The masking of aortic stenosis by mitral stenosis

doi:10.1016/0002-8703(65)90212-7

American Heart Journal

Volume 69, Issue 1, January 1965, Pages 22-30

https://doi.org/10.1016/0002-8703(65)90212-7 Get rights and content

Abstract

The clinical data (signs and symptoms, x-ray and electrocardiographic analysis) and hemodynamic findings in 10 patients with severe mitral and aortic stenosis have been presented.

All patients had signs, symptoms, and radiologic stigmata of mitral stenosis. Normal sinus rhythm was present in 7 of the 10 patients, and right ventricular hypertrophy in only 3. Many of the features usually considered to be a sine qua non of severe aortic stenosis were absent in these cases. However, all patients had at least one manifestation other than the typical murmur of aortic stenosis (e.g., angina, syncope, abnormal carotid pulse, left ventricular enlargement by x-ray or ECG examination, calcification of the aortic valve, or dilatation of the aortic root).

All patients with ECG evidence of left ventricular hypertrophy also had angina pectoris and significantly elevated timetension indices. This was due largely to a prolongation of the systolic ejection period. It is suggested that ECG evidence of left ventricular hypertrophy in this clinical setting, without significant mitral or aortic regurgitation, signifies severe left ventricular stress and severe aortic stenosis.

A decrease in cardiac output secondary to mitral stenosis reduces the differences in pressure across the aortic valve and, there-fore, reduces the total left ventricular stress, as reflected by the time-tension index. It is believed that this reduction in output is the basic cause of inconstancy of symptoms and signs of aortic stenosis in patients with tight mitral and aortic stenosis.

When aortic stenosis is suspected in patients with severe mitral stenosis, the only certain method of quantitative evaluation is catheterization of the left side of the heart, with simultaneous measurement of transvalvular pressure differences and blood flow.

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Cited by (27)

Assessment of Complex Multi-Valve Disease and Prosthetic Valves
2019, Heart Lung and Circulation
Citation Excerpt :
However, when both stenoses are severe, a greater reduction in cardiac output occurs than with just one severe stenosis, decreasing the flow rate and pressure gradients leading to underestimation of the severity of both valve stenoses [23]. Underestimating the concomitant severe AS may lead to dramatic clinical consequences if isolated mitral valve intervention is then considered, as relief of the mitral stenosis would suddenly increase the preload to a small, hypertrophied, and stiff left ventricle, resulting in pulmonary oedema [24]. Aortic valve involvement, in the form of primary regurgitation, stenosis, or mixed stenosis and regurgitation, is present in approximately one-third of patients with rheumatic MS (Figure 1) [8].
Multivalvular heart disease (MVD) is a highly prevalent condition causing significant morbidity and mortality. The complex haemodynamic interactions between coexisting valve lesions makes the diagnosis and treatment challenging. Current guidelines may not be adequate for managing the varying clinical scenarios of MVD and, therefore, the expertise of a multidisciplinary Heart Valve Team is of paramount importance. The indications for intervention should be based on a global assessment of the consequences of the multiple valve lesions after a careful estimation of the added surgical risk of combined procedures, the long-term risk of morbidity and mortality associated with multiple valve prostheses and the risk of reoperation if less-than-severe valve lesions are left untreated at the time of first evaluation. Echocardiography plays an important role in assessing patients and, as a general rule, an accurate echo diagnosis needs to combine different measurements. The emerging transcatheter valve therapies should be considered an option for high risk patients. More data on the natural history of MVD and the impact of intervention on outcome are required to better define the optimal management strategy.
Incidence and patterns of valvular heart disease in a tertiary care high-volume cardiac center: A single center experience
2014, Indian Heart Journal
Citation Excerpt :
In a study of 100 cases of combined aortic and mitral valve replacement, Melvin found that MR + AR was the most common combination of rheumatic valvular lesions.27 In a series of 150 patients with combined aortic and mitral valve disease, only 10 patients (6.7%) were found to have essentially pure AS and MS28; we found a slightly lower incidence of 4.2% for this combination in a similar analysis. The commonest etiology of TS was RHD and was almost exclusively seen in association with MS. In the necropsy series of Roberts and Virmani,4 though 12% of cases had some pathological involvement of tricuspid valve, stenosis of the valve was seen in only 2% and was seen only when associated MS and AS were present.
Diseases of the heart valves constitute a major cause of cardiovascular morbidity and mortality worldwide with rheumatic heart disease (RHD) being the dominant form of valvular heart disease (VHD) in developing nations. The current study was undertaken at a tertiary care cardiac center with the objective of establishing the incidence and patterns of VHD by Echocardiography (Echo).
Among the 136,098 first-time Echocardiograms performed between January 2010 and December 2012, an exclusion criterion of trivial and functional regurgitant lesions yielded a total of 13,289 cases of organic valvular heart disease as the study cohort.
In RHD, the order of involvement of valves was mitral (60.2%), followed by aortic, tricuspid and pulmonary valves. Mitral stenosis, predominantly seen in females, was almost exclusively of rheumatic etiology (97.4%). The predominant form of isolated MR was rheumatic (41.1%) followed closely by myxomatous or mitral valve prolapse (40.8%). Isolated AS, more common in males, was the third most common valve lesion seen in 7.3% of cases. Degenerative calcification was the commonest cause of isolated AS (65.0%) followed by bicuspid aortic valve (BAV) (33.9%) and RHD (1.1%). Multiple valves were involved in more than a third of all cases (36.8%). The order of involvement was MS + MR > MS + AR > MR + AR > AS + AR > MR + AS > MS + AS. Overall, 9.7% of cases had organic tricuspid valve disease.
RHD contributed most to the burden of VHD in the present study with calcific degeneration, myxomatous disease and BAV being the other major forms of VHD. Multiple valves were affected in more than a third of all cases.
Rheumatic Mitral and Aortic Stenosis: To Replace or Not To Replace-That Is the Question-Part 2
2010, Journal of Cardiothoracic and Vascular Anesthesia
Combined mitral and aortic stenosis of rheumatic origin with double-valve replacement in an octogenarian
2010, International Journal of Cardiology
Rheumatic Mitral and Aortic Stenosis: To Replace or Not To Replace-That Is the Question-Part 1
2010, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
If so, then what is the true AVA? Are clinicians “UNDERESTIMATING” the AS due to mitral stenosis?1 Low gradient is due to low flow (ie, reduced stroke volume and the actual AS is more than moderate; ie, improved stroke volume may worsen the gradient and the severity of AS).
Fate of mild aortic valve disease after mitral valve intervention
2001, Journal of Thoracic and Cardiovascular Surgery
Objective: This study was performed to assess the long-term outcome of untreated mild aortic valve disease present at the time of initial mitral valve intervention. Methods: A total of 284 patients with rheumatic heart disease aged 7 to 62 years (mean, 23.5 ± 12.2 years) who underwent mitral valve intervention and had mild aortic valve disease initially were followed up for 2 to 18 years (mean, 10.8 ± 3.7 years). At initial intervention, 232 patients had pure mild aortic regurgitation, and 52 patients had mild aortic stenosis with or without aortic regurgitation. Results: Among patients with mild aortic regurgitation initially, 11 (5%) patients progressed to moderate (n = 6) or severe (n = 5) regurgitation over an interval of 9 to 17 years (mean, 12.1 ± 2.8 years), and 1 patient had moderate aortic stenosis and severe aortic regurgitation after 10 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic regurgitation was 100%, 97.0% ± 1.7%, and 87.4% ± 4.6% at 5, 10, and 15 years, respectively. Seventeen (35%) patients with initial mild aortic stenosis (with or without regurgitation) had moderate or severe stenosis (with or without moderate-severe regurgitation) after an interval of 4.9 ± 3.8 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic stenosis was 75.6% ± 6.2%, 61.5% ± 8.5%, and 46.1% ± 11.2% at 5, 10, and 15 years, respectively. Ten patients required aortic valve replacement for aortic valve dysfunction. Conclusions: Mild aortic regurgitation present at the time of mitral valve intervention progresses very slowly and less frequently requires reintervention. However, mild aortic stenosis diagnosed initially progresses more often and more rapidly and thus needs closer follow-up.

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^☆: This work was supported in part by grants from the Life Insurance Medical Research Fund, The National Heart Institute, United States Public Health Service (Grants H-0450, HTS-5234, and HTS-5550), and the American Heart Association.

^∗: Postdoctoral Research Fellow, National Heart Institute, United States Public Health Service, Present address: Department of Medicine, Northwestern University Medical School, 303 East Chicago Ave., Chicago, Ill., 60611.

^∗∗: Research Fellow, American Heart Association.

^∗∗∗: Resident in Radiology, Peter Bebt Brigham Hospital

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Clinical communicationThe masking of aortic stenosis by mitral stenosis☆

Abstract

J. Thoracic & Cardiovas. Surg.

Am. Heart J.

Am. Heart J.

Am. J. Cardiol.

Am. J. Med.

Am. J. Med.

A clinical study of 1,000 consecutive cases of mitral stenosis two to nine years after mitral valvuloplasty

Circulation

Aortic stenosis

A.M.A. Arch. Int. Med.

Clinical communication
The masking of aortic stenosis by mitral stenosis☆