Newer advances in the diagnosis and treatment of mitral stenosis

Interventional Echocardiography of the MV: What the Interventionalist Wants to Know

The past 2 decades have seen a proliferation of transcatheter mitral valve (MV) therapies, which are less invasive and distinct from surgical MV repair or replacement. The commonly used MV transcatheter therapies include (1) percutaneous mitral balloon commissurotomy (PMBC) for rheumatic mitral stenosis; (2) edge-to-edge repair with the MitraClip for mitral regurgitation; (3) valve-in-valve implantation in bioprosthetic MV, native MV, or mitral ring; and (4) closure of paravalvular leaks (PVLs). This article will focus on the use of echocardiography in the diagnosis, patient selection, procedural guidance, and postprocedural follow-up for PMBC, with notes on the role of transesophageal echocardiography in transcatheter interventions for prosthetic valve degeneration and PVL closure.

Skin aging parameters: A window to heart block

BACKGROUND

Skin acts as a mirror to the internal state of the body.

HYPOTHESIS

We tried to find the relation between skin aging parameters and the incidence of degenerative AV block.

METHODS

This study included 97 patients divided into 2 groups; group D comprised 49 patients with advanced-degree AV block, and group C comprised the 48 matched control group. All were subjected to full history taking, thorough clinical examination, calculation of intrinsic skin aging score, and resting 12-lead surface electrocardiography (ECG). ECG for all patients assessed left ventricular end-systolic diameter, left ventricular end-diastolic diameter, ejection fraction, left atrium (LA) diameter, aortic root diameter, mitral annular calcification, aortic sclerosis. Coronary angiography was also performed when indicated for patients in group D.

RESULTS

Patients in group D had a higher percentages of uneven pigmentation, fine skin wrinkles, lax appearance, seborrheic keratosis, total score > 7 (38 [77.55%] vs 10 [20.83%]), mitral annular calcification score of 33 (67.34%) vs 5 (10.41%), aortic sclerosis score of 21 (42.85%) vs 4 (8.33%), and mean LA diameter of 39.98 ± 5.52 vs 36.21 ± 3 mm (P < 0.001). Total score > 6 is the best cutoff value to predict advanced-degree heart block with 89.79% sensitivity and 64.58% specificity. Seborrheic keratosis was the strongest independent predictor.

CONCLUSIONS

Any population with a total intrinsic skin aging score of >6 is at high risk for developing advanced-degree AV block and should undergo periodic ECG follow-up for early detection of any conduction disturbance in the early asymptomatic stages to minimize sudden cardiac death.

Genetic determinants of cardiometabolic risk: a proposed model for phenotype association and interaction

This review provides a translational and unifying summary of metabolic syndrome genetics and highlights evidence that genetic studies are starting to unravel and untangle origins of the complex and challenging cluster of disease phenotypes. The associated genes effectively express in the brain, liver, kidney, arterial endothelium, adipocytes, myocytes, and β cells. Progression of syndrome traits has been associated with ectopic lipid accumulation in the arterial wall, visceral adipocytes, myocytes, and liver. Thus, it follows that the genetics of dyslipidemia, obesity, and nonalcoholic fatty liver disease are central in triggering progression of the syndrome to overt expression of disease traits and have become a key focus of interest for early detection and for designing prevention and treatments. To support the "birds' eye view" approach, we provide a road-map depicting commonality and interrelationships between the traits and their genetic and environmental determinants based on known risk factors, metabolic pathways, pharmacologic targets, treatment responses, gene networks, pleiotropy, and association with circadian rhythm. Although only a small portion of the known heritability is accounted for and there is insufficient support for clinical application of gene-based prediction models, there is direction and encouraging progress in a rapidly moving field that is beginning to show clinical relevance.

Randomized comparison between Inoue balloon and metallic commissurotome in the treatment of rheumatic mitral stenosis: immediate results and 6-month and 3-year follow-up

The metallic commissurotome (MC) technique is a cheaper alternative to the Inoue balloon (IB) technique for percutaneous mitral valvuloplasty (PMV). There are no randomized trials comparing these techniques with longer follow-up of the patients. The objective of this study was to compare the immediate results and short- and medium-term follow-up of PMV using either the IB or the MC technique. Fifty patients with rheumatic mitral stenosis were randomly assigned to PMV using the IB (n = 27) or the MC (n = 23) technique. There were no significant differences between the groups regarding baseline clinical, echocardiographic, and hemodynamic data. Clinical and echocardiographic follow-up were done 6 months and 3 years after the procedure. The success rate was 100% in the IB group and 91.3% in the MC group (P = 0.15); two patients in the latter group developed mitral regurgitation grade 3/4, requiring elective surgery. The mean final mitral valve area was bigger in the MC group (2.17 +/- 0.13 vs. 2.00 +/- 0.36 cm2; P = 0.04), but after 6-month and 3-year follow-up, this difference was no longer significant (2.06 +/- 0.27 vs. 1.98 +/- 0.38 cm2, P = 0.22, and 1.86 +/- 0.32 vs. 1.87 +/- 0.34 cm2, P = 0.89, respectively). This finding suggests valve stretching as an important mechanism of valve dilation with the MC. Three patients in the MC group and two patients in the IB group (P = 0.65) developed mitral valve restenosis; one of them underwent repeat PMV and the other four, all asymptomatic, were clinically followed. PMV performed either with the IB or the MC technique is effective and provides excellent short- and medium-term outcomes regardless of the technique employed.

[Current standard in diagnosis and therapy of heart valve lesions]

We present a survey of the current standard in diagnosis and therapy of the most frequent heart valve lesions. During the last 50 years there has been a dramatic shift concerning the etiology of valve lesions with a rise of the agedependent degenerative towards rheumatic valve diseases. The aim of the diagnostic evaluation of valve lesions is primarily the clinical and hemodynamic grading of the severity of the valve disease, the recognition of relevant coexisting cardiac and extracardiac diseases and furthermore, an optimal timing of surgery in close correlation with the cardiac surgeons.

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.