CCCardiol CroatCardiologia CroaticaCardiol. Croat.1848-543X1848-5448Croatian Cardiac SocietyCC_12(4)_125-12610.15836/ccar2017.125Extended AbstractShould we rely on Doppler measurements in assessment of degenerative mitral stenosis?http://orcid.org/0000-0003-1762-9270OstojićZvonimirhttp://orcid.org/0000-0002-4721-3236LukšićVlatka Reškovićhttp://orcid.org/0000-0002-3437-6407HanževačkiJadranka ŠeparovićUniversity of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, CroatiaAddress for correspondence: Zvonimir Ostojić, Klinički bolnički centar Zagreb, Kišpatićeva 12, HR-10000 Zagreb, Croatia. / Phone: +385-91-895-0702 / E-mail: ostojiczvonimir@gmail.com04201712412512611032017060420172017Croatian Cardiac SocietyKeywords: mitral stenosisDoppler echocardiography3D echocardiography
Introduction: Compared to rheumatic mitral stenosis (RMS), degenerative mitral stenosis (DMS) is usually described as less sever. For the severity assessment echocardiographic Doppler parameters are often used, despite the well known possibility of DMS severity underestimation due to the influence myocardial diastolic function and concomitant valve patohlogy. (1, 2) The aim of this study was to compare severity of DMS compared to RMS and to determine whether Doppler parameters underestimate severity of DMS compared to other echocardiographic measurements.
Methods: We preformed a single center, retrospective, observational study including all patients who were diagnosed with mitral stenosis in past three years. Data were reanalyzed using fully digital echocardiographic database and hospital charts. Mitral stenosis (MS) was defined as turbulent flow with mean diastolic gradient >2 mmHg across mitral valve (MV) in conjunction with morphologic changes. In patients who had 3D examinations made, mitral valve area (MVA) was calculated according to pressure half time (PHT), continuity equation, 3D transthoracic echocardiography, and 3D transoesophageal echocardiography.
Results: Patients with DMS (N=38, female N=23; 60.5%) compared to patients with RMS were significantly older (80±9.4 vs. 67±7.1; p<0.001), with more pronounced risk factors for worse cardiovascular outcome (more hyperlipidemia, worse renal function, and coronary artery disease). Patients with RMS (N=47) had significantly higher rate of atrial fibrillation (47 vs. 35%; p=0.005). According to echocardiographic data patients with DMS had significantly higher left ventricular mass and increased relative wall thickness. They also had more sever and pronounced mitral annular calcification spread to both cusps. Patients with RMS had significantly larger left atrium area (LAA). In line with degenerative process, significant aortic stenosis (AS), defined to be at least moderate in severity, was more common in DMS group with no significant difference in other concomitant valve pathology (Table 1). Total 35 patients had MVA assessed using 3D planimetry. There was a significant difference in MVA when measured by PHT according to other methods irrespectively of MS etiology. In all cases MS was underestimated by PHT (Table 2).
Echocardiographic findings depending on etiology of mitral stenosis.
Degenerative
Rheumatic
P
IVSd (cm)1
1.38±0.35
1.14±0.25
<0.001
LVIDd (cm)2
4.93±0.68
5.06±0.59
0.36
LVPWd (cm)3
1.22±0.30
1.02±0.21
<0.001
Left ventricular mass (g)
267.37±89.11
212.14±58.46
<0.001
Relative wall thickness
0.51±0.15
0.41±0.1
<0.001
Ejection fraction
56±8
55±7.6
0.58
Mitral annular calcification4
2.45
1.46
<0.001
Mean pressure gradient
5.89±2.91
7.9±4.8
0.02
Maximal pressure gradient
14.21±5.4
18±8.3
0.01
MVA PHT5
1.92±0.76
1.55±0.38
0.02
MVA VTI6
1.26
1.26
0.07
LAA7
34.24±7.6
42.77±17.23
0.004
MI ≥28
11 (29%)
20 (42%)
0.19
AS ≥29
30 (79%)
15 (32%)
<0.001
AI ≥210
5 (13%)
10 (21%)
0.32
TI ≥211
8 (21%)
16 (34%)
0.18
PH12
48±18
55±22
0.2
TAPSE13
17.8±4.8
17.7±5.3
0.9
1Intraventricular septal width in diastole; 2Left ventricle internal dimension in diastole; 3Left ventricle posterior wall width in diastole; 4Mitral annulus calcification: 1- annular calcification; 2- calcification extend <1/2 of mitral cusp; 3- calcification extend >1/2 of mitral cusp; 5Mitral valve area calculated using pressure half time; 6Mitral valve area calculated using velocity time integral; 7Left atrium area; 8Mitral insufficiency at least moderate in severity; 9Aortic stenosis at least moderate in severity; 10Aortic insufficiency at least moderate in severity; 11Tricuspid insufficiency at least moderate in severity; 12Systolic pressure in pulmonary artery; 13Tricuspid annular plane systolic excursion.
Comparison of calculated mitral valve area with different echocardiographic methods.
Conclusion: As expected, patients with DMS are older, with higher rate of comorbidities and higher prevalence of significant AS. On the other hand, patients with RMS had larger LAA and more often AF. Our results indicate that Doppler assessment of MS, using PHT, significantly underestimates severity of MS in DMS patients when compared with other methods, especially 3D planimetry. Furthermore, the same observations are described in our group of patients with RMS. In our opinion, cause of misleading PHT measurement might be of different cause between groups, but this requires further studies.
LiteratureOktayAAGillilandYELavieCJRameeSJParrinoPEBatesMEchocardiographic Assessment of Degenerative Mitral Stenosis: A Diagnostic Challenge of an Emerging Cardiac Disease.Curr Probl Cardiol. 2017 Mar;42(3):71–100. 10.1016/j.cpcardiol.2017.01.00228232004PascaIDangPTyagiGPaiRG. Survival in Patients with Degenerative Mitral Stenosis: Results from a Large Retrospective Cohort Study.J Am Soc Echocardiogr. 2016 May;29(5):461–9. 10.1016/j.echo.2015.12.01226936152