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WHAT IS THE BEST OPTION OF TREATMENT FOR PATIENTS WITH SEVERE MITRAL STENOSIS ASSOCIATED WITH SEVERE TRICUSPID REGURGITATION
MOHAMMED EID FAWZY, FRCP, FACC, FESC; HESHAM HEGAZY, MD; HANI SERGANI, MD; AMR BADR, MD; ALIAL SANEI, MD, FRCS(C); MAIE SAADI AL SHAHID, MBBS, FRCP(EDIN); ALI HAMADANCHI, MD; CHARLES C. CANVER, MD, FACS, FACC, FCCP, FCCM
Background: Significant tricuspid regurgitation (TR) is occasionally associated with severe mitral stenosis (MS) and has an adverse impact on morbidity and mortality in patients undergoing mitral valve surgery. However, the effect of successful mitral balloon valvotomy (MBV) on severe TR is not fully elucidated. Objectives: The aim of the study was to evaluate the effect of MBV on severe TR in patients with severe MS undergoing MBV and what is the best option o f treating such patients. Methods: We analyzed the data of 57 patients with significant TR (grade > 2 on 1 to 3 scale) from the MBV database at our hospital. Patients were evaluated by Doppler echocardiography before MBV and at follow-up 1 to 15 years after MBV. Patients were divided into group A (31 patients) in which TR regressed by > 1 scale and group B (26 patients) in which TR did not regress. Results: The Doppler determined pulmonary artery systolic (PAS) pressure was initially higher and decreased at follow-up more in group A (from 71 + 24 to 36 + 8 mmHg; P < 0.0001) than in group B (from 48.7 + 17.8 to 41.6 + 13.1 mmHg; P = NS). Compared with patients in group B, patients in group A were younger (25 + 10 vs 35 + 11 years; P < 0.005) and had higher prevalence of functional TR (87% vs. 8%; P < 0.0001) and had lower incidence of AF (6.5% vs. 38%; P < 0.001). Significant decrease in right ventricular end diastolic dimension after MBV was noted in group A but not in group B. The mitral valve area (MVA) at last followup was higher in group A than in group B (1.8 + 0.3 vs. 1.6 + 0.3 m2; P < 0.05). Conclusions: (2) Regression of severe TR after successful MBV in patients with severe MS was observed in patients who had severe pulmonary hypertension. (2) MBV is the best option of treatment for patients with severe MS and associated severe TR provided the mitral valve morphology is suitable and pulmonary artery systolic pressure > 50 mmHg. The aim of this study was to investigate the fate of tricuspid regurgitation (TR) following mitral balloon valvotomy and to determine possible correlation between regression of TR and changes in pulmonary artery pressures and right heart dimensions. In 53 patients with significant TR before valvotomy, substantial regression in TR over time was observed in those with severe pulmonary hypertension. Key words: Mitral stenosis, mitral balloon valvuloplasty, tricuspid regurgitation
Introduction T r i c u s p i d v a l v e r e g u r g i t a t i o n (T R ) is a common finding in patients with significant mitral valve disease, and in the majority of cases it is From the Department of Cardiovascular Diseases, Consultant Cardiologist, King Faisal Heart Institute, King Faisal Specialist Hospital and Research Centre, Riyadh, Kingdom of Saudi Arabia Address reprint request and correspondence to Dr. Mohamed Eid Fawzy, King Faisal Heart Institute (MBC-16) King Faisal Specialist Hospital and Research Centre, P.O. Box 3354, Riyadh 11211, Saudi Arabia, Email: fawzy
[email protected]
Journal of the Saudi Heart Association, Vol. 17, No. 3, September 2005
functional, resulting from right ventricular and tricuspid annular dilatation caused by long-standing pulmonary hypertension. Because of its functional nature, TR in the setting of mitral valve disease is expected to regress after replacement of the diseased mitral valve Although early studies reported successful resolution of TR after replacement of the diseased mitral value,1 subsequent reports did not confirm these results.2"5 In fact, persistence of TR postoperatively contributed to increased morbidity and mortality despite adequate correction of the mitral valve.4"7 Moreover, TR has been reported to
SE V E R E M IT R A L ST E N O SIS
be associated with reduced exercise capacity after successful mitral valve replacement for rheumatic mitral valve disease7 and simultaneous surgical procedures for correction of the tricuspid valve are generally recommended.8 Data on the fate of TR in patients with severe MS undergoing MBV are scarce and conflicting.9"11 The aim of this study was to investigate whether TR resolves, persists, or progresses after percutaneous mitral balloon valvotomy (MBV), and whether MBV is the best option of treating patients with severe MS with concomitant severe TR. Methods Study Population We analyzed the data of 559 consecutive patients with rheumatic mitral stenosis from our prospective hospital database of MBV patients. All patients underwent two-dimensional echocardiography with color flow mapping before and late after the intervention. The study group consisted of 57 patients who had significant (grade 2-3) TR without tricuspid stenosis in the pre-valvotomy color Doppler study and had successful MBV defined as post procedure MVA > 1.5 cm2 and mitral regurgitation of < 2 + by Seller classification.12 The patients were divided into two groups: Group A comprising 31 patients in whom TR regressed by > 1 degree on a 1-3 scale of severity; and Group B comprising 26 patients in whom either no change or an increase in the severity of TR over time was observed. Demographic data and baseline clinical and echocardiographic characteristics of both groups are listed in Table 1. Two-Dimensional and Doppler Echocardio graphic Examination In all 57 patients a complete two-dimensional and color Doppler echocardiographic examination was performed before MBV, immediately after MBV, and at follow-up 1-15 years after MBV using commercially available equipment (Hewlett-Packard Unit Sonos 1500 and 5500) and standard techniques. A. Assessment o f TR and Pulmonary Artery Systolic Pressure (PASP) TR was assessed by integrating both Doppler color flow mapping images of the regurgitant jet and pulsed wave Doppler evidence of systolic flow reversal in the inferior vena cava or hepatic veins.
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161 Careful Doppler evaluation of the jet was performed in all obtainable views of the right ventricle and atrium, including the parasternal short-axis view at the aortic valve level, the right ventricular inflow view, the apical four-chamber view, and subcostal views. The color flow mapping display of reversed or mosaic signals originating from the tricuspid valve and extending into the right atrium during systole identified the presence of TR. The narrowest sector angle encompassing the regurgitant jet was used to obtain maximal frame rate. The area of disturbed flow that was traced included the aliased signals, as well as the immediately contiguous nonturbulent velocities that were moving in the same direction as the jet. Right atrial area was traced from the same frame as the maximal jet area. The severity of regurgitation was graded as mild (grade 1) if the jet area occupied less than 20% of the right atrial area, as moderate (grade 2) if this value was between 20% and 33% and as severe (grade 3) if this value was > 34%.13-15 Systolic flow reversal in the inferior vena cava or hepatic veins by pulsed wave Doppler echocardiography was considered as indicating at least moderate TR, regardless of the other findings. TR was defined as organic if thickening, doming, or restricted motion of the valve leaflets was present. The right ventricular systolic pressure was estimated by continuous wave Doppler using the modified Bernoulli equation (4 x [peak TR velocity]2) with 10 mm Hg added for the estimated right atrial pressure. The right ventricular systolic pressure was considered to be equal to the PASP unless there was pulmonary stenosis. B. Right Heart Dimensions On the apical four-chamber echocardiographic plane, the maximal tricuspid valve annulus diameter (TVADmax) during diastole was measured from the point of insertion of the septal tricuspid leaflet to the insertion of the anterior tricuspid leaflet. In addition, the smallest tricuspid valve annulus diameter (TVADmin) was measured during systole using the same beat and the same plane in which the largest diameter was noted. The right ventricular long axis (RVL) was measured from the apex to the midpoint of the tricuspid annulus at end-diastole. The right ventricular minor axes were measured from the septum to the free right ventricular wall at the mid-cavitary level in both, end-diastolic (RVEDD) and end-systolic frames (RVESD). These dimensions were corrected for body surface area.
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M O H A M M E D E ID F A W Z Y ET AL.
Mitral Balloon Valvotomy All patients underwent MBV using stepwise Inoue balloon technique as described previously.16'17 Standard left and right heart catheterizations were performed using fluid filled catheters and the following hemodynamic parameters were obtained before and immediately after MBV: left atrial pressure, mitral valve gradient, pulmonary artery pressure, pulmonary vascular resistance, and mitral valve area (Gorlin formula). A Micro-Siemens Computer (manufactured by Siemens-Elema A.B. Solna Sweden) was used in calculating the hemodynamic data. Cardiac output was estimated by the Fick method. Mitral regurgitation was evaluated with cine left ventriculography, and its severity was graded from 1+ to 4+ according to Sellers classification.12 Clinical Follow-up Clinical and echocardiographic follow-up ranged from 1 tol5 years (mean 5.3 + 3.8). Data were obtained during patient visits to the clinic. Followup was concluded in February 2005.
pulmonary hypertension (PASP > 50 mm Hg). In contrast, 24 out of 26 (92%) of patients in Group B had organic TR with PASP < 50 mm Hg. In comparison to Group A, patients in Group B were older (35 ± 11 vs 25 ± 10 years; P < 0.005) had slightly higher echo score, had higher prevalence of atrial fibrillation (38% vs 6.8% P < 0.005) (Table 1), lower mean transmitral valve gradient (15.2 ± 3.6 vs 17.7 ± 5.1 mm Hg; P< 0.05), larger baseline catheter mitral valve area (0.84 ± 0.18 vs 0.68 ± 0.18; P < 0.005), lower catheter PASP (45.4 ± 16.9 vs 70.2 ± 21.8 mm Hg; P < 0.0001), and lower pulmonary vascular resistance (275 ± 210 vs 444 ± 247 dynes.sec.cm'5; P 50 mmHg). Acknowledgement We would like to thank Ms. Stephanie Fermazi for her secretarial assistance.
H.
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1516.
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