The acute effect of percutaneous mitral balloon valvuloplasty on atrial electromechanical delay and P-wave dispersion in patients with mitral stenosis

Pulmonary Impedance and Wave Reflections in Adults with Mitral Stenosis: Immediate and Follow-Up Effects of Balloon Valvuloplasty

PURPOSE

We compared adults with mitral stenosis (MS) to 8 controls (CONT) to see how pulmonary impedance and wave reflections differ at baseline and after balloon valvuloplasty.

METHODS

We separated the MS patients into groups according to mean pulmonary artery pressure: moderate (MOD; ≤ 26 mmHg, n = 21) and high (HIGH; > 26 mmHg, n = 33). We made baseline high-fidelity measurements in all patients, in the MS groups after vasodilation with nitroprusside, immediately and 4 months after balloon valvuloplasty.

RESULTS

Comparing MOD vs CONT, using the Kruskal-Wallis test with Bonferroni correction, reveals evidence for higher baseline input resistance (R) (489 vs 205 dyne-sec/cm5, P = 0.07); first harmonic of impedance modulus (Z1) (97.3 vs 27.6 dyne-sec/cm5, P = 0.01); first zero crossing of impedance phase angle (F0) (4.49° vs 2.19°, P = 0.02) but no difference in wave reflection index (Pb/Pf). Baseline HIGH vs CONT comparisons reveal stronger evidence and larger differences than MOD for R (995 vs 205, P < 0.001); Z1 (151 vs 27.6, P < 0.001); F0 (5.25 vs 2.19, P < 0.001); as well as Pb/Pf (0.69 vs 0.42, P < 0.001). Responses to nitroprusside and valvuloplasty are also greater in the HIGH than MOD, but the HIGH parameters still differ from the CONT. Four months after valvuloplasty there is evidence for reverse remodeling in both groups. Further analyses reveal that sinus rhythm and younger age are potentially important factors for remodeling.

CONCLUSION

MS causes alterations in pulmonary hemodynamics that differ according to pressure levels. These changes are only partially reversed immediately after valvuloplasty. There is evidence for reverse remodeling 4 months afterwards.

Prognostic Value of Pulmonary Artery Systolic Pressure in Severe Rheumatic Mitral Stenosis

BACKGROUND

Current guidelines recommend intervention for asymptomatic rheumatic mitral stenosis (MS) with mitral valve area ≤1.5 cm2 based on indicators including pulmonary arterial systolic pressure (PASP) >50 mm Hg and new-onset atrial fibrillation; however, evidence supporting this is lacking.

METHODS

This single-center retrospective study included patients with rheumatic MS between 2006 and 2022. Pulmonary hypertension was evaluated by using echocardiography to estimate PASP. Primary outcomes were major adverse cardiovascular events (MACE), including all-cause mortality, hospitalization for heart failure, and arterial thromboembolic events for up to 5 years.

RESULTS

Overall, 287 patients with severe rheumatic MS were enrolled (mean age, 62.5±11.3 years; 74.6% women). During a median follow-up of 2.52 years, MACE occurred in 99 patients. There were no differences in echocardiographic parameters, such as the mean mitral valve pressure gradient, mitral valve area, and proportion of mitral valve area <1.0 cm2, between patients who developed primary outcomes and those who did not. Survival analysis showed a worse prognosis in patients with estimated PASP (ePASP) >50 mm Hg than in those with ePASP ≤50 mm Hg (log-rank P<0.001); however, atrial fibrillation was not a significant prognostic indicator. As a continuous variable, ePASP (mm Hg) was a significant predictor of MACE (adjusted hazard ratio, 1.027 [95% CI, 1.011-1.042]; P<0.001). Receiver operating characteristic analysis revealed an optimal ePASP threshold of >45 mm Hg, which was an independent predictor of MACE in patients with severe rheumatic MS (adjusted hazard ratio, 2.127 [95% CI, 1.424-3.177]; P<0.001). Competing risk analysis considering mitral valve intervention as a competing risk showed similar results.

CONCLUSIONS

Our study demonstrated the prognostic significance of ePASP, rather than atrial fibrillation, in relation to MACE among patients with severe rheumatic MS. Additionally, we proposed a lower ePASP threshold (>45 mm Hg) as a predictor of an unfavorable prognosis.

The effects of catheter ablation of outflow tract premature ventricular complexes on atrial electromechanical delay

BACKGROUND

Consistent data from several studies have shown that catheter ablation of frequent premature ventricular complexes (PVCs) results in substantial improvement in left ventricular ejection fraction (LVEF), left ventricular diastolic function, and left atrial volume and mechanics. However, the effects of catheter ablation of PVCs on atrial electromechanical properties have not been documented yet.

AIMS

In the present study, we investigated the short-term effects of radiofrequency catheter ablation (RFCA) of outflow tract PVCs on atrial electromechanical delay (EMD).

METHODS

A total of 71 subjects with idiopathic outflow tract PVCs who underwent RFCA were included. Interatrial and intra-atrial EMDs were measured by tissue Doppler imaging before and 3 months after catheter ablation.

RESULTS

The study population was divided into normal ejection fraction (EF) and low-EF subgroups according to their LVEF. In all study groups, substantial improvement was found in lateral electromechanical coupling time (PA), septal PA, right ventricular PA, interatrial EMD, left-sided intra-atrial EMD, and right-sided intra-atrial EMD. No treatment heterogeneity was observed when comparing low-EF and normal-EF subgroups with respect to atrial EMDs (interatrial EMD, interaction p = .29; left-sided intra-atrial EMD, interaction p = .13; right-sided intra-atrial EMD, interaction p = .88).

CONCLUSION

RFCA of outflow tract PVC has a favorable early effect on intra- and inter-atrial EMDs irrespective of preprocedural LVEF.

Arrhythmias in Patients With Valvular Heart Disease: Gaps in Knowledge and the Way Forward

The prevalence of both organic valvular heart disease (VHD) and cardiac arrhythmias is high in the general population, and their coexistence is common. Both VHD and arrhythmias in the elderly lead to an elevated risk of hospitalization and use of health services. However, the relationships of the two conditions is not fully understood and our understanding of their coexistence in terms of contemporary management and prognosis is still limited. VHD-induced left ventricular dysfunction/hypertrophy and left atrial dilation lead to both atrial and ventricular arrhythmias. On the other hand, arrhythmias can be considered as an independent condition resulting from a coexisting ischemic or non-ischemic substrate or idiopathic ectopy. Both atrial and ventricular VHD-induced arrhythmias may contribute to clinical worsening and be a turning point in the natural history of VHD. Symptoms developed in patients with VHD are not specific and may be attributable to hemodynamical consequences of valve disease but also to other cardiac conditions including arrhythmias which are notably prevalent in this population. The issue how to distinguish symptoms related to VHD from those related to atrial fibrillation (AF) during decision making process remains challenging. Moreover, AF is a traditional limit of echocardiography and an important source of errors in assessment of the severity of VHD. Despite recent progress in understanding the pathophysiology and prognosis of postoperative AF, many questions remain regarding its prevention and management. Furthermore, life-threatening ventricular arrhythmias can predispose patients with VHD to sudden cardiac death. Evidence for a putative link between arrhythmias and outcome in VHD is growing but available data on targeted therapies for VHD-related arrhythmias, including monitoring and catheter ablation, is scarce. Despite growing evidences, more research focused on the prognosis and optimal management of VHD-related arrhythmias is still required. We aimed to review the current evidence and identify gaps in knowledge about the prevalence, prognostic considerations, and treatment of atrial and ventricular arrhythmias in common subtypes of organic VHD.

Evaluation of atrial fibrillation risk in patients with vasovagal syncope

BACKGROUND

This study aimed to determine whether autonomic dysfunction in patients with vasovagal syncope with a positive tilt test may cause an alteration in atrial electromechanical properties and pose a risk for subsequent atrial arrhythmias, especially atrial fibrillation.

METHODS

The data of 27 patients with vasovagal syncope and a matched control group comprising 28 healthy individuals were compared. All patients underwent a tilt table test. Atrial electromechanical intervals (PA) were measured from the mitral lateral annulus, mitral septal annulus, and tricuspid annulus with tissue Doppler imaging. Left atrium volumes were measured with the disc method in apical four-chamber imaging.

RESULTS

Although atrial electromechanical intervals such as lateral PA, septal PA, and tricuspid PA durations were significantly longer (p = 0.009, p = 0.002, p = 0.011, respectively), interatrial, right intra-atrial, and left intra-atrial durations were similar in the vasovagal syncope group and the control group (p = 0.298, p = 0.388, p = 0.069, respectively). Left atrial volumes (maximum, minimum, and presystolic) were significantly increased in the vasovagal syncope group when compared with the control group (p = 0.001, p = 0.001, p = 0.007, respectively). There was no difference between vasovagal syncope types in terms of atrial electromechanical intervals.

CONCLUSION

Interatrial and intra-atrial intervals were similar in the vasovagal syncope group and the control group. However, an increase in atrial volumes and a prolongation of certain atrial electromechanical intervals were observed in patients with vasovagal syncope. These findings suggest an alteration in atrial electromechanics caused by autonomic dysfunction that can lead to subsequent atrial arrhythmias, especially atrial fibrillation.

Efficacy and safety of percutaneous mitral balloon valvotomy in patients with mitral stenosis: A systematic review and meta-analysis

Aims

Percutaneous mitral balloon valvotomy PMBV is an acceptable alternative to Mitral valve surgery for patients with mitral stenosis. The purpose of this study was to explore the immediate results of PMBV with respect to echocardiographic changes, outcomes, and complications, using a meta-analysis approach.

Methods

MEDLINE, and EMBASE databases were searched (01/2012 to 10/2018) for original research articles regarding the efficacy and safety of PMBV. Two reviewers independently screened references for inclusion and abstracted data including article details and echocardiographic parameters before and 24–72 h after PMBV, follow-up duration, and acute complications. Disagreements were resolved by third adjudicator. Quality of all included studies was evaluated using the Newcastle-Ottawa Scale NOS.

Results

44/990 references met the inclusion criteria representing 6537 patients. Our findings suggest that PMBV leads to a significant increase in MVA (MD = 0.81 cm²; 0.76–0.87, p < 0.00001), LVEDP (MD = 1.89 mmHg; 0.52–3.26, p = 0.007), LVEDV EDV (MD = 5.81 ml; 2.65–8.97, p = 0.0003) and decrease in MPG (MD = −7.96 mmHg; −8.73 to −7.20, p < 0.00001), LAP (MD = −10.09 mmHg; −11.06 to −9.12, p < 0.00001), and SPAP (MD = −15.55 mmHg; −17.92 to −13.18, p < 0.00001). On short term basis, the pooled overall incidence estimates of repeat PMBV, mitral valve surgery, post-PMBV severe MR, and post-PMBV stroke, and systemic thromboembolism were 0.5%, 2%, 1.4%, 0.4%, and 0.7%% respectively. On long term basis, the pooled overall incidence estimates of repeat PMBV, mitral valve surgery, post-PMBV severe MR, and post-PMBV stroke, systemic thromboembolism were 5%, 11.5%, 5.5%, 2.7%, and 1.7% respectively

Conclusion

PMBV represents a successful approach for patients with mitral stenosis as evidenced by improvement in echocardiographic parameters and low rate of complications.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Immediate And Long Term Effects Of Percutaneous Mitral Balloon Valvuloplasty On Atrial Conduction Velocities In Patients With Mitral Stenosis

Background

P-wave dispersion (PWD) is an electrocardiographic (ECG) marker of nonuniform and heterogeneous atrial conduction with ECG leads of different orientation. The aim of our study was to investigate the immediate and long term effects of successful percutaneous mitral balloon valvuloplasty (PMBV) on PWD in severe rheumatic MS patients and to analyse the restenosis, atrial fibrillation (AF) and redo balloon valvuloplasty rate.

Methods

We enrolled 41 consecutive MS patients with sinus rhythm who underwent PMBV. A 12-lead ECG and transthoracic echocardiography were performed for each patient one day before, within 72 hours after the procedure and followed up by clinical visit at a mean of 5,57±1,46 (3-8) year.The mean patient age was 44.1±10.86 years.

Results

Pmax 1(pre PMBV) and PWD 1(pre PMBV) decreased 1-3 days after PMBV. MVA improved immediately after the procedure; but lately the mean MVA decreased significantly indicating the initiation of restenosis. Composite endpoints were associated with LA 1 (p = 0.02), MVA 2 (1-3 days after PMBV) (p= 0.019), mean gradient 2 (p= 0.028), PWD 3 (3 years after PMBV) (p < 0.001) and Pmax 3 (3 years after PMBV) (<0,001). AF incidence was associated with PWD 2 (p=0,019) and PWD 3 (p=0,010). There was 14 composite endpoint on follow up and at multivariate analysis PWD 3 was identified as an independent predictor of the composite endpoint (p=0.048, hazard ratio=1.36, 95% confidence interval (CI): 1,002-1.867).

Conclusions

This study has demonstrated that Pmax and PWD significantly decreased within 3 days after PMBV. Furthermore, long term PWD was associated with AF and identified as an independent predictor of the composite endpoint.

Usefulness of the Macruz Index for Predicting Successful Percutaneous Mitral Balloon Valvuloplasty in Patients with Mitral Stenosis

OBJECTIVE

The aim of this study was to determine whether the Macruz index (P/P-R segment) could predict the severity of valvular involvement and the success of percutaneous mitral balloon valvuloplasty (PMBV) in patients with mitral stenosis (MS).

SUBJECTS AND METHODS

Sixty-one patients with MS eligible for PMBV and 72 healthy subjects (61 females and 11 males) with sinus rhythm were enrolled into this study. PMBV was performed in all patients using a percutaneous transseptal antegrade approach and a multitrack balloon technique. The P/P-R segment ratio and echocardiographic variables were measured before and 48-72 h after the procedure. The optimal cutoff point for differences in the Macruz index to determine clinical success was evaluated by receiver operating characteristic analysis by calculating the area under the curve as giving the maximum sum of sensitivity and specificity for the significant test.

RESULTS

In the patient group (mean age 42.9 ± 11.1 years), the preprocedural Macruz index was significantly higher than in the control group (2.79 ± 1.03 vs. 1.29 ± 0.11; p < 0.001). In the successful-procedure group (n = 53), the mean postindex value was significantly lower (2.12 ± 0.71 vs. 2.81 ± 1.0, p = 0.020), and the decrease in the Macruz index was significantly higher than in the unsuccessful-procedure group (p = 0.007). An index decrease of 0.105 was the best cutoff value to distinguish the successful-PMBV group from the unsuccessful- PMBV group (area under the curve = 0.888, 95% confidence interval 0.788-0.988, p < 0.001).

CONCLUSION

The Macruz index was significantly higher in patients with MS compared to healthy subjects. A greater decrease in the Macruz index was associated with a successful PMBV.

Immediate effect of percutaneous transvenous mitral commissurotomy on atrial electromechanical delay and P-wave dispersion in patients with severe mitral stenosis

BACKGROUND

Mitral stenosis (MS) is associated with prolonged inter- and intra-atrial electromechanical delays and increased P-wave dispersion, which are markers of atrial fibrillation (AF) risk. This study was conducted to assess the immediate effect of successful percutaneous transvenous mitral commissurotomy (PTMC) on these parameters.

METHODS

This single center observational study included 25 patients with severe MS (aged 34.1 ± 7.1 years, with mean mitral valve area (MVA) of 0.74 ± 0.13 cm(2)), in sinus rhythm, who underwent successful PTMC at our hospital. P-wave dispersion (PWD) was calculated by subtracting minimum P-wave duration (P min) from maximum P-wave duration (Pmax), measured on a 12-lead surface ECG obtained from each patient in supine position at a paper speed of 50mm/s and 20mm/mV. Inter-atrial (AEMD), left intra-atrial (L-IAEMD), and right intra-atrial (R-IAEMD) electromechanical delays were measured on tissue Doppler imaging. PTMC was performed using the standard Inoue Balloon technique. All these parameters were evaluated and compared before and 24-48 h after PTMC.

RESULTS

Successful PTMC led to significant reduction in AEMD (p < 0.001), L-IAEMD (p < 0.001), and R-IAEMD (p < 0.001). There were no changes in Pmax, Pmin, and PWD immediately after PTMC.

CONCLUSIONS

Successful PTMC has a favorable early impact on inter- and intra-atrial electromechanical delays, which are considered as novel parameters of atrial electromechanical remodeling in MS patients. Prospective large-scale studies are required to confirm whether improvement in these markers translates into reduced long-term AF risk.

Left atrial asynchrony and mechanical function in patients with mitral stenosis before and immediately after percutaneous balloon mitral valvuloplasty: a real time three-dimensional echocardiography study

OBJECTIVE

This study evaluated the feasibility of assessing left atrium (LA) function and asynchrony in patients with rheumatic mitral stenosis (MS) before and immediately after percutaneous balloon mitral valvuloplasty (PBMV) by real time three-dimensional echocardiography (RT3DE).

METHODS

Thirty patients with rheumatic MS who underwent PBMV and 30 controls were enrolled. RT3DE was used to measure LA volume and function, the standard deviation of time to the minimal systolic volume divided into 16 segments, 12 segments, or 6 segments (Tmsv 16-SD, Tmsv 12-SD, Tmsv 6-SD), and the maximum differences (Tmsv 16-Dif, 12-Dif, 6-Dif) in RT3DE derived values in MS patients before and 2 days after PBMV were obtained and compared with those of normal controls. The associations between the LA asynchrony and heart volume, function, mitral valve area (MVA), maximum mitral valve gradient (MVGmax ), mean mitral valve gradient (MVGmean), and mean LA pressure (MLAP) were investigated.

RESULTS

Left atrium asynchrony indexes were significantly larger, and LA function parameters were significantly lower in the MS group than in the controls (P < 0.05 for all). Of all the LA asynchrony indexes, LA Tmsv16-SD was most significantly correlated with the LA volume and function parameters, MVGmax , MVGmean , and MLAP (P < 0.05 for all). LA asynchrony indexes and LA volume significantly deceased, and LA function significantly increased post-PBMV (P < 0.05).

CONCLUSION

Real time three-dimensional echocardiography is a reliable and reproducible method to quantify LA function and asynchrony. RT3DE revealed a significant, early improvement in LA function and asynchrony in MS patients after PBMV.

Impact of continuous positive airway pressure therapy on atrial electromechanical delay and P-wave dispersion in patients with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea (OSA) has been shown to be associated with atrial fibrillation (AF). Prolongation of inter- and intraatrial conduction times during sinus rhythm has also been shown to be related to AF generation. Nasal continuous positive airway pressure (CPAP) is an effective treatment modality of OSA.

METHODS

Twenty-four OSA patients diagnosed through polysomnography and 18 controls were included in the study. The basal inter- and intraatrial electromechanic delays prior to onset of the therapy were measured using tissue Doppler imaging. P-wave dispersion (Pd) was calculated on the basis of 12-lead electrocardiography. Same measurements were performed in OSA patients 6 months after the initiation of the therapy.

RESULTS

Interatrial (39.2 ± 8 vs. 21.1 ± 2.8 ms, P < 0.001), left intraatrial (20.5 ± 7.2 vs. 11.1 ± 2 ms, P = 0.003), and right intraatrial electromechanical delays (20.7 ± 11 vs. 10 ± 2.6 ms, P < 0.001) prior to CPAP therapy were found to be significantly greater in OSA group as compared with the controls. Pd was also greater in the OSA group as compared with the controls (44 ± 7 vs. 28.5 ± 4 ms, P < 0.001). However, significant improvement has been noted after 6 months of CPAP therapy in interatrial (P < 0.0001), left intraatrial (P = 0.002), and right intraatrial electromechanical delays (P < 0.0001) as well as in Pd (P < 0.0001) as compared to baseline values in patients with OSA.

CONCLUSION

Our findings suggested that CPAP therapy provides more homogenous conduction through atria in patients with OSA. This effect may translate into decreased risk for AF associated with OSA.