Prognostic Role of Preoperative Tricuspid Annular Plane Systolic Excursion (TAPSE) in Mitral Valve Replacement (MVR) for Rheumatic Mitral Stenosis Patients

Tricuspid annular plane systolic excursion has been proposed as a simple and reproducible parameter for quantitative assessment of the right ventricular ejection fraction. The prognostic importance of preoperative TAPSE in patients with mitral valve replacement for rheumatic mitral stenosis patients is still under focused. Therefore, the objective of the study was to predict the outcome after MVR in rheumatic mitral stenosis patients in relation to preoperative TAPSE. This comparative cross-sectional study was conducted at the Department of Cardiac Surgery, National Heart Foundation Hospital and Research Institute. A total of 72 patients of rheumatic mitral stenosis patients who underwent mitral valve replacement were included in the study. They were divided into two groups: Group A and B. Group A included 36 patients with TAPSE 0.05) except for the preoperative TAPSE. Mean TAPSE of Group A was 13.17 (±1.40) and Group B was 18.61 (±1.57), the difference was statistically significant (p 0.05). Among the postoperative complications, including postoperative atrial fibrillation was higher in Group A (30.56%) than Group B (11.11%), mean ventilation time was higher in Group A (27.78%) than Group B (5.56%), length of intensive care was higher in Group A (33.33%) than Group B (11.12%), and hospital stay was higher in Group A (25.0%) than Group B (5.56%), (p < 0.05). Higher preoperative TASPE could be used as a prognostic tool for MVR in rheumatic mitral stenosis patients in our settings.

Primary Left Atrial Intimal Sarcoma Disguised as Functional Mitral Stenosis: A Case Study

A 66-year-old female with a 1-month history of increasing fatigue, dyspnea on exertion, and palpitations presented with clinical signs of heart failure. Chest computed tomography (CT) revealed a large, mobile left atrial (LA) mass attached to the mitral valve causing severe mitral stenosis and mitral regurgitation. The mass was surgically debulked and the mitral valve was replaced. Pathology revealed a poorly differentiated malignant spindle cell neoplasm with diffuse nuclear positivity of MDM2 and multifocal positivity of CDK4, consistent with intimal sarcoma. This case seeks to describe an uncommon presentation of a rare malignancy, and the surgical and medical management of the disease.

CHANGES OF PLASMA DYNORPHIN LEVELS BEFORE AND AFTER PERCUTANEOUS BALLOON MITRAL COMMISSUROTOMY IN PATIENTS WITH MITRAL STENOSIS

Plasma dynorphin A1-13 levels were measured in 33 patients with mitral stenosis before and after percutaneous balloon mitral commissurotomy (PBMC). The results show that the basal levels of plasma dynorphin in blood from the antecubital vein in the patients were significantly higher than those in 31 healthy control subjects. The increase in circulating dynorphin closely correlated with the functional cardiac status and the presence of atrial fibrillation. Ten to fifteen minutes after PBMC, plasma dynorphin levels in blood from the femoral vein increased significantly. Seventy-two hours after the procedure, the levels of plasma dynorphin in blood from the antecubital vein had decreased significantly , but they did not decrease to the normal range. Plasma dynorphin levels in blood from the femoral vein were positively correlated with the mean left atrial pressure and the mean right atrial pressure before the first balloon inflation. Plasma dynorphin levels in blood from the antecubital vein were positively correlated with the heart rate and the mean transmitral pressure gradient, and negatively with the mitral valve area before and 72 hours after PBMC.

Rheumatic Aortic Valve Disease with Mitral Stenosis—A Case Report

Congenitally malformed aortic valves are more susceptible to valve injury due to rheumatic fever, mechanical stress of altered flow patterns, atherosclerotic risk factors and degenerative changes. Rheumatic involvement usually occurs in childhood and it is progressive leading to diffuse thickening and fibrosis at leaflet edges and thus differentiated from other patterns of valve damage. Background of this case report revealed the bicuspid nature of the aortic valve due to rheumatic commissural fusion and analysis of echocardiographic parameters in combined lesions of both aortic and mitral valves with severe LV (left ventricular) dysfunction. Left ventricular (LV) and left atrial (LA) dilations predisposing to the formation of smoke (SEC-spontaneous echo contrast) in LV and LA as a consequence of mitral and aortic valve disease are illustrated by 2D echocardiographic imaging in this 41-year-old male.

Effect of rheumatic mitral stenosis on end-diastolic volume of left ventricle

Objective To investigate the relations between the pathological contraction of the valve and sub-valvular apparatus in rheumatic mitral stenosis and end-diastolic volume of left ventricle. Method From 1990-2004, 90 patients with only moderate or severe rheumatic mitral stenosis （mitral group）, and 24 patients with combined moderate or severe rheumatic mitral stenosis and significant aortic regurgitation （ combined valves group）, diagnostically confirmed by surgery and pathology, were measured using echocardiaogram the end-diastolic volume and diameter, stroke volume and ejection fraction of left ventricle. Result Compared with mitral group combined valves group showed slight increases of end-diastolic volume and diameter （116.49 ± 37.93 ml and 136.72±70.67 ml, respectively; 49.34 ± 6.71 mm and 51.08 ± 8.32 mm, respectively; both P 〈 0.05）, and slight decreases of ejection fraction, but significant increases of stroke volume （71.37 ± 25.01 ml and 91.06 ± 36.67 ml, respectively; P〈0.05） of left ventricle. Conclusion The pathological shortening of mitral valve and sub-valvular apparatus caused by long-term rheumatic disease is the main cause of decreased left ventricular volume in mitral stenosis.

Analysis of risk factors for left atrial thrombosis in patients with rheumatic mitral stenosis

Objective To analyse the risk factors for left atrial thrombosis in patients with rheumatic mitral stenosis. Methods From January 2001 to December 2008,2277 patients with rheumatic mitral stenosis underwent operations in our hospital. There were 737 males and 1540 females,the age ranged from 19 to 84 years [average (50.9 ±10.2) years]. Left atrial thrombosis group

CHANGES OF PLASMA ENDOTHELIN CONCENTRATIONS BEFORE AND AFTER PERCUTANEOUS BALLOON MITRAL VALVULOPLASTY IN PATIENTS WITH MITRAL STENOSIS

Plasma concentrations of endothelin in bloor from the femoral vein and the antecubital vein were measured in 35 patients with mitral stenosis and heart failure before and after percutaneous balloon mitralvalvuloplasty(PBMV). The basal plasma concentrations of endothelin in blood from the antecubirtal vein in the patients were significantly higher than those in 32 control subjects (15. 40± 3. 32 vs. 9. 59± 2. 66 pg/ml, P<0. 001). Plasma endothelin concentrations in patients in New York Heart Association functional classes Ⅱ and Ⅲ were significantly higher than those in control subjects, respectively. The concentrations of endothelin in patients with atrial fibrillation were also significantly higher than those in patients with normal sinus rhythm. Ten to fifteen minutes after PBMV, plasma endothelin concentrations in blood from the femoral vein significantly decreased from 16. 14 ± 3. 34 to 13. 74 ± 3. 78 pg/ml (P<0. 01 ). Seventy-two hours after the procedure, the concentrations of endothelin in blood from the antecubital vein had fallen to 12. 31 ± 2. 55 pg/ml (P<0. 001 vs. before PBMV and control subjects). Plasma endothelin concentrations still tended to be higher in patients with atrial fibrillation than those in normal sinus rhythm, but the difference did not reach statistical significance. There were weak but significantly correlations of plasma endothe lin concentrations with the mean left atrial pressure (r= 0. 424 , P < 0.001 ), mean right atrial pressure (r=0. 323, P<0. 01), mean transmitral pressure gradient (r= 0. 397, P<0. 001), heart rate (r= 0. 350,P<0. 005)and mitral valve area (r=-0. 454, P<0. 001) in the patients before and after PBMV.

Application of Percutaneous Balloon Mitral Valvuloplasty in Patients of Rheumatic Heart Disease Mitral Stenosis Combined with Tricuspid Regurgitation

Background： Tricuspid regurgitation （TR） is frequently associated with severe mitral stenosis （MS）, the importance of significant TR was often neglected. However, TR influences the outcome of patients. The aim of this study was to investigate the efficacy and safety of percutaneous balloon mitral valvuloplasty （PBMV） procedure in rheumatic heart disease patients with mitral valve （MV） stenosis and tricuspid valve regurgitation. Methods： Two hundred and twenty patients were enrolled in this study due to rheumatic heart disease with MS combined with TR. Mitral balloon catheter made in China was used to expand MV. The following parameters were measured before and after PBMV： MV area （MVA）, TR area （TRA）, atrial pressure and diameter, and pulmonary artery pressure （PAP）. The patients were followed for 6 months to 9 years. Results： After PBMV, the MVAs increased significantly （1.7 ± 0.3 cm2 vs. 0.9 ± 0.3 cm2, P 〈 0.01）; TRA significantly decreased （6.3 ± 1.7 cm2 vs. 14.2 ± 6.5 cm2, P 〈 0.01）, right atrial area （RAA） decreased significantly （21,5 ± 4.5 cm2 vs. 25.4 ± 4.3 cm〈 P 〈 0.05）, TRA/RAA （%） decreased significantly （29.3 ± 3.2% vs. 44.2 ± 3.6%, P 〈 0.01）. TR velocity （TRV） and TR continue time （TRT） as well as TRV - TRT decreased significantly （ 183.4± 9.4 cm/s vs. 254.5 ± 10.7 cm/s, P 〈 0.01 ; 185.7 ± 13.6 ms vs. 238.6 ±l 1.3 ms, P 〈 0.01 ; 34.2 ±5.6 cm vs. 60.7 ± 8.5 cm, P 〈 0.01, respectively）, The postoperative left atrial diameter （LAD） significantly reduced （41.3 ± 6.2 mm vs. 49.8± 6.8 mm, P 〈 0.01） and the postoperative right atrial diameter （RAD） significantly reduced （28.7 ±5.6 mm vs. 46.5 ± 6.3 mm, P 〈 0.01 ）; the postoperative left atrium pressure significantly reduced （ 15.6 ± 6.1 mmHg vs. 26.5 ± 6.6 mmHg, P 〈 0.01 ）, the postoperative right atrial pressure decreased significantly （ 13.2 ±2.4 mmHg vs. 18.5 ±4.3 mmHg, P 〈 0.01 ）. The pulmonary arterial pressure decreased significantly after PBMV （48.2 ± 10.3 mmHg vs. 60.6 ±15.5 mmHg, P 〈 0.01）. The symptom of chest tightness and short of breath obviously alleviated. All cases followed-up for 6 months to 9 years （average 75± 32 months）, 2 patients with severe regurgitation died （1 case of massive cerebral infarction, and 1 case of heart failure after 6 years and 8 years, respectively）, 2 cases lost access. At the end of follow-up, MVA has been reduced compared with the postoperative （1.4 ± 0.4 cm2 vs. 1.7 ±0.3 cm2, P 〈 0.05）; LAD slightly increased compared with the postoperative （45.2 ± 5.7 mm vs. 41.4 ± 6.3 mm, P 〈 0.05）, RAD slightly also increased compared with the postoperative （36.1 ± 6.3 mm vs. 28.6 ± 5.5 mm, P 〈 0.05）, but did not recover to the preoperative level. TRA slightly increased compared with the postoperative, but the difference was not statistically significant （P 〉 0.05）. The PAP and left ventricular ejection fraction appeared no statistical difference compared with the postoperative （P 〉 0.05）, the remaining patients without serious complications. Conclusions： PBMV is a safe and effective procedure for MS combined with TR in patients of rheumatic heart disease. It can alleviate the symptoms and reduce the size of TR. It can also improve the quality-of-life and prognosis. Its recent and mid-term efficacy is certain. While its long-term efficacy remains to be observed.

Mitral pseudostenosis due to a large left atrial myxoma

Myxomas are benign cardiac tumours that are mostly （75%） located in the left atrium, but they also can be found in the right atrium （15%-20%）, in the right ventricle （4%） and in the left ventricle （3%）.

CHANGES OF PLASMA BETA-ENDORPHIN LEVELS BEFORE AND AFTER PERCUTANEOUS TRANSVENOUS MITRAL COMMISSUROTOMY IN PATIENTS WITH MITRAL STENOSIS

To clarify the contribution of left atrial pressure to the secretion of beta-endorphin, we have investigated the relation between plasma beta endorphin levels and hemodynamic changes in 35 patients with mitral stenosis undergoing percutaneous transvenous mitral commissurotomy (PTMC). Before PTMC, plasma beta-endorphin levels obtained from the antecubital vein (28.91 ± 5.59 pg / ml) and from the femoral vein (28.20 ± 5.44 pg / ml) in the patients with mitral stenosis were significantly higher than those obtained from the antecubital vein in the healthy volunteers (22.59 ± 3.86 pg / ml, n = 34, P< 0.001 for each). The levels of beta-endorphin in the femoral vein correlated well with the mean left atrial pressure (r=0.777, P< 0.001) and the mean right atrial pressure (r = 0.450, P<0.01) before the procedure. The antecubital venous levels of beta-endorphin in patients in New York Heart Association functional Classess Ⅱ (26.45 ± 5.39 pg / ml, n = 20) and Ⅲ (32.20 ± 4.02 pg / ml, n = 15) were significantly higher than those in control subjects (P< 0.005 and P< 0.001, respectively). The differences between Classes Ⅱ and Ⅲ were significant (P < 0.001). The plasma levels of beta-endorphin in the patients complicated with atrial fibrillation were also significantly higher than those in patients with normal sinus rhythm (33.31 ± 3.22 pg / ml, n= 13 vs 26.32± 5.07 pg / ml, n = 22, P< 0.001). In ten to fifteen minutes after commissurotomy, plasma levels of beta-endorphin in the femoral vein significantly increased from 28.20 ± 5.44 to 33.14 ± 5.72 pg / ml (P< 0.001). In seventy-two hours after the procedure, plasma beta-endorphin levels in the antecubital vein fell to 24.37 ± 2.59 pg / ml (P< 0.001 vs before PTMC and P<0.05 vs control subjects). Plasma beta-endorphin levels in the patients with atrial fibrillation (26.62 ± 2.36 pg / ml, P< 0.001 vs before PTMC and P< 0.002 vs control subjects) were still higher (P< 0.001) than those in patients with normal shins rhythm (23.05 ± 1.65 pg / ml, P< 0.001 vs before PTMC and P>50 vs control subjects. There was a significant correlation between the levels of beta-endorphin in the antecubital vein and heart rate (r = 0.502, P< 0.001), mean transmitral pressure gradient (r = 0.543, P< 0.001) or mitral valve area (r = -0.710, P< 0.001) before and 72 hours after the procedure.

Effect of Dauricine on Redistribution of Glycoprotein Ⅳ in Platelet Membrane of Patients with Mitral Stenosis

Objective: To investigate the effect of dauricine on the irreversible platelet aggregability of patients with mitral stenosis (MS).Methods: Glycoprotein Ⅳ (GPⅣ ) and thrombospondin (TSP) levels on the membrane surface of the stationary platelet or platelet activated by thrombin (0. 05 U/ml, 0. 1 U/ml,0. 5 U/ml, 1. 0 U/ml) in 16 patients with MS were measured with flow cytometric method and compared with those of the healthy (14 subjects). Results: The GPⅣ level of stationary platelet, the GPⅣ and TSP level of activated platelet in MS patients were higher than those in the healthy significantly (P < 0. 01,< 0. 05, < 0. 005 ), while the TSP level of stationary platelet in the patients was not different to the healthy (P > 0. 05). The GPⅣ redistribution on the activated platelet surface was apparently inhibited by dauricine (50 μmol/L, P < 0. 05 - 0. 005) and the release of TSP from intracellular α-granules was inhibited by dauricine only in the activated platelets induced by thrombin of low concentration (0. 05 U/ml and 0. 1 U/ml, P < 0. 05 - 0. 01 ), inhibiting effect was not found in those activated with high concentration of thrombin. Conclusion: The activity and reactivity to thrombin of platelets increased in MS patients, and dauricine was able to reduce the occurrence of the irreversible platelet aggregation in MS patients.Original article on CJIM(Chin) 1998; 18(8): 461

Assessment of the Outcome of Severe Mitral Stenosis during Late Pregnancy

Objectives Percutaneous balloon mitral valvuloplasty (PBMV) is one way to improve the rheumatic mitral stenosis. How does the procedure work in gravida and fetus is not very clear. We analyzed the effects and safety of PBMV operation on pregnant patients with severe rheumatic mitral stenosis. Methods Eight pregnant patients suffering from severe mitral stenosis underwent facilitated PBMV operation with Inoue balloon, and were followed up for (2.0±1.1) years. Contents included outcome of pregnancy, infant growth, hemodynamics, echocardiography, cardiac function, mitral valves replacement or repeat valvuloplasty. Results Mitral valve area (MVA) before, one week and one year after facilitated PBMV were (0.84±0.21) cm2, (1.69±0.23) cm2 and (1.51±0.24) cm2 respectively. The transmitral pressure gradient dropped from (22.1±4.7) mm Hg to (9.9±3.1) mm Hg (P<0.001) (1 mm Hg=0.133 kPa). After facilitated PBMV, all patients showed remarkable immediate symptomatic and hemodynamic improvement without severe mitral regurgitation. All of these patients could maintain New York heart association (NYHA) Ⅰ or Ⅱ for (2. 0±1.1) years after the operation. Two patients demanded induced abortion concerning about the teratogenic effect of X-ray on fetus. All the other six patients continued their gestation and had full-term cesarean section without complications. Their newborns developed healthy and normally till now. Conclusions Facilitated PBMV is a feasible, safe and effective device for selected pregnant patients with mitral stenosis. The operation is well tolerated by the fetus.

Anesthesia for pregnant women with Mitral stenosis

Background Rheumatic heart disease is still a major heart problem associated with pregnancy in south China, despite its declining trend. The mortality and morbidity are considerably reduced1 by better perinatal care, where the anesthesiologist plays a major role in the multidisciplinary approach. Nevertheless, in wealthy nation, rheumatic disease has become uncommon and complex congenital heart disease is increasing in the recent decades. With the advent of intensive obstetric and anesthetic care, the death rate of pregnant women with heart disease is lower in mitral stenosis compared with other congenital heart diseases like Eisenmenger＇s syndrome, pulmonary vascular obstructive disease and Marfan＇s syndrome with aortopathy2. Although mitral stenosis is often associated with mitral regurgitation, morbidity is usually related to mitral stenosis3.

Hypercoagulability existing in the local left atrium of patient with mitral stenosis

Objective To investigate the pathogenesis of thromboembolism in patients with mitral stenosis in a pre-thrombotic state.Methods The biochemical markers’ levels in plasma for platelet activity [soluble P-selectin (GMP-140)],states of thrombin generation [antithrombin Ⅲ (AT Ⅲ) and protein C (PC)],fibrinolysis [D-dimer (DD), plasminogen activator inhibitor 1 (PAI-1),tissue plasminogen activator (t-PA) and FDP] and von Willebrand factor (vWF) were determined from blood specimens obtained from the femoral veins and arteries and the right and left atria of 43 consecutive patients (20 with atrial fibrillation and 23 with sinus rhythm) with mitral stenosis (MS),undergoing percutaneous mitral valvuloplasty. The same parameters were compared with those of 15 control subjects,who had no detectable heart disease,but with paroxysmal supraventricular tachycardia undergoing radiofrequency catheter ablation of the left accessory pathway through a transseptal passage. Results Blood from the left atrium contained an excessive amount of platelet activity,thrombin generation and fibrinolysis compared with the blood from the right atrium,and the femoral veins and arteries. However blood from the right atrium was much lower in these activities when compared with those from the left atrium,and the femoral veins and arteries in both groups. Compared with those in the control subjects, GMP-140 in the left atrium was significantly higher ( P <0.05) and AT Ⅲ was significantly lower ( P <0.05) in patients with MS. Compared with the patients with MS and spontaneous left atrial echocontrast (LASEC)≤1,the patients with MS and LASEC≥2 had significantly higher levels of GMP-140 in plasma ( P <0.05),and significantly lower levels of AT Ⅲ ( P <0.05) and PC ( P <0.01) levels in the left atrium. However, there were no significant differences between patients with atrial fibrillation and those with sinus rhythm regarding amounts of plasma coagulation markers in the left atrium. Univariate regression analysis revealed that LASEC was negatively correlated with plasma levels of blood from the left atria in the patients with MS. Conclusion Coagulability is increased in the left atria of patients with MS and is positively correlated with LASEC.

Left atrial appendage flow velocity in rheumatic mitral stenosis

The left atrial appendage ( LAA ) has been considered a relatively insignificant portion of the cardiac anatomy. Because thrombi have been found to have a predilection to form within the LAA, a better understanding of the LAA is necessary. Transesophageal echocardiography (TEE) is a technique that makes clear imaging of the

Assessment of right ventricular function for patients with rheumatic mitral stenosis by 64-slice multi-detector row computed tomography： comparison with magnetic resonance imaging

Background Right ventricular （RV） dysfunction ensues due to rheumatic mitral stenosis （RMS）. The evaluation of RV function is clinically important for the diagnosis, treatment, and follow-up for patients with different degrees of RMS. The purpose of this study was to determine whether the 64-slice multi-detector row computed tomography （64-slice MDCT） can assess the RV function in RMS with high accuracy and reproducibility when compared to MR imaging （MRI）. Methods Right ventricular end-diastolic and end-systolic volumes （RV-EDV and RV-ESV）, stroke volume （RV-SV）, ejection fraction （RV-EF）, cardiac output （RV-CO）, and wall mass （RV-Mass） were measured with dedicated cardiac analysis software on 64-slice MDCT and compared with values measured with MRI in 43 consecutive patients with RMS. Agreement between MRI and 64-MDCT results were compared with Bland and Altman analysis and linear regression analysis. Repeated measurements were performed to determine intraobserver and interobserver variability. Results No significant differences were revealed in calculated RV function parameters between the two methods. RV-EDV, RV-ESV, RV-SV, RV-EF, RV-CO, and RV-Mass by 64-slice MDCT were similar to those by MRI （P〉0.05）. There were good correlations （r=0.98, 0.97, 0.96, 0.96, 0.95 and 0.77, respectively） and close agreement （bias=-0.2 ml, -1.0 ml, 0.8 ml, 0.5%, 26.1 ml, and 0.5 g, respectively, P〉0.05）. The variability in 64-slice MDCT measurements was similar to that in MRI values. Conclusion ECG-gated 64-slice MDCT could assess the RV function in RMS with high accuracy and reproducibility when com~）ared to MRI.

CC-chemokine receptor 7 and its ligand CCL 19 promote mitral valve interstitial cell migration and repair

The effect of CC-chemokine receptor 7 （CCR7） and CC-chemokine ligand 19 （CCL19） on rheumatic mitral ste- nosis is unknown. This study aimed to explore the roles of CCR7 and CCL19 in rheumatic mitral stenosis by mea- suring the expression of CCR7 and CCL19 in human mitral valves from rheumatic mitral stenosis patients. Additionally, we examined their effects on human mitral valve interstitial cells （hMVICs） proliferation, apoptosis and wound repair. CCR7 and CCL19 expression was measured in the mitral valves from rheumatic mitral stenosis patients （n= 10） and compared to normal mitral valves （n=5）. CCR7 was measured in cultured hMVICs from rheu- matic mitral stenosis patients and normal donors by RT-PCR and immunofluorescence. The cells were also treated with exogenous CCL19, and the effects on wound healing, proliferation and apoptosis were assayed. In the rheu- matic mitral valves, valve interstitial cells expressed CCR7, while mononuclear cells and the endothelium expressed CCL19. Healthy mitral valves did not stain positive for CCR7 or CCL19. CCR7 was also detected in cultured rheu- matic hMVICs or in normal hMVICs treated with CCL19. In a wound healing experiment, wound closure rates of both rheumatic and normal hMVICs were significantly accelerated by CCL19. These effects were abrogated by a CCR7 neutralizing antibody. The CCR7/CCL19 axis did not influence the proliferation or apoptosis of hMVICs, indicating that wound healing was due to increased migration rates rather than increased proliferation. In conclu- sion, CCR7 and CCL19 were expressed in rheumatic mitral valves. The CCR7/CCL19 axis may regulate remodel- ing of rheumatic valve injury through promoting migratory ability of hMVICs.

Predictors of Complications during Percutaneous Multitrack Balloon Mitral Valvuloplasty

Background: Percutaneous mitral balloon valvuloplasty is the main procedure in mitral stenosis (MS). It can replace surgical commissurotomy in many cases;however, mitral regurgitation (MR) remains the major procedure complication. Objectives: This study was conducted to investigate predictors of MR as a complication followingpercutaneous mitral valvuloplasty (PMV) using multitrack balloon technique. Methods: This cohort study was conducted at both Menoufia University Hospital and Mabaret Misr Elkadima Hospital. We enrolled 121 patients with moderate to severe MS who were subjected to PMV using multitrack balloon technique during the period from October 2017 to October 2019. Transthoracic echocardiographic evaluation was performed for all patients before and after the procedure. Patients who developed severe MR post procedure were compared with other patients to identify important distinction points. Results: Most patients (N = 109, 90.1%) developed no/mild MR (group A), whereas 12 (9.9%) patients developed severe MR (group B) after PMV. Those who developed severe MR had significantly higher weight, height, body mass index, and body surface area (P value < 0.001 for each). Also, there was a significant difference between both groups regarding pre-operative Wilkins score (8.7 ± 1.3 for severe MR versus 7.9 ± 1.2 for No/Mild MR, P = 0.046). Patients who developed severe MR had higher incidence of other valvular lesions such as mild aortic regurgitation (91.7% versus 36.7%, P < 0.001), higher mitral valve (MV) commissural calcification (50.0% versus 14.7%, P = 0.008), pre-operative MR (100.0% versus 35.8%, P < 0.001), higher prevalence of atrial fibrillation (100.0% versus 38.5%, P < 0.001). Regarding balloon sizing, it was significantly higher among patients who developed severe MR compared with those having mild or no MR (P = 0.001). Multivariate regression analysis identified MV balloon sizing (OR 3.877, CI 95% 1.131 - 13.289, P = 0.031) and MV commissural asymmetry of calcification (OR 67.48, CI 95% 5.759 - 790.72, P = 0.001) as significant predictors of outcomes of MV commissurotomy. Conclusion: Mitral valve calcification, balloon sizing, and MV asymmetry are significant factors that can predict the development of MR after balloon valvuloplasty.

Rheumatic Mitral Valvulitis with a “Giant Vegetation”—A Case Report

Infective endocarditis (IE) is the infection of inner endothelial layer of the heart including the heart valves and it may present as rapidly progressive or manifest itself as subacute or chronic disease. The epidemiology of infective endocarditis has been changed over the past few decades and the incidence of IE in children in United States and Canada is 1 in 1250 pediatric hospital admissions in the early 1980s. At least 70% of infective endocarditis in children occurs with congenital heart disease whereas rheumatic heart disease in southern states of India and the degenerative mitral valve disease (myxomatous, mitral valve prolapse) in the western countries are the most underlying predisposing conditions to infective endocarditis in adolescents. The characteristic lesion of infective endocarditis is “vegetation” and a “large” vegetation >10 mm in size has been reported with an incidence of 15.9% - 62.5% in patients. The significance of vegetation size has been a subject of discussion for many years to predict the embolic episodes. Background of this case study illustrated the varying size and shape of giant vegetation attached to the anterior leaflet of mitral valve in an underlying rheumatic mitral valvulitis and its consequence of valve damage such as chordal rupture, flail leaflet and mitral regurgitation with a description of anatomic features and echocardiographic manifestations in a 10-year-old female child.

Assessment of mitral valve reserve capacity before and after percutaneous balloon valvuloplasty with isoproterenol stress echocardiography

Objective: To explore whether successful valvuloplasty increases mitral valve reserve capacity in patients with mitral stenosis. Methods: Thirty-eight patients with pure rheumatic mitral stenosis underwent isoproterenol stress echocardiography before and after successful percutaneous balloon valvuloplasty. The mitral valve area (by direct planimetry of two-dimensional echocardiography), mean transmitral pressure gradient (by continuous-wave Doppler echocardiography), and cardiac output (by M-mode echocardiography) were measured at rest and under isoproterenol infusion to achieve heart rate of different stages. Results:Between the measurements before and after valvuloplasty, significant differences were observed in the mitral valve area (0. 91±0. 28 vs 1. 87±0. 23 cm2, P<0. 01), mean transmitral pressure gradient (12. 5±6. 3 vs 3. 9±1. 9 mmHg, P<0. 01) and cardiac output (3. 93±1. 44 vs 4. 73±1. 01 L/min, P<0. 05) at rest. Before valvuloplasty, the mean transmitral pressure gradient increased significantly (P<0. 01) as heart rate increased, but there were no significant differences in the measurements of mitral valve area and cardiac output (both P>0. 05). In contrast, there was a significant increase after valvuloplasty in the mean transmitral pressure gradient (P<0. 01), but both mitral valve area and cardiac output further increased (both P< 0. 01) as heart rate increased. Moreover, valvuloplasty decreased the mean transmitral pressure gradient at peak heart rate from 23. 0±4. 5 to 7. 75±2. 30 mmHg (F<0. 01) under submaximal stress. Conclusion: Successful percutaneous balloon valvuloplasty soon causes a significant increase of mitral valve reserve capacity in patients with mitral stenosis, which is conspicuously manifested under condition of hemodynamic stress. Stress echocardiography provides a safe, feasible and non-invasive means of assessing the reserve capacity.