M-mode and two-dimensional echocardiographic correlation with findings at catheterization and surgery in patients with mitral stenosis

doi:10.1016/0002-8703(83)90284-3

American Heart Journal

Volume 105, Issue 1, January 1983, Pages 98-102

https://doi.org/10.1016/0002-8703(83)90284-3 Get rights and content

Abstract

Thirty-two consecutive patients referred to our institution for evaluation of rheumatic mitral stenosis were studied with M-mode echocardiography (M-mode E), two-dimensional echocardiography (2DE), and cardiac catheterization. Twenty-three of these patients underwent mitral valve surgery, 11 requiring mitral valve replacement, and 12 requiring open mitral commissurotomy. Clinical and noninvasive parameters were assessed in order to predict catheterization-determined mitral valve areas as calculated by the Gorlin formula, and to predict the choice of operation in patients selected for surgery. For the prediction of valvular area, 2DE planimetry correlated highly (r = 0.89, p < 0.01) with Gorlin formula results. The presence or absence of pericardial effusion, the anterior-posterior valve leaflet separation (M-mode E), and the left atrium-aortic index (2DE) correlated poorly with the degree of mitral stenosis as determined by the Gorlin formula. The most useful predictors of type of mitral surgery were age over 50 years, 2DE valve classification, the presence or absence of calcium at fluoroscopy, and degree of anterior leaflet-septal separation (M-mode E).

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We sought to assess the hemodynamic significance of mitral stenosis (MS) using a new index.
We studied 88 patients with MS. Maximum separation of mitral leaflet tips in diastole in parasternal long-axis and apical 4-chamber views was measured. These two parameters were averaged to yield the mitral leaflet separation index. The index was compared with mitral valve area by planimetry and pressure half-time.
The mitral leaflet separation index was measurable in 76 (86.4%) patients. There was excellent correlation with mitral valve area by planimetry (r = 0.91, P < .001) and pressure half-time (r = 0.86, P < .001) across a wide range of mitral valve areas. Good correlation was found even in atrial fibrillation (r = 0.86 and r = 0.79, respectively). The index could discriminate between hemodynamically significant and insignificant MS (P < .001). An index of 0.81 cm or less predicted severe MS with 92.3% sensitivity and 100% specificity whereas a value of 1.11 cm or more identified mild MS with 85.7% sensitivity and 100% specificity.
The mitral leaflet separation index is an independent and reliable measure of MS severity that is easy to measure.
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1998, American Heart Journal
Atrial fibrillation (AF) is frequently found in association with rheumatic mitral valve disease. To study the interrelation of factors contributing to the risk of AF in patients with mitral stenosis, we examined a cardiac catheterization database of a series of 314 patients. Patients with AF were older, 53.4 ± 6.1 years versus 51.7 ± 7.2 years (p = 0.03), and had a lower cardiac index, 2.3 ± 0.6 L/min/m² versus 2.6 ± 0.7 L/min/m² (p = 0.0002), than patients in sinus rhythm at catheterization. The mitral valve area was significantly smaller in patients with AF than in patients in sinus rhythm, 1.2 ± 0.5 cm2 versus 1.6 ± 0.7 cm2 (odds ratio 1.40/0.25 cm² decrease; p = 0.0001) as was mitral valve index. The pressure-AF association with the highest statistical significance was seen with mean right atrial pressure, 10.6 ± 4.9 mm Hg versus 7.6 ± 3.8 mm Hg (odds ratio 2.24; p < 0.0001). Other variables with significant positive associations by univariate analysis were pulmonary artery wedge pressure, pulmonary artery mean pressure, and pulmonary resistance. When stepwise logistic multiple regression analysis was performed, the results indicated that both severity of mitral stenosis and increased right atrial pressure were independently associated with AF in this population with mitral stenosis. After adjustment was performed for these variables, age was not independently associated with AF. (Am Heart J 1998:135:138-45.)
Influence of mitral valve morphology on mitral balloon commissurotomy: Immediate and six-month results from the NHLBI Balloon Valvuloplasty Registry
1992, American Heart Journal
Echocardiographic data were analyzed in 555 patients undergoing mitral balloon commissurotomy (MBC). Patients were enrolled in the National Heart, Lung, and Blood Institute Balloon Valvuloplasty Registry from 24 centers. There were 456 women and 99 men with a mean age of 54 years. Before MBC the two-dimensional echocardiographic variables of mitral valve thickness, mobility, calcification, and subvalvular disease were evaluated and assigned scores of 1 to 4. The mitral valve morphology score was related to mitral valve area (MVA) measured after MBC by cardiac catheterization. The leaflet mobility score was related to the immediate post-MBC MVA: 2.2 ± 0.8 cm² for grade 1, 1.9 ± 0.7 cm² for grade 2, 1.7 ± 0.7 cm² for grade 3, and 1.9 ± 0.9 cm² for grade 4 (p < 0.001). Results of the MVA after MBC showed a similiar relationship for each echocardiographic variable. The total morphology score (sum of the four variables) showed a weak relationship to MVA immediately after MBC (r = −0.24), which was persistent at 6 months after MBC (r = −0.25). Multiple regression analysis showed that the MVA after MBC is predicted by pre-MBC MVA (p < 0.001), left atrial size (p = 0.01), balloon diameter (p = 0.02), cardiac output (p = 0.004), and leaflet mobility (p = 0.01). The R² of the model was 0.31 (p < 0.001). Total morphology score, leaflet thickness, calcification, and subvalvular disease were not important univariate or multivariate predictors of the results of MBC. These data suggest that although mitral valve morphology, particularly leaflet mobility, relates to MVA after MBC, other variables such as the severity and duration of disease are also important and are influenced by the larger balloon sizes used in the procedure. Mitral valve morphology should not be used alone in the selection of patients for MBC.
Reproducibility of Doppler echocardiographic quantification of aortic and mitral valve stenoses: Comparison between two echocardiography centers
1991, The American Journal of Cardiology
Doppler echocardiography has been widely used as a noninvasive method to quantify valvular heart diseases. This study assessed the variability between 2 echocardiography centers concerning 2-dimensional and Doppler echocardiographic results in the quantification of mitral and aortic valve stenoses. Forty-two patients were studied by 2 different echocardiography centers in a blinded, independent fashion. In patients with aortic and mitral valve stenosis, mean and maximal flow velocities were measured. The aortic valve orifice area was calculated according to the continuity equation. Mitral valve orifice area was determined by direct planimetry and by pressure half-time. In patients with an aortic valve stenosis, a close relation between the 2 centers was found for the maximal and mean flow velocities (coefficient of correlation, r = 0.72 to 0.92; coefficient of variation, 3.7 to 7.7%). A close correlation and a small observer variability was found for the flow velocity ratio determined by flow velocities measured in the left ventricular outflow tract and over the stenotic valve (r = 0.88; coefficient of variation, 0.01 ± 0.009). In contrast, there was a poor correlation between the diameter of the left ventricular outflow tract and the aortic orifice area (r = 0.36 and 0.59, respectively). In patients with a mitral valve stenosis, mean and maximal velocities were closely correlated (r = 0.85 and 0.77, respectively). Velocities were not found to be significantly different between the 2 centers. Variability between the 2 centers for the mitral valve orifice area was 9.8% (2-dimensional echocardiography) and 5.7% (pressure half-time). These results underline the accuracy and excellent reproducibility of Doppler echocardiographic measurements in patients with aortic and mitral valve stenoses. In patients with an aortic valve stenosis, the flow velocity ratio is the most observer- and machine-independent parameter.
In vivo identification of mitral valve fibrosis and calcium by real-time quantitative ultrasonic analysis
1990, The American Journal of Cardiology
Conventional echocardiography provides fundamental information about mitral valve morphology and function but has a relatively low specificity in evaluating valve calcific deposits, which is critical information for the preoperative decision to perform commisurotomy or replacement. In vitro radiofrequency ultrasonic quantitative analysis of the mitral valve has been demonstrated to be a reliable tool in identifying normal, fibrotic and calcific valves. This study evaluates quantitative ultrasound characterization of the mitral valve in vivo. Thirty-three patients, scheduled to undergo mitral valve replacement, and 20 normal subjects (10 young and 10 older control subjects) were studied with a 2.25-MHz transducer. Radiofrequency signal was analyzed by a microprocessor system (used with an M-mode commercially available echocardiograph) for on-line evaluation of ultrasonic backscatter with 8 bits of amplitude resolution, 40-MHz sampling rate and a 1-μs acquisition gate. The integrated value of the rectified radiofrequency signal amplitude was deemed the integrated backscatter index. The highest value recorded with the ultrasonic analysis from each valve was taken as representative and expressed as the percent value with respect to the pericardial integrated backscatter index value of that subject. The 33 excised mitral valves underwent histologic examination. Four groups were identified: young controls (group I, n = 10); older controls age-matched with patients (group II, n = 10); patients with fibrotic mitral valves (group III, n = 13); and patients with calcific mitral valves (group IV, n = 20). A statistically significant (p < 0.01) difference was found among the 4 groups for the percent integrated backscatter index: group 15 ± 2, group II 8 ± 4 (p < 0.05 vs group I), group III 17 ± 9 and group IV 52 ± 30. In conclusion, a microprocessor-based system for online evaluation of radiofrequency ultrasonic signal is able to differentiate normal, fibrotic and calcific mitral valves in vivo.

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^☆: The opinions or assertions expressed herein are those of the authors and are not to be construed as official or as reflecting the views of the Navy Department.

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M-mode and two-dimensional echocardiographic correlation with findings at catheterization and surgery in patients with mitral stenosis☆

Abstract

Am Heart J

Am J Cardiol

Am J Cardiol

Am J Cardiol

The heart

Echocardiography

JAMA