) in estimating mitral valve orifice area (MVOA). Twnety-five control patients without evidence of cardiac disease had an AEI of 0.91 +/- 0.01. In the mitral stenosis group, the mean AEI was 0.47 +/- 0.09, with Gorlin and Gorlin calculated MVOAs of 1.44 +/- 0.56. There was close correlation between the AEI and MVOA (r = 0.93). The AEI did not correlate well with the left atrial size (r = 0.10), or the EF slope of the mitral valve (r = 0.20). The AEI was useful in separating patients with mitral stenosis into mild, moderate, and severe groups. Twelve out of 12 patients with severe mitral stenosis (MVOA less than or equal to 1.0 sq cm) had an AEI of less than or equal to 0.42. Ten out of 13 patients with moderate mitral stenosis (MVOA of 1.1--1.5 sq cm) had an AEI of 0.43 to 0.51. Eight out of ten patients with mild mitral stenosis (MVOA greater than or equal to 1.6 sq cm) had an AEI of greater than or equal to 0.52. The overall predictive value of the AEI in subclassifying the severity of mitral stenosis was 86 percent. In conclusion, the AEI appears to be a sensitive index in estimating MVOA in mitral stenosis.