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 ::  Abstract
 ::  Introduction
 ::  Material and Methods
 ::  Results
 ::  Discussion
 ::  References
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ARTICLE
Year : 1979  |  Volume : 25  |  Issue : 4  |  Page : 201-206

Echocardiography in surgical assessment of mitral stenosis


Department of Cardiology, K.E.M.Hospital, Parel, Bombay-400012, India

Correspondence Address:
A S Vengsarkar
Department of Cardiology, K.E.M.Hospital, Parel, Bombay-400012
India
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Source of Support: None, Conflict of Interest: None


PMID: 529178

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 :: Abstract 

Eighty patients of isolated mitral stenosis were studied echo­cardiographically to assess the nature of the stenosed mitral valve as this seems to have a significant bearing on the surgical treatment of mitral stenosis. Echocardiographic findings were compared with the surgical observations and correlated with the post-operative re­sults. EF slope did not have significant correlation with surgically estimated mitral valve area. Calcification was found in 21.25% patients. Leaflet echo thickness as a sign of mitral valve calcifica­tion has a high sensitivity (88%) though it lacks specificity (42%). A combined echo graphic sign of leaflet echo thickness of greater than 6 mm, and an opening amplitude of less than 16 mm was asso­ciated with an adverse outcome (mitral regurgitation) in 41.6% patients, compared to an incidence of 21% in the remaining.



How to cite this article:
Vengsarkar A S, Kulkarni D R, Parikh D S. Echocardiography in surgical assessment of mitral stenosis. J Postgrad Med 1979;25:201-6

How to cite this URL:
Vengsarkar A S, Kulkarni D R, Parikh D S. Echocardiography in surgical assessment of mitral stenosis. J Postgrad Med [serial online] 1979 [cited 2020 Feb 28];25:201-6. Available from: http://www.jpgmonline.com/text.asp?1979/25/4/201/42218



 :: Introduction Top


The nature of the diseased mitra valve is what a surgeon strives to know [1],[19] in the management of mitra stenosis and this has been desperately sought after in the clinical signs and roentgenography [3] but not with encouraging returns. [6],[20] Echocardiography introduced in 1954 came to the forefront as it seemed to offer this very knowledge by way of imaging the diseased valve it a non-invasive manner. The technique has subsequently been employed in an attempt to predict the severity of the stenosis [8],[9],[10],[12],[15],[24] and the state of the mitral apparatus in the assessment of its mobility,thickness and calcifica­tion. [13],[14],[23]

In an earlier communique [27] we have put forth our experience regarding the ultrasonic assessment of surgical mitral stenosis; this has encouraged us to un­dertake the present study as an exten­sion of the previous work.


 :: Material and Methods Top


Eighty patients with pure isolated mitral stenosis were studied. There were 34 males and 46 females. The age ranged from 10 to 50 years [Table 1]. All patients were studied pre-operative­ly in a detailed clinical examination, haemogram, chest X-ray, and a 12 lead electrocardiogram. The echoes were recorded with Unirad sonograph machine; a non-focused 2.25 mHz trans­ducer with a diameter of 13 mm was used. The records were photographed with a 400 ASA 120 size roll film on e Graflex No. 107 A Camera. Previously reported recording techniques were used [11],[23] to make the echoes compara­ble the only control adjusted was the gain, which was lowered till the left side of the interventricular septum was seen clearly. 'The tricuspid valve was recorded in 50 cases. The EF slope was measured along with the opening ampli­tude (DE), and total amplitude (CE); the echo thickness of the both leaflets was measured in millimeters. The thickness of the systolic segment was measured in millimeters at its widest part.

The post-operative echoes were re­corded on the 7th day after operation, by the same method.

During surgery the following inform­ation was obtained directly from the operating surgeon; valve narrowing by finger palpation; [8],[12] associated mitral regurgitation; fibrosis; leaflet calcification; subvalvular crowding and fusion; and all were graded in 3 groups according to the severity. The final orifice size, regurgita­tion, and mobility were assessed similarly at the end of the procedure. The patients were reassessed clinically on the 7th post-operative day with special attention paid to the apical murmurs and the 3rd heart sound. The murmurs were graded in the conventional manner.

The EF slope was correlated with sur­gically estimated mitral valve area, the leaflet echo thickness with the surgically estimated calcification. The surgical re­sults were classified in 4 groups. (1) Death within 7 post operative days. (2) Mitral regurgitation-when a systolic murmur graded 2 or more was associated with a 3rd heart sound. (3) Residual mitral stenosis when a significant mid diastolic murmur was heard at the apex. (4) The remaining patients had optimum results. These subgroups were correlated with various echographic features such as EF slope, EF thickness and opening amplitude.


 :: Results Top


(A) Measurements: The EF slope ranged from 0 to 50 mm/sec., the normal range employed in this laboratory being 60 to 210 mm/sec. There were only 2 patients with an EF slope above 30 mm/ sec. Both these patients were operated as the symptoms indicated significant car­diac decompensation.

The opening amplitude ranged from 7 mm to 20 mm. 56 of 80 (70%) patients had opening amplitude greater than 16 mm.

The leaflet echo thickness ranged from 2 mm to 10 mm.

Posterior leaflet was recorded in each case and a normal posterior leaflet movement was found in 2 patients.

(B)Correlations: The EF slope did not have a significant correlation with the surgically estimated mitral valve area (See [Figure 1] below).

Calcific deposits were found in 17 pa­tients (21.25%). 15 of 39 patient (38.4%) with leaflet echo thickness of more than 6 mm had calcification while only 2 of 41 (4.9%) patients with leaflet echo thick­ness of less than 6 mm had calcification. The number of- patients with calcification and the total number of patients in each leaflet thickness group are shown in [Figure 2].

A pre-operative grade I mitral regur­gitation was found at surgery in 6 patients (7.5%); in none of these did it increase post-operatively. These cases did not belong to the group of patients who developed mitral regurgitation post­operatively.

The surgical outcome in 80 patients was as follows-(i) Death-4 patients (5%), (ii) Mitral regurgitation-21 pa­tients (26.25%), (iii) Residual mitral stenosis-3 patients (3.75%), (iv) 52 patients (65%) had optimum results.

In a combined consideration of exces­sively thick leaflet echoes (more than 6 mm) and severely reduced opening am­plitude (less than 16 mm) (See [Figure 3] on page 200 A) plotted against the incidence of post-operative mitral regurgitation it was observed that 5 of 12 (41.6%) pati­ents with such echoes had post-operative mitral regurgitation; 16 of the remaining 68 patients (23.5%) without such echoes (See [Figure 4] on page 200 B) had mitral regurgitation.

In 10 (12.5%) patients a normalization of the posterior leaflet was observed post-operatively (See [Figure 5] on page 200 B).

Tricuspid valve abnormality was not detected in any patient.


 :: Discussion Top


The abnormally low diastolic closing rate of anterior mitral leaflet (less than 30 mm) is the cardinal feature of surgical mitral stenosis. [11] The lower limit of normal EF slope is 60 mm/sec. at this centre. All of our patients had EF slope below 50 mm/sec and only 2 had the EF slope above 30 mm/sec. These 2 patients though outside the range of EF slope of surgical mitral stenosis were operated because of significant symptoms and were found to have moderate mitral valve stenos s. With rare exception [27] reduced EF slope is still a characteristic of mitral stenosis; a few other conditions which cause reduced EF slope are aortic stenosis, [7] IHSS, [25] reduced left ventricular compliance' , and pulmonary hypertension [21]

Many authors have discussed the deter­minants of the 'EF' slope of the mitral valve echo; in this regard the size, the duration of transmitral pressure gradient, [16] left ventricular filling rate [18] , ventricular compliances [5] , mitral ring motion, [31] peak inflow velocity [28] have all been considered; but the issue remains to be clarified. In its genesis, the EF slope is a complex pheno­menon with many of these factors playing a varying role in a patient with mitral stenosis; [17] to consider it alone as an index of severity of mitral stenosis would therefore seem an over simplifi­cation. This is borne out by the poor correlations observed in this and other series. [2] The favourable early re­ports [8],[10],[12] included mild mitral stenosis and normals as well.

Though the diastolic opening amplitude is partially contributed to by annular movement [31] it mostly reflects the mobi­lity of valve cusps. Despite a severe ori­fice narrowing it may be normal if the chordo-papillary apparatus is intact; [30] it is diminished with subvalvar fibro-calcific disease. [29] A severely diminished opening amplitude specially when considered along with leaflet echo thickness, was thought a possible predictor of adverse surgical outcome after commissurotomy. [29] In cases with opening amplitude of less than 16 mm and a standardized leaflet echo thickness greater than 6 mm there was a higher incidence post-operative mitral regurgitation (42%) as compared to the remaining cases (21%).

The destroyed leaflets become the seat of fibrosis and calcification [4] in a significant number of cases. Rarely other compo­nents of mitral valve also get calcified [4],[26]

Leaflet echo characteristics do not appear to provide useful clues which may influence surgical management by detection of calcification in mitral steno­sis. [22] Multilinear and coalescent echoes [23] independent of thickness were reported by one of the authors [27] not to be specific for calcification. Excessively thick leaf­let echoes (more than 6 mm) as a sign of calcification employed in this series also lacked specificity (42%) (See [Figure 2] on page 203), possibly due to the un­known variable of valve interface charac­teristics; the sign, however, had a high sensitivity (88%) for leaflet calcification.

Patients with thick leaflet echoes and reduced opening amplitude appeared to have higher incidence of post-operative mitral regurgitation (41.6%) as compared to the incidence (23.5%) of the remaining patients without such echoes; this subject is therefore being studied at these institutions in a larger number in regard to its predictive value as related to the sur­gical outcome in mitral commissurotomy.

Posterior mitral leaflet moves anterior­ly during diastole in mitral stenosis [7] but ocasionally it moves posteriorly (See [Figure 6] on page 200 B) which is explained by selective involvement of the anterior leaf­let; relative predominance of the posterior leaflet and the annular movement has also been considered; if the latter predomin­ates normal leaflet movement becomes possible [18] . The posterior leaflet was nor­mal pre-operatively in only two patients (2.5%); one patient had an EF slope of 50 mm/sec. These two findings suggested mild mitral stenosis though the symptoms or surgical findings did not corroborate this. The other patient had EF slope of 20 mm/sec and the anterior mitral leaflet was moderately thickened, suggesting moderate mitral stenosis, which was con­firmed at surgery. Normal posterior leaflet motion in mitral stenosis has been reported in upto 10% [18]

The posterior leaflet exhibited a normal movement post-operatively in 10 patients (12.50%). As a group they had a near normal opening amplitude (19.6 mm. mean) and 7 of them had leaflet thick­ness less than 6 mm. No specific factors have been reported as being contributory to the normalization of posterior mitral leaflet post-operatively.

 
 :: References Top

1.Brewer, L. A.: In discussion of the arti­cle by Olinger, G. N., Rio. F. W. and Maloney, J. V.: Closed valvotomy for calcific mitral stenosis. J. Thorac. Cardio­vase., Surg. 62. 357-365, 1971.  Back to cited text no. 1    
2.Cope, G. D., Kisslo, J. A., Johnson, M. L. Behar, V. S.: A reassessment of the echocardiogram in mitral stenosis. Circu­lation, 52: 664-670 1975.  Back to cited text no. 2    
3.Davies, P. and Bucky, N. L.: Tomography of calcific aortic and mitral valves. Brit Heart J. 21: 17-22 1959.  Back to cited text no. 3    
4.Dekker, A., Black, H. and von Lichten­berg, F.: Mitral valve r stenosis. A Pathological study. J. Thorac Cardiovasc. Surg., 55: 434-446, 1968.  Back to cited text no. 4    
5.DeMaria, A, N., Miller, R. R. Amster­dam E. A., Markson, W. and Mason, D. T.: Mitral valve early diastolic clos­ing velocity in the echogram: relation to sequential diastolic flow and ventricular compliance. Amer. J. Cardiol., 37: 693­700, 1976.  Back to cited text no. 5    
6.Diveley, W. L., Daniel, R. A., Scott, H. W. and Foster, J. H: Results in the surgical treatment of mitral stenosis. Ann. Surg., 147: 614-624 1958.  Back to cited text no. 6    
7.Duchak, J. M. Jr., Chang, S. and Feigenbaum, H.: The posterior mitral valve echo and the echocardiographic diagnosis of mitral stenosis. Amer. J. Cardiol. 29: 628-632 1972.  Back to cited text no. 7    
8.Edler, I.: Ultrasound cardiography in mitral valve stenosis. Amer. J. Cardiol., 19: 18-31, 1967.  Back to cited text no. 8    
9.E]ler, I and Hertz: C. H.: Use of utra­sonic reflectoscope for continuous record­ing of movements of heart walls. Kungl. Fysicgraf, Sallskap. Lund. Fordhandl,, 24: 1-19, 1954.  Back to cited text no. 9    
10.Effert, S.: Pre-and post-operative evalua­tion of mitral stenosis by ultrasound. Amer. J. Cardiol., 19: 59-65. 1967.  Back to cited text no. 10    
11.Feigenbaum, H.: "Echocardiography" 2nd edition. Lea and Febiger, Philadelphia. 1976.  Back to cited text no. 11    
12.Gustafson A.: Correlation between ultra­sound cardiography, hemodynamics and surgical findings in mitral stenosis. Amer. J. Cardiol. 19: 32-41, 1967.  Back to cited text no. 12    
13.Joyner, C. R.: Ultrasound cardiogram in the selection of patients for mitral valve surgery. Ann. N. Y. Acad. Sci., 118: 512­524, 1955.  Back to cited text no. 13    
14.Joyner C. R., Dyrda, I., Barrett, J. S. and Reid, J. M.: Pre-operative deter­mination of the functional anatomy of the mitral valve. Circulation (suppl II), 32: 120, 1965 (abs).  Back to cited text no. 14    
15.Joyner, C. R., Reid, J. M. and Bond, J. P.: Reflected ultrasound in the assess­ment of mitral valve disease. Circulation, 27: 503-511, 1963.  Back to cited text no. 15    
16.Laniado, S., Yellin, E., Kotler, M,Levy, L. Stadler, J. and Terdiman, R.:A study of the dynamic relations between the mitral valve echogram and phasic mitral flow. Circulation, 51: 104-113, 1975.  Back to cited text no. 16    
17.Layton, C., Gent, G.. Pridie, R., Mc­ Donald, A. and Brigden, W.: Diastolic closure rate of normal mitral valve. Brit Heart J. 35: 1066-1074, 1973.  Back to cited text no. 17    
18.Levisman, J. A., Abbasi, A. S. and Pearce, M. L.: Posterior mitral leafle motion in mitral stenosis. Circulation, 51 511-514, 1975.  Back to cited text no. 18    
19.Litwak, R. S., Gadboys, H. L., Baror M. G., Lev R. and Wallace, H. W. Elective open heart stugery in mitral stenosis. Amer. J. Cardiol., 16: 206-216 1965.  Back to cited text no. 19    
20.Logan, A. and Turner, R.: Surgical treatment of mitral stenosis with particular reference to the transventricular ap­proach with a mechanical dilator. Lancet 2: 874-880, 1959.  Back to cited text no. 20    
21.McLaurin, L. P., Gibson, T. C., Waider W., Grossman, W. and Craige, E.: An appraisal of mitral valve echocardiogram: mimicking mitral stenosis in condition: with right ventricular pressure overload Circulation, 48: 801-809, 1973.  Back to cited text no. 21    
22.Michel1. G.: Calcific mitral stenosis and mitral valvotomy. Brit. Med. J. 1: 687­691, 1960.  Back to cited text no. 22    
23.Nanda, N. C . , Gramiak, R . , Shah, P. M and Do Weese, J. A.: Mitral commis­surotomy versus replacement. Pre-opera­tive evaluation by echocardiography. Cir­culation, 51: 263-267, 1975.  Back to cited text no. 23    
24.Segal, B. L., Likoff, W. and Kingsley B.: Echocardiography. Clinical applica­tion in mitral stenosis. J. Amer. Med. Assoc. 195: 161-166, 1966.  Back to cited text no. 24    
25.Shah, P. M., Gramiak, R., and Kramer, D. H.: Ultrasound localization of left ventricular outflow obstruction in hyper­trophic obstructive cardiomyopathy. Cir­culation, 40: 3-12, 1969.  Back to cited text no. 25    
26.Silverman, M. E. and Hurst, J. W.: The mitral complex. Interaction of the anatomy, physiology and pathology of the mitral annulus, mitral valve leaflets, chordae tendinae and papillary muscles. Amer. Heart J., 76: 399-418, 1968.  Back to cited text no. 26    
27.Vengsarkar, A. S.: Echocardiography in surgical assessment of mitral valve disease. Presented at the mid-annual Conference of the Cardiological Society of India & the Association of Thoracic Surgeons of India held at Chandigarh in Sept. 1976.  Back to cited text no. 27    
28.Vignola, P. A., Walker, H. J., Pohost, G. M. and Zir, L. M.: Relation between phasic mitral flow and the echocardio­gram of the mitral valve in man. Brit. Heart J., 39: 1292-1298, 1977.  Back to cited text no. 28    
29.Wharton, C.F.P., and Bescos, L. L.: Mitral valve movement; a study using an ultrasound technique. Brit. Heart J., 32: 344-349, 1970.  Back to cited text no. 29    
30.Winters. W. L., Riccetto, A., Gimenez, J., McDonough, M. and Soulen R.: Re­flected ultrasound as a diagnostic instru­ment in study of mitral disease. Brit. Heart J., 29: 788-800, 1967.  Back to cited text no. 30    
31.Zaky, A., Nasser, W. K. and Feigenbaum, H.: Study of mitral valve action recorded by reflected ultrasound and its application in the diagnosis of mitral stenosis. Circulation, 37: 789-799, 1968.  Back to cited text no. 31    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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