Radiation-induced dystrophic calcification and severe valvular stenosis: the central role of multimodality 3D cardiac imaging in disease assessment and planning of combined transcatheter aortic and mitral valve replacement.

Cardiac disease after mediastinal radiotherapy can result in progressive valvular thickening and dystrophic calcification with ensuing leaflet restriction and dysfunction. This can ultimately manifest as valvular stenosis and/or regurgitation. We report a case of a 61-year-old woman with symptomatic severe aortic stenosis and severe mitral stenosis due to severe dystrophic calcification postmediastinal radiotherapy for lymphoma. She was deemed surgically inoperable due to dense, continuous calcification throughout the leaflets and annuli of both valves, aortomitral continuity, proximal coronary arteries and proximal porcelain aorta. She underwent simultaneous transcatheter aortic valve replacement and transcatheter mitral valve replacement with an excellent technical and clinical result at 7-month follow-up. We also describe the central role of multimodality three-dimensional transoesophageal echocardiography and multidetector cardiac CT imaging in assessing the severity of valve disease, characterising the nature of cardiac calcification and guiding decisions on surgical operability and transcatheter intervention.

Three-dimensional transesophageal echocardiography vs cardiac magnetic resonance in the assessment of planimetric mitral valve area in rheumatic mitral stenosis.

AIM: Rheumatic heart disease is a common cause of valvular disease, especially in developing countries. Echocardiography is the gold standard investigation modality for cardiac valves. In rheumatic mitral stenosis (MS), three-dimensional transesophageal echocardiography (3D TEE) provides better alignment of the image plane at the mitral tips and more accurate and reproducible planimetric measurement of mitral valve area (MVA). Cardiac magnetic resonance (CMR) is a new method that provides evaluation of cardiac anatomy and function noninvasively. Previous studies showed strong correlation between planimetric MVA measured by two-dimensional transthoracic echocardiography and CMR. We aimed to compare the planimetric MVAs assessed by 3D TEE and CMR in rheumatic MS patients. To best of our knowledge, this is the first study that compares 3D TEE and CMR for the assessment of the planimetric MVA in rheumatic MS. METHODS: We retrospectively evaluated 28 rheumatic MS patients who underwent 3D TEE and ECG-gated CMR. 3D TEE planimetric MVAs were measured manually by multiplanar reconstruction (MPR) method and CMR planimetric MVAs were measured manually on short-axis cine images. Then, 3D TEE and CMR measurements were compared. RESULTS: A total of 28 patients' (mean age 44 ± 12, 82.1% female) planimetric 3D TEE MVAs (1.00 ± 0.20 cm2 ) and CMR MVAs (1.04 ± 0.17 cm2 ) were found to be highly correlated (P < 0.0001, r: 0.744) with Pearson correlation analysis. Bland-Altman analysis showed strong agreement between two techniques. CONCLUSION: For the diagnosis and the follow-up of rheumatic MS, planimetric CMR MVA is an alternative noninvasive method which highly correlates with planimetric 3D TEE MVA.

Echocardiographic Assessment of Degenerative Mitral Stenosis: A Diagnostic Challenge of an Emerging Cardiac Disease.

Degenerative mitral stenosis (DMS) is characterized by decreased mitral valve (MV) orifice area and increased transmitral pressure gradient due to chronic noninflammatory degeneration and subsequent calcification of the fibrous mitral annulus and the MV leaflets. The "true" prevalence of DMS in the general population is unknown. DMS predominantly affects elderly individuals, many of whom have multiple other comorbidities. Transcatheter MV replacement techniques, although their long-term outcomes are yet to be tested, have been gaining popularity and may emerge as more effective and relatively safer treatment option for patients with DMS. Echocardiography is the primary imaging modality for evaluation of DMS and related hemodynamic abnormalities such as increased transmitral pressure gradient and pulmonary arterial pressure. Classic echocardiographic techniques used for evaluation of mitral stenosis (pressure half time, proximal isovelocity surface area, continuity equation, and MV area planimetry) lack validation for DMS. Direct planimetry with 3-dimensional echocardiography and color flow Doppler is a reasonable technique for determining MV area in DMS. Cardiac computed tomography is an essential tool for planning potential interventions or surgeries for DMS. This article reviews the current concepts on mitral annular calcification and its role in DMS. We then discuss the epidemiology, natural history, differential diagnosis, mechanisms, and echocardiographic assessment of DMS.

Stress echocardiographic assessment of mitral valve function repaired using rough-zone trimming.

BACKGROUND: We invented novel mitral valve repair technique; rough-zone trimming procedure (RZT) for anterior mitral valve prolapse. Prolapse site was resected in obtuse triangle shape and sutured edges to creates deep coaptation and improves regurgitation. Though it is simple and reproducible technique, functional mitral stenosis is a risk. Valve function and hemodynamics were investigated using dobutamine stress echocardiography (DSE) in patients after mitral valve repair using RZT. METHODS: Patients underwent RZT for the anterior mitral valve (AML, n = 10), quadrangular resection (QR) of the posterior mitral valve (PML; n = 4), RZT + QR of bileaflet valves (bileaflet; n = 4) and healthy individuals (control; n = 10) and were assessed by DSE (doses up to 20 µg/Kg/min). Echocardiographic data including mitral valve area (MVA), mitral valve mean pressure gradient (MVmeanPG), and systolic pulmonary artery pressure (sPAP) were measured at rest and at peak stress. RESULTS: Rest/stress MVA (cm(2)), MVmeanPG (mmHg) and sPAP (mmHg) were 2.8 ± 0.4 and 3.4 ± 0.3, 3.3 ± 1.1 and 7.4 ± 4.1, and 25.7 ± 4.7and 49.1 ± 4.1, respectively, in the AML group. Dobutamine stress increased all parameters but not to pathological levels. The results were similar to those of the other groups after mitral valve repair, whereas MVA was larger and MVmeanPG was lower in the control than in the AML group. CONCLUSIONS: Valve repair using RZT does not pathologically obstruct the mitral valve, either at baseline or during dobutamine stress, and does not affect valve hemodynamics and reserve.

Proximal flow convergence method by three-dimensional color Doppler echocardiography for mitral valve area assessment in rheumatic mitral stenosis.

BACKGROUND: The two-dimensional (2D) proximal isovelocity surface area (PISA) method has important technical limitations for mitral valve orifice area (MVA) assessment in mitral stenosis (MS), mainly the geometric assumptions of PISA shape and the requirement of an angle correction factor. Single-beat real-time three-dimensional (3D) color Doppler imaging allows the direct measurement of PISA without geometric assumptions or the requirement of an angle correction factor. The aim of this study was to validate this method in patients with rheumatic MS. METHODS: Sixty-three consecutive patients with rheumatic MS were included. MVA was assessed using the transthoracic 2D and 3D PISA methods. Planimetry of MVA (2D and 3D) and the pressure half-time method were used as reference methods. RESULTS: The 3D PISA method had better correlations with the reference methods (with 2D planimetry, r = 0.85, P < .001; with 3D planimetry, r = 0.89, P < .001; and with pressure half-time, r = 0.85, P < .001) than the conventional 2D PISA method (with 2D planimetry, r = 0.63, P < .001; with 3D planimetry, r = 0.66, P < .001; and with pressure half-time, r = 0.68, P < .001). In addition, a consistent significant underestimation of MVA using the conventional 2D PISA method was observed. A high percentage (30%) of patients with nonsevere MS by 3D planimetry were misclassified by the 2D PISA method as having severe MS (effective regurgitant orifice area < 1 cm(2)). In contrast, the 3D PISA method had 94% agreement with 3D planimetry. Good intra- and interobserver agreement for 3D PISA measurements were observed, with intraclass correlation coefficients of 0.95 and 0.90, respectively. CONCLUSIONS: MVA assessment using PISA by single-beat real-time 3D color Doppler echocardiography is feasible in the clinical setting and more accurate than the conventional 2D PISA method.

Three-dimensional echocardiographic assessment before and after percutaneous transvenous mitral commissurotomy in patients with rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Real-time three-dimensional transthoracic echocardiography (RT3DE) is a relatively recent imaging technique that provides excellent image quality of the mitral valve. It has been suggested that this new echocardiographic modality, which allows a precise cross-section of the mitral orifice at the tips of the leaflets with correct plane orientation, may provide a more accurate assessment of rheumatic mitral stenosis (MS) than two-dimensional echocardiography (2DE), before and after percutaneous transvenous mitral commissurotomy (PTMC). METHODS: A total of 50 patients with symptomatic mitral stenosis who underwent PTMC was evaluated prospectively. Patients in all age groups, with evidence of severe MS admitted to the authors' institution, in whom PTMC was feasible were included. RESULTS: A good valve opening was observed in 45 patients (90%). The mitral valve area (MVA) assessed before PTMC with 3DE (3D-MVA) correlated well with that assessed with 2DE (2D-MVA) (0.85 +/- 0.12 cm2 versus 0.86 +/- 0.13 cm2, p < 0.001); the mean difference between methods was small (0.01 +/- 0.11 cm2) and correlation excellent (r = 0.64, p < 0.001). After PTMC, values of 3D-MVA did not differ from, and correlated well with, values of 2D-MVA (1.79 +/- 0.20 cm2 versus 1.74 +/- 0.18 cm2, p = 0.006); the mean difference between methods was small (0.05 +/- 0.02 cm2) and correlation excellent (r = 0.76, p = 0.0001). Before PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.01 +/- 0.11 cm2, lower limit -0.24, upper limit 0.22). After PTMC, Bland-Altman analysis showed a good agreement between methods (mean difference -0.05 +/- 0.13 cm2, lower limit -0.3, upper limit 0.2). Evaluation of the commissural opening after PTMC, using RT3DE, showed that excellent commissural evaluation was possible in all patients. Compared with RT3DE, an underestimation of the degree of commissural fusion using 2DE was observed in 32%, with a weak agreement between methods. CONCLUSION: RT3DE provided accurate measurements of MVA, similar to 2D planimetry. RT3DE also improved the description of valvular anatomy and provided a unique assessment of the extent of commissural splitting.

Dobutamine stress echocardiography for noninvasive assessment and risk stratification of patients with rheumatic mitral stenosis.

OBJECTIVES: We sought to evaluate the impact of dobutamine stress echocardiography (DSE) in patients with known rheumatic mitral stenosis (MS) in order to assess its safety, feasibility, and prognostic correlation to well-known clinical outcomes. BACKGROUND: Noninvasive prognostic assessment of MS still represents an unresolved task in patients with clinically challenging disease. METHODS: Dobutamine stress echocardiography was performed in 53 patients with MS (8 males; age 37.4 +/- 11.3 years) with no major complications. RESULTS: During follow-up (60.5 +/- 11.0 months), 29 patients presented with clinical events: 16 hospitalizations, seven cases of acute pulmonary edema, and six symptomatic supraventricular arrhythmias. On multivariate analysis, the diastolic mitral valve mean gradient at peak DSE (DSE-MG) was the best predictor of clinical events (p < 0.008), especially in patients with moderate disease (p < 0.001). The best performance of DSE for the detection of clinical events was obtained at a cut-off value of 18 mm Hg DSE-MG (sensitivity 90%, specificity 87%, and accuracy 90%). The addition of DSE to the conventional cardiology work-up would allow a 17% increment for the detection of high-risk patients in the entire population and a 40% increment in patients with presumed moderate disease. CONCLUSIONS: In patients with MS, DSE is a safe and highly feasible stress test. A DSE-MG > or =18 mm Hg identifies a subgroup of high-risk patients in whom a more aggressive approach may be warranted; on the other hand, patients with a DSE-MG <18 mm Hg predicts an uneventful clinical course and may justify a more conservative strategy.

Clinical applicability for the assessment of the valvular mitral stenosis severity with Doppler echocardiography and the proximal isovelocity surface area (PISA) method.

Evaluation of the severity of valvular mitral stenosis and measurements of the effective rheumatic mitral valve area by noninvasive echocardiography has been well accepted. The area is measured by the two-dimensional planimetry (PLM) method and the Doppler pressure half-time (PHT) method. Recently, the proximal isovelocity surface area (PISA) by color Doppler technique has been used as a quantitative measurement for valvular heart disease. However, this method needs more validation. The aim of this study was therefore to investigate the clinical applicability of the PISA method in the measurements of effective mitral valve area in patients with rheumatic valvular heart disease. Forty-seven patients aged from 23 to 71 years, with a mean age of 53 +/- 13 (25 male and 22 female, 15 with sinus rhythm, mean heart rate of 83 +/- 14 beats per minute, with rheumatic valvular mitral stenosis without hemodynamically significant mitral regurgitation) were included in the study. Effective mitral valve area (MVA) derived by the PISA method was calculated as follows: 2 x Pi x (proximal aliasing color zone radius)2x aliasing velocity/peak velocity across mitral orifice. Effective mitral valve areas measured by three different methods (PLM, PHT, and PISA) were compared and correlated with those calculated by the "gold standard" invasive Gorlin's formula. The MVA derived from PHT, PLM, PISA and Gorlin's formula were 1.00 +/- 0.31cm2, 0.99 +/- 0.30 cm2, 0.95 +/- 0.30 cm2 and 0.91 +/- 0.29 cm2, respectively. The correlation coefficients (r value) between PHT, PLM, PISA, and Gorlin's formula, respectively, were 0.66 (P = 0.032, SEE = 0.64), 0.67 (P = 0.25, SEE = 0.72) and 0.80 (P = 0.002, SEE = 0.53). In conclusion, the PISA method is useful clinically in the measurement of effective mitral valve area in patients with rheumatic mitral valve stenosis. The technique is relatively simple, highly feasible and accurate when compared with the PHT, PLM, and Gorlin's formula. Therefore, this method could be a promising supplement to methods already in use.

Closed mitral commissurotomy in Archangel, Northern Russia, 1965-1993. Operative assessment of 367 patients operated on for rheumatic mitral stenosis.

OBJECTIVE: Preoperative and operative assessment of the 367 patients operated on for rheumatic mitral stenosis with closed mitral commissurotomy (CMC) at the regional hospital in Archangel, northwest Russia, between 1965 and 1993. DESIGN: Retrospective survey. RESULTS: Mean age at first attack of rheumatic fever was 15 years +/- 1.09 years. Mean age at time of surgery was 33.4 years +/- 0.92. Preoperatively, most patients (67%, n = 245) were in New York Heart Association stage III; 29% (n = 107) in stage IV. Digital commissurotomy alone was performed in 16% (n = 57) and a transventricular dilator was used in 84% (n = 310). Operative blood loss was average (384.4 ml +/- 34 ml); 20% (n = 73) developed wound infection, 21% (n = 77) pericarditis. In-hospital stay was above 50 days for both sexes. In-hospital mortality was 1.6% (n = 6). CONCLUSION: Rheumatic heart disease developed rapidly in these patients. CMC has a place as a low cost treatment of mitral stenosis when a heart lung machine is not available.

A comparative study of balloon mitral valvuloplasty and closed mitral commissurotomy in patients with rheumatic mitral stenosis.

Rheumatic mitral stenosis is frequently encountered in our country. It affects younger population and is a major cause of morbidity Mitral valvotomy is the definitive therapy for this disease and can be achieved by closed mitral commissurotomy (CMC), open mitral commissurotomy (OMC) or by percutaneous transluminal mitral valvuloplasty (PTMV). Compared to CMC, PTMV is less invasive but more expensive at this moment. With the reduction of cost, PTMV may become the procedure of choice for the treatment of rheumatic mitral stenosis in future.

Clinical assessment and management of mitral stenosis.

There have been significant advances in the diagnosis and treatment of the patient with mitral stenosis over the past two decades. Two-dimensional and Doppler echocardiography have supplanted the cardiac catheterization laboratory in the diagnosis and determination of the hemodynamic severity of the stenotic mitral valve. The development of a catheter-based approach for splitting fused commissures has led to earlier indications for intervention. It is likely that with the resurgence of rheumatic fever as well as influx of immigrant populations, the incidence of mitral stenosis may increase in the twenty-first century. It is thus important for the clinician to have a complete understanding of the evaluation and treatment options for the patient with mitral stenosis in the modern-day era.

Assessment of mitral valve volume by quantitative three-dimensional echocardiography in patients with rheumatic mitral valve stenosis.

BACKGROUND: Thickening of mitral leaflets in rheumatic mitral valve stenosis is well described in necropsy studies; however, volume computation of the thickening mitral leaflets has not been attempted. 4trial fibrillation is one of the complications of rheumatic mitral stenosis. Quantitative assessment of thickened mitral valve and its relation to clinical complications is clinically desirable. HYPOTHESIS: The study was undertaken to compare measurement of mitral valve volume in normal subjects and in patients with rheumatic mitral valve stenosis. METHODS: An HP Sonos 2500 echocardiographic system with 5 MHz multiplane transesophageal transducer was used for data acquisition, and TomTec Echoscan computer setup was used to off-line volume computation. Study subjects included 10 normal subjects (mean age 44.8 years) and 36 patients with rheumatic mitral valve stenosis (22 female, 14 male) with an age range of 25 to 69 years (mean age 47 +/- 9.6 years). Mitral valve volumes were compared between the normal subjects and patients with mitral valve stenosis, and further comparison was made between the sinus rhythm (SR) and atrial fibrillation (AF) groups in patients with mitral valve stenosis. In all study subjects, the mitral valve area (MVA) was determined by two-dimensional echocardiography. RESULTS: Quantitative three-dimensional (3-D) echocardiography showed that mitral valve volume was significantly larger in patients with mitral valve stenosis than in normal subjects (9.0 +/- 2.2 and 4.5 +/- 0.7 ml, respectively, p < 0.001). When patients with mitral valve stenosis were divided into the SR and AF groups, mitral valve volume was found to be significantly larger in the AF group than in the SR group (9.76 +/- 2.2 ml. and 7.72 +/- 1.5 ml, respectively, p < 0.01) and patients in the AF group tended to be older (p < 0.05) with larger left atrial diameter (LAD) (p < 0.01). However, MVA between the two groups showed no statistical significance (1.1 +/- 0.43 and 1.0 +/- 0.34 cm2, respectively, p > 0.2). When the study subjects were divided into two groups (< 50 and > or = 50 years) according to age, the comparison of mitral valve volume between these two groups (9.37 +/- 2.18 and 8.56 +/- 2.14 ml, p > 0.2) showed no statistical significance. CONCLUSIONS: Quantitative 3-D echocardiography can be applied for the measurement of mitral valve volume in vivo. Patients with rheumatic mitral valve stenosis with atrial fibrillation have a propensity to have a larger mitral valve volume and are older than the patients with sinus rhythm; however, the age per se does not seem to be a cause for larger mitral valve volume.

Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis.

OBJECTIVE: This review discusses the latest developments in selected clinical features and catheter-based therapy of mitral stenosis. DATA SOURCES: English-language journal articles and reviews in the clinical and epidemiological literature as related to mitral valve stenosis from 1965 through March 1993, identified by bibliography review and expert consultation. STUDY SELECTION: Selected studies included clinical trials with adequate patient population description and short- and long-term (5 years) follow-up for topics related to mitral valve stenosis in the clinical literature. DATA EXTRACTION: Two reviewers participated in extracting the data with the aim of presenting a balanced and comprehensive review of the subject. DATA SYNTHESIS AND CONCLUSIONS: The main conclusions are (1) mitral stenosis should no longer be viewed as a largely "geriatric disease" in the United States due to a recent inflow many young immigrants from countries where rheumatic fever continues partially or wholly unabated; (2) clinical and anatomical features of mitral stenosis are age-dependent; when clinical presentation occurs at 30 vs 70 years of age, for example, the degree of valve obstruction may be similar but differences exist in the frequency of atrial fibrillation, the magnitude of reduction in cardiac output, the degree of valve deformity and calcification, and the frequency of coexistent coronary artery disease; and (3) mitral stenosis therapy has undergone a reorientation with the introduction of percutaneous mitral balloon valvotomy, which has proven to be safe, cost-effective, and to provide short- and long-term improvements in symptomatic and hemodynamic status in selected patients.

[Cardiological evaluation of the asthmatic adult in the allergologist's office]. / Valoración cardiológica del adulto asmático en el consultorio del alergólogo.

The basic and clinic measurements in the initial cardiovascular work-up of the adult asthmatic are reviewed. This is complemented with the physiopathology of the two problems the frequently arise when an asthmatic is evaluated: 1) if asthma could cause a heart disease and 2) if a heart disease may be hidden in a presumed asthma.

[Noninvasive assessment of the function of the lesser circulation and of the right heart in mitral stenosis]. / Neinvazivnaia ostenka funktsional'nogo sostoianiia malogo kruga krovoobrashcheniia i pravogo otdela serdtsa pri mitral'nom stenoze.

Functional status of the pulmonary circulation network and the right compartments of the heart was assessed by two-dimensional Doppler echocardiography at rest and under isometric stress (handgrip with both hands) in 36 patients with varying degrees of mitral stenosis. An early stage of the condition is characterized by hyper-reactivity of the pulmonary circulation vessels as well as intact right-ventricular contractility. Hypertensive response of the pulmonary circulation vessels in combination with inadequately small increase in right-ventricular contractility are suggestive of an early stage of right-ventricular heart failure.

Two-dimensional echocardiographic assessment of infective endocarditis in children.

We examined 11 children with infective endocarditis initially and serially by two-dimensional echocardiography. Nine (82%) of the 11 patients had echocardiographic findings at initial examination compatible with infective endocarditis. These results provided strong evidence in support of the diagnosis before bacteriologic confirmation was available. Congestive heart failure, major emboli, and/or the need for surgical intervention occurred in seven of the nine patients with positive two-dimensional echocardiograms. Echocardiographic evidence of vegetations persisted during antibiotic therapy and resolved slowly during many months. Serial echocardiograms were useful in cases in which obvious valve destruction or marked increase in vegetation size imaged echocardiographically could be combined with clinical evidence of progressive heart failure to support a decision for early surgical intervention. Two-dimensional echocardiography can make important contributions to the diagnosis and management of children with infective endocarditis.

Echocardiographic assessment of left ventricular function in mitral valve disease.

Echocardiography was used to study left ventricular size and contraction in 90 patients with isolated mitral valve disease--47 patients with mitral stenosis, 26 with mixed mitral valve disease and 89 with mitral regurgitation. Left ventricular measurements included the end-diastolic internal dimension (LVIDd), mural thickness (PWTd), an index of circumferential myocardial contraction--fractional shortening (see article)--and stroke volume (LVSV). The left ventricle was abnormally small only when mitral stenosis was severe. Reduced myocardial contraction was common in patients with rheumatic valvular heart disease but was rarely severe. In mitral regurgitation without left ventricular failure, measurements were characteristic of volume overload with increases in LVIDd, LVSV and PWTd which were related to the severity of regurgitation. In other diseases, left ventricular failure is usually associated with reduced myocardial contraction (FS) but in mitral regurgitation with failure, myocardial contraction (FS 32%) did not differ significantly from normal (34%). The reduction in afterload caused by mitral regurgitation probably increases myocardial contraction and may lead to underestimation of the severity of myocardial impairment. Also potentially misleading was severe mitral regurgitation with normal values for LVIDd and LVSV (three patients). When the distinction between cardiomyopathy with secondary mitral regurgitation and primary mitral regurgitation was difficult clinically, echocardiography could usually make the distinction by demonstrating severe reduction of myocardial contraction with a slight or moderate increase in LVSV.