Value and limitations of Doppler echocardiographic determination of mitral valve area in Lutembacher syndrome

Atrial septal defect with pulmonary hypertension: when/how can we consider closure?

Patients having atrial septal defect (ASD) with moderate and more importantly severe pulmonary arterial hypertension (PAH) pose a clinical dilemma. Closing ASD in those with irreversible PAH and not closing it when the PAH is reversible can cost patients dearly, both in terms of quality of life and longevity. In our experience, there is no single parameter that can help in decision making in this difficult subset of patients and therefore we recommend a multi-dimensional approach, which takes into consideration clinical, radiological, electrocardiographic and hemodynamic variables as a whole. ASD with restrictive left ventricular (LV) physiology can lead to pulmonary venous hypertension, which can manifest as life threatening acute pulmonary edema following device closure. All high-risk candidates prone to having this combination should be prepared with diuretics and vasodilators prior to bringing them to catheterization laboratory and should be assessed with temporary balloon/device occlusion prior to permanent closure of the defect. In those cases of ASD with borderline operability either due to severe PAH or LV restrictive physiology, perforated device may be helpful in preventing acute or long-term complications of complete closure.

Is Transoesophageal Echocardiography Necessary for the Percutaneous Management of Lutembacher Syndrome: A Case Report

Lutembacher syndrome is defined as a combination of congenital Atrial Septal Defect (ASD) with an acquired Mitral Stenosis (MS). There are various challenges involved in the percutaneous management of Lutembacher syndrome. Here, we present a case that had a very small Left Atrium (LA) and Left Ventricle (LV) cavities with an anteriorly placed ASD. We used Transoesophageal echocardiography (TEE) to take a separate interatrial septal puncture and complete the Balloon Mitral Valvotomy (BMV) procedure. Finally both the defects in interatrial septum were closed with the help of a large device.

Transcatheter therapy of Lutembacher syndrome

Lutembacher syndrome is a combination of congenital atrial septal defect (ASD) and acquired mitral stenosis (MS). The combination of these 2 diseases has hemodynamic influences on each other and the degree of MS may be underestimated. Traditionally, Lutembacher syndrome is corrected by surgical treatment. Nowadays, these 2 diseases are amenable to transcatheter treatment without the need for surgery. Here, we describe a 28-year-old female with Lutembacher syndrome who benefited from combined transcatheter therapy of balloon valvuloplasty for MS and device closure for ASD with an Amplatzer septal occluder.

[Percutaneous mitral commissurotomy and Lutembacher syndrome]

INTRODUCTION

Lutembacher syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. This condition is usually treated surgically by mitral valve operation with concomitant closure of the atrial septal defect.

MATERIALS AND METHODS

Between 1993 and 2003, 4 patients with congenital Lutembacher syndrome had percutaneous mitral commissurotomy without closure of the atrial septal defect at our institution. The 4 patients were very symptomatic with right-sided heart failure signs and NYHA functional class III-IV.

RESULTS

The procedure was carried out successfully for the four patients. Mitral valve area increased from 0.87 to 1.97 cm2 at mean; left atrial pressure decreased from 28.2 to 12.7 mmHg and the mean valve mitral gradient was reduced from 15.5 to 3.9 mmHg. Functional and clinical improvement was observed in all the cases. During a mean follow up of 55 +/- 29 months, our 4 patients remain pauci symptomatic under medical treatment.

CONCLUSION

The percutaneous treatment of the Lutembacher syndrome is currently a possible alternative to the surgery among patients having an anatomy favourable to the procedure.

Echocardiographic assessment of left and right heart hemodynamics in a patient with Lutembacher's syndrome

We present a case of a 53-year-old woman with intractable shortness of breath that was originally ascribed to bronchiolitis obliterans organizing pneumonia. Subsequently evaluation by echocardiography and cardiac catheterization revealed that she had Lutembacher's syndrome, an uncommon combination of congenital atrial septal defect (ASD) and acquired mitral stenosis that is difficult to diagnose clinically. Our case illustrates the pitfalls and advantages of echocardiographic assessment of the mitral valve area (MVA) and the left atrial pressure (LAP). The pressure half-time method used most commonly for estimating MVA echocardiographically is inaccurate and may lead to underestimation of the severity of mitral stenosis in patients with Lutembacher's syndrome. On the other hand, the presence of ASD provides an additional method of calculating LAP, the most important determinant of symptoms in patients with mitral stenosis.

Giant left atrium secondary to tight mitral stenosis leading to acquired Lutembacher syndrome: a case report with emphasis on role of echocardiography in assessment of Lutembacher syndrome

Lutembacher syndrome is an unusual clinical entity of congenital secundum atrial septal defect in combination with rheumatic mitral stenosis. Although this classic form is seldom seen by the adult cardiologist, spontaneous Lutembacher syndrome as discussed later or the iatrogenic variant is not infrequently encountered. The pathophysiologic, clinical, and hemodynamic differences of mitral valve disease in the presence of atrial septal defect compared with isolated mitral stenosis are highlighted in this case review. Special emphasis has also been given to echocardiographic evaluation of this syndrome complex, particularly in the setting of percutaneous mitral valvuloplasty, which produces the iatrogenic form of Lutembacher syndrome.

Transcatheter treatment of a case of Lutembacher syndrome

Lutembacher syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. This condition is usually treated by mitral valve operation with concomitant closure of the atrial septal defect. We describe a case of Lutembacher syndrome that was treated successfully with percutaneous transcatheter mitral commissurotomy using the Inoue balloon and closure of the atrial septal defect with the Amplatzer atrial septal defect occluder.

Definitive percutaneous treatment of Lutembacher's syndrome

Definitive percutaneous treatment of a patient with Lutembacher's syndrome was successfully accomplished using the Amplatzer septal occluder to close a secundum atrial septal defect and the Joseph mitral balloon catheter to dilate rheumatic mitral valve stenosis. Transcatheter therapy is an effective alternative to surgery in selected patients with Lutembacher's syndrome. Cathet. Cardiovasc. Intervent. 48:199-204, 1999.

Mitral Stenosis, Sinus Venosus Atrial Septal Defect, and Partial Anomalous Pulmonary Venous Return: Diagnosis by Multiplane Transesophageal Echocardiography

We describe a 42-year-old man with rheumatic mitral stenosis, sinus venosus atrial septal defect, and anomalous drainage of the right upper pulmonary vein to the superior vena cava. Transthoracic echocardiography (TTE) failed to identify the atrial septal defect and the partial anomalous pulmonary venous return. Transesophageal echocardiography (TEE), using a multiplane probe, was useful in delineating the abnormalities. To our knowledge, this is the first reported patient with rheumatic mitral stenosis and sinus venosus defect. (ECHOCARDIOGRAPHY, Volume 13, November 1996)

Effect of atrial septal occlusion on mitral area after Inoue balloon valvotomy

The purpose of this study was to examine the influence of the atrial communication created during transseptal passage of the Inoue balloon catheter on calculated mitral valve area after balloon valvotomy for severe mitral stenosis. Even in the absence of oxymetric evidence for a shunt, atrial septal puncture may result in left-to-right shunting of blood with reported spurious increases in postvalvotomy mitral valve area calculations ranging from 16-29% in prior studies. Occlusion of the septal puncture site after double balloon valvotomy has previously been shown to result in decreased postvalvotomy mitral valve area determinations. We evaluated 20 patients undergoing mitral dilation. Each patient had three postvalvotomy measurements made: (1) with the Inoue balloon catheter positioned across the septum, (2) during septal occlusion with a 7F balloon-tip catheter, and (3) without any catheters across the septum. With the Inoue catheter across the septum after successful valvotomy, the cardiac output was 4.6 +/- 1.5 L/min and the calculated mitral valve area was 1.7 +/- 0.5 cm2. No difference was found in either cardiac output or valve area when the septum was unobstructed by catheters. During septal occlusion, however, the postvalvotomy cardiac output decreased to 4.3 +/- 1.3 L/min (P < 0.001) and the calculated mitral area decreased by 12% to 1.5 +/- 0.5 cm2 (P < 0.001). The calculated mitral valve areas determined with the Inoue catheter in place after valvotomy were in agreement with echo derived data. Although statistically significant differences in post-Inoue valvotomy cardiac output and calculated mitral valve area were found during septal occlusion, these differences were small.(ABSTRACT TRUNCATED AT 250 WORDS)