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Mukhopadhyay S, Dwivedi Y, Yusuf J, Uppal A, Mehta V. Prevalence and predictors of left atrial appendage inactivity in patients of rheumatic mitral stenosis in sinus rhythm: An observational study. Echocardiography 2021; 38:1860-1869. [PMID: 34672389 DOI: 10.1111/echo.15223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Systemic thromboembolism is a known complication of rheumatic mitral stenosis (RMS) in sinus rhythm (SR). Left atrial appendage (LAA), the commonest site of thrombus formation is usually hypocontractile (inactive) in such patients. We aimed to study the prevalence of LAA inactivity (LAAI) in severe RMS and assess its independent predictors. METHODS The study population consisted of 100 patients of severe RMS in SR. Transthoracic and transesophageal echocardiography were done to assess LAA contractile function. Patients with LAA-peak emptying velocity < 25 cm/seconds were defined as having LAAI. RESULTS The mean age of study subjects was 31.66±8.69 years and 56% were females. 73% patients had LAAI (Group A), while remaining 27% had normal LAA function (Group B). Mitral-valve area (MVA) and lateral annulus systolic velocity (Sa-wave) were significantly lower while mitral valve mean gradient (MVMG) and serum fibrinogen were significantly higher (all p-values < 0.001) in group A patients. On multivariate binary logistic regression analysis, MVMG (p < 0.001), Sa-wave (p = 0.02), and serum fibrinogen (p = 0.005) were independent predictors of LAAI. Optimal cut-off values of MVMG, Sa-wave and serum fibrinogen for predicting LAAI were 11.5 mm Hg, 6.8 cm/seconds and 300 mg/dl, respectively. Sixty-Seven (90.55%) patients in group A compared to 13(48.1%) in group B had LA/LAA smoke. LAAI was the only independent predictor of left atrium (LA)/LAA smoke with or without associated thrombus. CONCLUSION There is high prevalence of LAAI in patients of severe MS in SR. MVMG, Sa-wave, and serum fibrinogen levels are independent predictors of LAAI. LAAI is an independent predictor of LA/LAA smoke with or without associated thrombus.
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Affiliation(s)
- Saibal Mukhopadhyay
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
| | - Yogesh Dwivedi
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
| | - Jamal Yusuf
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
| | - Abhimanyu Uppal
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
| | - Vimal Mehta
- Department of Cardiology, G.B. Pant Postgraduate Institute of Medical Research (GIPMER), New Delhi, India
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Babur Guler G, Dogan AC, Kalkan AK, Demir AR, Uygur B, Birant A, Zencirkiran Agus H, Pastore MC, Memiç K, Uzun F, Cameli M, Erturk M. Does patent foramen ovale presence procure favourable outcomes in patients with severe rheumatic mitral stenosis? Int J Cardiovasc Imaging 2021; 37:2871-2879. [PMID: 34109513 DOI: 10.1007/s10554-021-02257-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/26/2021] [Indexed: 11/29/2022]
Abstract
Mitral stenosis (MS) is tolerated for an extended period in patients with atrial septal defect (ASD) known as Lutembacher syndrome due to depressurizing effect. In a similar way, patients with patent foramen ovale (PFO) may have clinical benefits in severe MS. We aim to evaluate the clinical effects of PFO in rheumatic MS. Transthoracic and transesophageal echocardiography records of the patients with symptomatic severe MS were screened for the period between 2008 and 2019 in a single center. 320 symptomatic patients with severe MS were included and presence of PFO recorded. Left atrial appendix (LAA) thrombotic status was defined as clear, spontaneous echo contrast, and thrombus. Two different statistical models were used to determine the predictors of either smallest (mitral valve area) MVA at symptomatic presentation or more thrombogenic LAA. 34 patients had PFO. Multivariable ordinary least square model demonstrated that increase in systolic pulmonary arterial pressure, ejection fraction and presence of PFO were associated with smaller MVA on presentation. Multivariable proportional odds logistic regression model demonstrated that advanced age, increased left atrial diameter, absence of PFO were associated with more thrombotic status whereas larger MVA was associated with decreased thrombotic status in LAA. Presence of PFO in severe MS results in two clinical benefits as (i) being asymptomatic with smaller MVA and (ii) having less LAA thrombosis probably caused by depressurizing effect on the left atrial pressure. Our study could serve as an example for patient groups with expected symptomatic benefits from left atrium pressure offloading interventions.
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Affiliation(s)
- Gamze Babur Guler
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey.
| | - Arda Can Dogan
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Ali Kemal Kalkan
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Ali Rıza Demir
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Begum Uygur
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Ali Birant
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Hicaz Zencirkiran Agus
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Maria Concetta Pastore
- Department of Medical Biotecnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Kadriye Memiç
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Fatih Uzun
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
| | - Matteo Cameli
- Department of Medical Biotecnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Mehmet Erturk
- Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey
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Saji M, Ragosta M, Dent J, Lim DS. Use of intracardiac echocardiography to guide percutaneous transluminal mitral commissurotomy. Catheter Cardiovasc Interv 2015; 87:E69-74. [DOI: 10.1002/ccd.25943] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 03/14/2015] [Indexed: 11/09/2022]
Affiliation(s)
- Mike Saji
- Advanced Cardiac Valve Center; Department of Medicine; University of Virginia; Charlottesville Virginia
| | - Michael Ragosta
- Advanced Cardiac Valve Center; Department of Medicine; University of Virginia; Charlottesville Virginia
| | - John Dent
- Advanced Cardiac Valve Center; Department of Medicine; University of Virginia; Charlottesville Virginia
| | - D. Scott Lim
- Advanced Cardiac Valve Center; Department of Medicine; University of Virginia; Charlottesville Virginia
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Drissi S, Sabor H, Ounsy A, Mouine N, Sabry M, Benyass A, Zbir EM, Lassana K, Elhaithem N. Predictive factors of left atrial spontaneous echo contrast in patients with rheumatic mitral valve stenosis: a retrospective study of 159 patients. Int Arch Med 2014; 7:32. [PMID: 24995039 PMCID: PMC4081018 DOI: 10.1186/1755-7682-7-32] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 06/20/2014] [Indexed: 11/10/2022] Open
Abstract
Background Mitral valve stenosis is a common manifestation of chronic rheumatic heart disease. The presence of spontaneous echo contrast in the left atrium and left atrial appendage has been reported to be an independent predictor of thrombo-embolic risk in patients with mitral stenosis. The objective of this study was to retrospectively investigate various clinical and echocardiographic variables to predict the spontaneous echo contrast in these patients. Methodology This is a bicentric retrospective study which includes 159 cases of symptomatic mitral stenosis from January 2011 to June 2012. All of the patients had transthoracic and transesophageal echocardiography. Patients who had significant mitral regurgitation (> Grade I), significant aortic valve disease, previous mitral valvulotomy and anticoagulation or antiplatelet therapy were excluded from the study. Our study population was divided into two groups based on the presence (Group I) or absence (Group II) of spontaneous echo contrast. Result Left atrial spontaneous contrast was present in 34.6% of cases. Patients in this group have more frequent atrial fibrillation (P = 0.001), larger left atrial area (P = 0.027) and diameter (P=0.023), smaller mitral valve area (P = 0.025), and higher mean transmitral diastolic gradient (p = 0.003) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean age (p = 0.38), duration of symptoms (p = 0.4) and left ventricular ejection fraction (p = 0.7) between patients with and without spontaneous echo contrast. On multivariate analysis, only mitral valve area and transmitral diastolic gradient (OR: 18.753, 1.21, CI [1,838-191,332], [1,064-1,376], p: 0.013, 0.004, respectively) were found to be independently associated to the presence of spontaneous echo contrast. Conclusion Patients with severe rheumatic mitral stenosis in atrial fibrillation or sinus rhythm have a higher risk of developing spontaneous echo contrast. These patients might benefit from prophylactic anticoagulation. The long-term outcomes can be ascertained in a study over a longer period and with periodic follow-up.
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Affiliation(s)
- Sanaa Drissi
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco ; Department of Cardiology, Avicenne University Hospital, Rabat, Morocco
| | - Hicham Sabor
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Ahlam Ounsy
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco ; Department of Cardiology, Avicenne University Hospital, Rabat, Morocco
| | - Najat Mouine
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Mohamed Sabry
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Aatif Benyass
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - El Mehdi Zbir
- Department of Cardiology, Mohammed V Military Teaching Hospital, Rabat, Morocco
| | - Konate Lassana
- Department of Cardiology, Avicenne University Hospital, Rabat, Morocco
| | - Naima Elhaithem
- Department of Cardiology, Avicenne University Hospital, Rabat, Morocco
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Manjunath CN, Srinivasa KHS, Panneerselvam A, Prabhavathi B, Ravindranath KS, Rangan K, Dhanalakshmi C. Incidence and Predictors of Left Atrial Thrombus in Patients with Rheumatic Mitral Stenosis and Sinus Rhythm: A Transesophageal Echocardiographic Study. Echocardiography 2011; 28:457-60. [DOI: 10.1111/j.1540-8175.2010.01361.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Vaideeswar P, Pandit SP, Khandeparkar JMS. Left atrial tunnelled thrombus. Int J Cardiol 2005; 98:361-2. [PMID: 15686796 DOI: 10.1016/j.ijcard.2004.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2003] [Accepted: 01/07/2004] [Indexed: 10/26/2022]
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Goswami KC, Yadav R, Rao MB, Bahl VK, Talwar KK, Manchanda SC. Clinical and echocardiographic predictors of left atrial clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis: a prospective study in 200 patients by transesophageal echocardiography. Int J Cardiol 2000; 73:273-9. [PMID: 10841970 DOI: 10.1016/s0167-5273(00)00235-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The objective of this study was to prospectively investigate various clinical and echocardiographic variables to predict the left atrial and left atrial appendage clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis. We studied 200 consecutive patients (112 males and 88 females; mean age 29.6+/-9.6 years). Left atrial clot and spontaneous echo contrast were present in 26 and 53.5% of cases, respectively. There were no significant differences in the mitral valve area, mean transmitral diastolic gradient and left ventricular ejection fraction between patients with and without clot. Patients with clot were older (34.4+/-11.4 vs. 28.2+/-8.5 years, P<0.001), had longer duration of symptoms (41. 4+/-36.0 vs. 28.8+/-22.9 months, P<0.001), more frequent atrial fibrillation and spontaneous echo contrast (69.2 vs. 16.9%, P<0. 00001 and 76.9 vs. 45.3%, P<0.00001, respectively) and larger left atrial area and diameter (41.0+/-12.7 vs. 29.9+/-7.4 cm(2), P<0.00001 and 53.9+/-8.3 vs. 47.6+/-7.4 mm, P<0.0001, respectively) as compared to patients without clot. Similarly patients with spontaneous echo contrast were older (31+/-10.4 vs. 27.8+/-8.3 years, P<0.01), had more frequent atrial fibrillation (48.6 vs. 9.7%, P<0.0001), left atrial clot (37.4 vs. 12.9%, P<0.0001), larger left atrial area and diameter (37.6+/-11.2 vs. 28.1+/-6.7 cm(2), P<0.00001 and 52.2+/-8.3 vs. 45.9+/-6.5 mm, P<0.00001, respectively) and smaller mitral valve area (0.77+/-0.14 vs. 0.84+/-0.13 cm(2), P<0.01) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean transmitral diastolic gradient and left ventricular ejection fraction. On multiple regression and discriminant function analysis, atrial fibrillation and left atrial area were independent predictors of left atrial clot formation. In a subgroup of patients with sinus rhythm, larger left atrial area and presence of spontaneous echo contrast were significantly associated with the presence of clot in left atrium and appendage. We conclude that in patients with severe mitral stenosis, the presence of atrial fibrillation and in the subgroup of the patients with sinus rhythm the presence of large left atrium (> or =40 cm(2)) and spontaneous echo contrast were associated with higher risk of clot formation in the left atrium and might be benefited by prophylactic anticoagulation.
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Affiliation(s)
- K C Goswami
- Department of Cardiology, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, -110029, New Delhi, India
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Goswami KC, Bahl VK, Talwar KK, Shrivastava S, Manchanda SC. Percutaneous balloon mitral valvuloplasty using the Inoue balloon: analysis of echocardiographic and other variables related to immediate outcome. Int J Cardiol 1999; 68:261-8. [PMID: 10213276 DOI: 10.1016/s0167-5273(98)00371-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
To determine whether the mitral valve morphology influences the results of percutaneous balloon mitral valvuloplasty for mitral stenosis, two-dimensional echocardiography was performed before valvuloplasty in 126 patients (mean age 25.5+/-9.4 years) and in 30 normal controls. The 2D echocardiographic features of mitral valve leaflets: thickness, length and motion; diastolic mitral valvular excursion; chordal length; mitral annular diameter; subvalvular distance ratio; distance between mid mitral annulus to left ventricular apex, base and tip of papillary muscle and effective balloon dilating area, effective balloon dilating area/body surface area and effective balloon dilating diameter/mitral annular diameter were then correlated to the immediate post-valvuloplasty mitral valve area. For the total patients population, post-valvuloplasty valve area increased from 0.67+/-0.17 to 2.1+/-0.86 cm2 (P<0.0001), mean transmitral diastolic gradient decreased from 24.5+/-9.0 to 6.0+/-3.0 mm Hg (P<0.0001), mean left atrial pressure decreased from 29.7+/-6.2 to 12.7+/-4.8 mm Hg (P<0.0001), mean pulmonary artery pressure decreased from 44.8+/-14.2 to 25.4+/-9.5 mm Hg (P<0.0001) and cardiac index increased from 2.7+/-0.38 to 3.1+/-0.55 l/min/m2 (P<0.0001). The patients were divided into three groups on the basis of post-valvuloplasty mitral valve area. Group I had valve area <1.5 cm2, group II had valve area from 1.5 to 1.9 cm2 and group III had valve area > or =2.0 cm2. On comparison, no statistically significant difference was found in any of the echocardiographic variables in the three groups. On univariate, multivariate, multiple regression and discriminate function analysis, none of the variables were found to have significant influence on immediate result of valvuloplasty. There was no significant difference in the incidence of mitral regurgitation in any of the three groups. We conclude that the extent of mitral valvular and subvalvular deformity do not have a significant effect on the immediate outcome of mitral valvuloplasty using the Inoue balloon and it can be successfully performed in patients with severe subvalvular fibrosis. Unique balloon geometry and stepwise balloon sizing may explain these acceptable immediate results in severely deformed valves.
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Affiliation(s)
- K C Goswami
- Department of Cardiology, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi
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