Mitral Stenosis

The correlation between the coaptation height of mitral valve and mitral regurgitation after mitral valve repair

Background

To investigate the association between the coaptation height of mitral valve and mitral regurgitation after mitral valve repair.

Methods

From Sep 2014 to Jun 2015, 20 patients underwent mitral valve valvuloplasty for mitral regurgitation were included. Ring annuloplasty was performed in all cases. Mitral valve short-axis dimension (MVd), coaptation height (CH), Left ventricular ejection fraction (LVEF) were measured by the transesophageal echocardiography before the operation in operation room and 3 months and 12 months after the operation by the transthoracic echocardiography. A degree from 0 to 4 was used to measure the degree of mitral regurgitation.

Results

There were 14 patients with 0, 3 patients with 1, 3 patients with 2 of mitral regurgitation 12 months after the operation. CH (3.53 ± 1.91 mm) increased significantly at 3 months (5.05 ± 1.09 mm) and 12 months after operation (5.22 ± 1.15 mm) (p < 0.05). MVd and LVEF were not significantly changed after mitral valve repair. Furthermore, CH after resuscitation have a statistically significant negative correlation with the degree of mitral regurgitation 12 months after operation.

Conclusion

The mitral valve repair with mitral valve ring induce the morphologic change of the mitral valve structure. The increase of CH after mitral valve repair may be one of the main factors in regulation of mitral regurgitation.

Initial experience of using intracardiac echocardiography (ICE) for guiding balloon mitral valvuloplasty (BMV)

BACKGROUND AND AIMS

BMV is an established treatment for rheumatic mitral valve stenosis. The procedure is historically guided by fluoroscopy, and the role of intracardiac echocardiogram (ICE) guidance is not well defined. We report our initial experience of using ICE to guide BMV procedures.

METHODS

During BMV procedure, ICE catheter was inserted into the right atrium from the right femoral vein, and the septal puncture was monitored by ICE, as well as positioning of the balloon in the mitral valve. Comparisons were made between ICE, transthoracic echocardiography (TTE), and catheterization derived hemodynamic measurements (cath).

RESULTS

Seventeen patients with mitral stenosis underwent the procedure. The mean age was 44.4 ± 21 years. The mean MV area increased from 0.9 ± 0.1 cm(2) to 1.7 ± 0.2 cm(2), P < 0.0001 and the mean gradient decreased from 12.6 ± 5.8 mmHg to 4.9 ± 1.8 mmHg, P < 0.001. Atrial septum puncture and guidance of the balloon into the MV apparatus were obtained in all patients under ICE guidance. Severe MR developed in one patient and was readily detected by ICE. ICE derived gradient measurements were comparable to those obtained by TTE, and cath.

CONCLUSION

ICE guidance of BMV is feasible, and useful in monitoring safe septal puncture, optimizing balloon positioning, and in detecting complications. The hemodynamic measurements obtained were comparable to those obtained by TTE, and cath.

Echocardiography-guided interventions

A major advantage of echocardiography over other advanced imaging modalities (magnetic resonance imaging, computed tomographic angiography) is that echocardiography is mobile and real time. Echocardiograms can be recorded at the bedside, in the cardiac catheterization laboratory, in the cardiovascular intensive care unit, in the emergency room-indeed, any place that can accommodate a wheeled cart. This tremendous advantage allows for the performance of imaging immediately before, during, and after various procedures involving interventions. The purpose of this report is to review the use of echocardiography to guide interventions. We provide information on the selection of patients for interventions, monitoring during the performance of interventions, and assessing the effects of interventions after their completion. In this document, we address the use of echocardiography in commonly performed procedures: transatrial septal catheterization, pericardiocentesis, myocardial biopsy, percutaneous transvenous balloon valvuloplasty, catheter closure of atrial septal defects (ASDs) and patent foramen ovale (PFO), alcohol septal ablation for hypertrophic cardiomyopathy, and cardiac electrophysiology. A concluding section addresses interventions that are presently investigational but are likely to enter the realm of practice in the very near future: complex mitral valve repairs, left atrial appendage (LAA) occlusion devices, 3-dimensional (3D) echocardiographic guidance, and percutaneous aortic valve replacement. The use of echocardiography to select and guide cardiac resynchronization therapy has recently been addressed in a separate document published by the American Society of Echocardiography and is not further discussed in this document. The use of imaging techniques to guide even well-established procedures enhances the efficiency and safety of these procedures.

Initial clinical experience with intracardiac echocardiography in guiding balloon mitral valvuloplasty: technique, safety, utility, and limitations

The objective of this study was to examine the feasibility and technique of intracardiac echocardiography during percutaneous balloon mitral valvuloplasty. Echocardiographic imaging is commonly used during mitral valvuloplasty. Intracardiac echocardiography is a newer technology that may provide superior imaging during complex valvular interventions. Intracardiac echocardiography and transthoracic echocardiography were performed in 19 patients undergoing percutaneous balloon mitral valvuloplasty. Intracardiac ultrasound images were obtained via the femoral vein in all patients. Imaging projections and catheter locations that were useful for the performance of mitral valvuloplasty were defined. Intracardiac echocardiography guided transseptal puncture, augmented the assessment of valve apparatus deformity, facilitated balloon positioning across the mitral valve, and permitted postprocedural valvular assessment including identification of mitral regurgitation with color Doppler. Intracardiac echocardiography provided essential imaging guidance and procedural monitoring during percutaneous mitral valvuloplasty.

The advantages of On-line transesophageal echocardiography guide during percutaneous balloon mitral valvuloplasty

The purpose of this study was to evaluate the potential advantages of on-line transesophageal echocardiography during percutaneous balloon mitral valvuloplasty (PBMV). One hundred thirty-four consecutive patients who underwent PBMV were included in this study. Group 1 included 64 patients who underwent PBMV under fluoroscopy guide only, and group 2 included 70 patients who underwent PBMV under on-line transesophageal echocardiography guide. Inoue balloons were used in all cases. The mitral valve area after valvuloplasty was comparable between the 2 groups. The procedure time was significantly shorter in group 2 (99 +/- 48 min vs 64 +/- 22 min, P <.0001 ), and the average fluoroscopy time was shorter in group 2 without statistical significance (30 +/- 17 min vs 19 +/- 15 min, P =.25 ). Five (7.8%) patients in group 1 and 2 (2.8%) patients in group 2 underwent surgery because of procedure-related complications. The limitation of this study was the learning curve of the operator, because the 2 groups were treated serially. In conclusion, transesophageal echocardiography can be used effectively during balloon mitral valvuloplasty, and it may help to reduce the rate of complications resulting from trans-septal catheterization and balloon valvuloplasty and to reduce procedure time and fluoroscopy time.

Utility of three-dimensional echocardiography during balloon mitral valvuloplasty

OBJECTIVES

We investigated the role of three-dimensional echocardiography in assessing mitral valve anatomy in greater detail in patients immediately before and after balloon mitral valvuloplasty (BMV).

BACKGROUND

Three-dimensional echocardiography is a recently developed, evolving imaging technique that allows visualization of intracardiac structures from any perspective.

METHODS

We studied 19 patients undergoing BMV using transesophageal echocardiography (TEE) (Chicago, Illinois) to image the mitral valve. The TEE was interfaced to a TomTec three-dimensional workstation that allows electrocardiographic and respiratory cycle gated image acquisition. The acquired images are digitized, and after postprocessing a three-dimensional image is reconstructed. The mitral valve was viewed "en-face" as if looking up from the left ventricle.

RESULTS

The mean mitral valve area (by pressure half-time from the Doppler of the two-dimensional echocardiogram) increased after BMV from 0.86+/-0.06 cm2 to 2.07+/-0.10 cm2, p < 0.0001. This was similar to the mitral valve areas obtained by planimetry from the three-dimensional images. The three-dimensional reconstructions showed a complete commissural split in 10 patients and partial splitting in 9 patients. In three of the eight patients who had an increase in the amount of mitral regurgitation secondary to BMV, the three-dimensional reconstructions were able to detect tears within the valve leaflet. One leaflet tear actually extended up to the mitral valve annulus and was associated with the only case of severe mitral regurgitation.

CONCLUSIONS

The three-dimensional echocardiographic reconstruction enabled visualization of the mitral valve so that commissural splitting and leaflet tears not seen on the two-dimensional echocardiogram became visible.

Valvular heart disease in pregnancy. A contemporary perspective

Valvular heart disease may have a significant impact on the course and outcome of pregnancy with implications for fetal as well as maternal health. Optimally, serious symptomatic valvular heart disease should be detected and treated before pregnancy. Whether a pregnant woman is known to have valvular heart disease or is diagnosed during pregnancy, it is imperative that she is managed by an experienced multidisciplinary team. Although medical therapy may alleviate symptoms of heart failure in some patients, definitive intervention either with percutaneous balloon valvuloplasty or with surgical valve replacement may be necessary.

Echocardiography in Percutaneous Balloon Mitral Valvuloplasty

Percutaneous balloon valvuloplasty (BV) has been used successfully in recent years for the relief of mitral stenosis, and in many instances, as an alternative to cardiac surgery. This procedure requires precise evaluation of both valve morphology and function for preprocedure decision making and follow-up of patients. Two-dimensional (2-D) echocardiography is a unique, noninvasive tool for evaluating morphologic characteristics of valve, subvalvular apparatus, and valve annular size. Doppler echocardiography provides functional information on transvalvular flow velocity, which can be used to derive pressure gradient across valve and regurgitant flow. Mitral valve area can be either obtained from 2-D echocardiography or derived from Doppler pressure half time. Echocardiography is currently the most widely used technique for assessing results of percutaneous BV. More recently, transesophageal echocardiography (TEE) has been used for the evaluation of patients undergoing percutaneous mitral BV in whom left atrial thrombus is suspected and for the intraoperative monitoring of the valvuloplasty procedure. In this article we discuss the advantages and limitations of both transthoracic echocardiography and TEE, its recent developments in monitoring the procedure, evaluation of immediate results and long term follow-up after the valvuloplasty procedure, and its clinical utility in the selection of patients for percutaneous BV.

On Line Echocardiography in Evaluating Left Atrial Changes in Acute Mitral Regurgitation and in Monitoring a Catheter-Mounted Balloon for its Correction

The purpose of this study was to evaluate changes in the left atrial size in acute mitral regurgitation (AMR) and monitor its correction by a catheter-mounted balloon (B). In 16 dogs, pressure changes in the left atrium (LA) were related to LA size and regurgitant mitral flow after the production of AMR by severing the mitral cusps. TEE was used for evaluating LA area (ALA) and the mitral regurgitation flow area (AMRF). TEE was also used in monitoring the position of a catheter-mounted B inserted through the LV apex and positioned on the mitral ring to relieve AMR. The B was inflated during systole and deflated during diastole. The ALA increased by 4.89 ± 1.21 cm2 (mean ± 1 SD) (p < 0.001) after AMR, the AMRF increased by 3.01 ± 0.85 cm2 (p < 0.001) and the mean atrial pressure (LAP) by 9.38 ± 2.43 mmHg (p < 0.001). In all experiments the position of the B could be confirmed in the 2D image and in 4 the reduction of AMRF by the function of the B was documented by the colour flow Doppler. It is concluded that after AMR the size of the LA increases along with the increase in LA pressure and a phasically inflated balloon and its effect on AMR can be easily identified and monitored by TEE.

Doppler echocardiographic evaluation of severe rheumatic submitral valve stenosis

The submitral apparatus may play a predominant role in rheumatic mitral stenosis and should be evaluated aggressively with Doppler echocardiography, especially in patients in whom percutaneous mitral balloon valvotomy is being considered. The following case presents a patient with rheumatic mitral valve stenosis in whom some noninvasive clues alerted us to the presence of predominant submitral stenosis.