European Journal of Cardiovascular Medicine

Rheumatic heart disease, the most common cardiovascular ailment in India and many other developing countries, remains a significant health problem (1).

Mitral stenosis (MS) is the most common valve disease seen as a sequel of rheumatic fever and usually presents with exertional dyspnoea and right-side heart failure and pulmonary arterial hypertension. MS is known to cause structural and functional abnormalities of the left atrium (LA) (2). Normal Left Atrial function consists of reservoir, conduit and pump function (3,4). In Mitral Stenosis Left Atrial function may be disrupted because of increased Left Atrial afterload. Many methods have been used previously to assess atrial function, both invasive and non-invasive. During left ventricular (LV) systole, LA enlarges lead to LA longitudinal lengthening, and lengthening is recorded as a positive strain, permitting the measurement of longitudinal stretching of LA. Peak atrial longitudinal strain (PALS) is the predictor of atrial fibrillation (AF) and cardiovascular outcome (5,6).

Quantification of regional and global LA deformation or LA strain by 2D STE is a diagnostic tool, capable to evaluate LA function (7). Since its introduction in 1984 by Inoue et al, PTMC has become established as a safe and effective treatment for rheumatic MS, with results that are equivalent to surgical valvotomy (8).

Acute Rheumatic Fever is clearly the result of an exaggerated immune response to Group A Streptococcal pharyngitis (9). Due to inflow obstruction, the atrial booster pump contributes less to Left Ventricular filling in Mitral Stenosis even during sinus rhythm, despite a proportional increase, with increasing severity, in the Left Atrial pre load (10). Patients with Mitral Stenosis were found to have increased Left Atrial size and decreased Left Atrial pump function. The risk of cerebrovascular accident (CVA) increases in patients with rheumatic atrial fibrillation (AF) by 6- to 17- fold, and the disturbed LA function in patients with MS in sinus rhythm (SR) can also increase the risk of CVA (11).

We conducted present study with aim to assess the outcomes of successful BMV on the LA functions in patients with isolated severe rheumatic MS in sinus rhythm over a period of one year follow up.

A Prospective observation study conducted in the department of cardiology at LPS institute of Cardiology, between Feb 2020 to March 2022. Patients with Severe mitral stenosis with suitable valve morphology who are undergoing PTMC will be selected for this study.

Patients with symptomatic severe rheumatic MS who are undergoing PTMC and having normal sinus rhythm, Normal LV ejection fraction (EF) (≥55%), having right ventricular systolic annular velocity ≥9.5 cm/s before procedure and having suitable valve morphology by echocardiography (Wilkins score ≤ 8) are included in the study. All other were excluded from our study.

All patients were subjected to thorough history taking, full clinical examination, 12 lead ECG, full 2D, M mode & Doppler transthoracic echocardiographic and transoesophageal echocardiography study in standard views. Left Atrial regional function and deformation properties were studied using 2D speckle Strain imaging. All details were plotted in tables and statistically studied.

Transesophageal echocardiography (TEE) was performed for assessment of left atrial functions as well as to rule out any clot. We measured the fractional area change as its ejection fraction (EF) by the Simpson method. After PTMC TEE was performed at least after1 month and then at 12 months follow up.

During the period of 2 year, 50 patients were included in the study of who underwent successful Percutaneous BMV for severe symptomatic rheumatic Mitral Stenosis. Relevant parameter related to study measured prior to study, 24 hr post BMV, 01 month and 01-year post BMV. Among 50 patients included in study 22(44%) were male and 28(56%) were female. Youngest patient was 13-year female and eldest one was 51 years male.

Table 01: Distribution of patients by age and sex.

Table 02: 2-D Echo/Doppler and LA parameters Pre and Post BMV (P value, a- pre BMV vs 24hr post BMV, b- pre BMV vs 1month post BMV, c- pre BMV vs 12 months post BMV)

PALS= Peak atrial longitudinal stain

Peak atrial longitudinal stain improved significantly over a period of 12 months. At end of 1 month post BMV there was a 74% increment of PALS. At the end of 12 months post BMV this improvement in PALS remained maintained.

LA dimension also reduced immediately 24 hr after BMV from 42.4 ± 7.6mm to 41.1±5.4. At 1 month follow up reduction in LA dimension from 42.4 ± 7.6mm to 40.3±4.2 mm occurred which was significant (P value-0.043). LA volume also reduced significantly 24 hr post bmv (P value-< 0.033) and during 1 month (P value-< 0.021) and 12 months follow up (P value-< 0.011). Indexed LA volume also reduced from 56.8±14.3 ml/m2 to 48.4±12.5 at 24 hr post BMV while 45.4±13.3 ml/m2 at 1 month follow up and 45.2±13.1 ml/m2 at 12 months follow up all were significant.

MVA by planimetry increased significantly from pre BMV value of 0.89±0.11 cm2 to 1.83±0.3 cm2 at 24 hr post BMV ( P value0.031) while at 1month follow up it was 1.89±0.2 cm2( P value0.011) and at 12 months this improvement was maintained. MV gradient also reduced significantly from 21.4±3.22 mm Hg to 7.83±2.12 mmHg (P value- 0.031) at 24 hr post BMV ,6.34±1.8 mmHg at 1 month post BMV (P value- 0.023) 6.4±1.9mmHg at 12 months post BMV(P value- 0.026 and both was significant.

PASP also reduced significantly from pre BMV value of 63.6±8.5 mmHg to 58.3±6.3 mmHg 24 hr post BMV (P value0.034), to 38.4±4.5 mm Hg at 1month follow up (P value-0.003) and to 34.4±5.5 mm Hg at 12 months follow up visit.

In MS, chronic tension in the LA from volume and pressure overload results in physiological and anatomical changes (12). In our study left atrial size as determined by Left Atrial dimensions in M mode and 2D echo in A4C/A2C view. Left Atrial dimension, volume and indexed volumes were significantly higher in patients with Mitral Stenosis as compared to normal patient without mitral stenosis. Similarly in a study by Rohani et al (13): Acute effect of BMV and MVR in patients with MS Positive peak LA strain improved from pre BMV value of 5.1±11.6 % to post BMV 6.5±17.7% (P value).

Di Salvo et al (14) had reported atrial peak Systolic Strain as one of the best predictors for maintenance of sinus rhythm in patients with lone AF. In a study by Adavane, et al (15).  Indexed LA volume fell from 56  ± 14 to 48 ± 12 mL/m2 (P = 0.0002) immediately after BMV and to 45 ± 13 mL/m2 at 1 month (P < 0.0001).

In our study MVA by planimetry increased significantly from pre BMV value of 0.89±0.11 cm2 to 1.83±0.3 cm2 at 24 hr post BMV. In a study by Vieira ML et al (16), Mitral valve area increased to 1.7+0.11 cm2 post- BMV with a statistical significance.

In a study by Sravan K Reddy et al (17). there was a significant decrease in mitral mean gradient (MMG) and systolic pulmonary artery pressure (sPAP). after BMV, while in our study MV gradient also reduced significantly from 21.4±3.22 mm Hg to 7.83±2.12 mmHg( P value- 0.031) at 24 hr post BMV ,6.34±1.8 mmHg at 3 month post BMV(P value- 0.023) 6.4±1.9mmHg at 12 months post BMV(P value- 0.026 and both was significant.

Similar results were found by Aslanabadi N, Jafaripour I, et al (18) where they studied the effects of PTMC on left atrial appendage function in patients with sinus Rhythm and Atrial Fibrillation by TEE.

All Left atrial parameters in terms of mitral valve area, left atrial volume index, mean gradient across mitral valve, pulmonary artery systolic pressure have shown significant improvement. This study showed that PTMC is able to improve the functions of Left Atrium and thus may decreases the complications like pulmonary artery hypertension, atrial fibrillation, reduces SEC and risk of thromboembolism. However Use of strain imaging for left atrial function is still not validated completely and its use is still in infancy stage and finally a larger study is needed to confirm our findings.

Picture 01 BMV using Accura balloon.

Picture 02: peak Atrial longitudinal strain (PALS) using 2D speckle imaging improved after BMV.

Picture 03: MVA as calculated by planimetry improved after BMV.

Picture 04: Continuous wave Doppler to see reduced mitral valve gradient after BMV

Picture 05 : Peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) (20) .Modified from Cameliet al.

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