Details
Category: Volume 06 Issue 07 July 2018
Hits: 1038

Title: A Study of Assessment of Mitral valve area before and after percutaneous balloon mitral valvuloplasty using Mitral leaflet separation index in a tertiary care center

Authors: Dr Nambirajan Jayabalan, Dr Ravishankar Govindarajulu, Dr Swaminathan Nagarajan, Dr Elamaran Chidambaram, Dr Prathap kumar Gorijavaram

 DOI:  https://dx.doi.org/10.18535/jmscr/v6i7.178

Abstract

Background: Rheumatic fever and rheumatic heart disease continue to be endemic and leads the major acquired heart disease in India and other developing countries. The incidence of rheumatic fever and rheumatic mitral stenosis is very high in our country, having an incidence of 25-45% of the acquired heart disease, with a women to men ratio of 2:1. Percutaneous balloon mitral commissurotomy is the best mode of nonsurgical treatment offering better results in suitable valves. Mitral leaflet separation (MLS) index is one of the best method to assess the severity of mitral stenosis. The aim of this study is to   assess the Mitral valve area before and after percutaneous balloon mitral valvuloplasty using Mitral leaflet separation index in a tertiary care center

Methods: A retrospective study was done in the Institute of Cardiology, Madras Medical College, Chennai, Tamil nadu. Fifty patients with rheumatic mitral stenosis who underwent Percutaneous balloon mitral commissurotomy were evaluated clinically and echocardiographically during and after the procedure. In all patients the Mitral valve stenosis severity was assessed using mitral valve area in 2D echo by planimetry, pressure half time and mitral leaflet separation index. The mitral leaflet separation index (MLS) was estimated by measuring average of distance between the maximal separation of tip of  mitral valve leaflets in end-diastole in parasternal long axis and four chamber  echocardiographic views.

Results: In our study, the mean age of the population was 20.51 ± 10.22 years and included mostly female gender (83%). The mitral valve area measured after Balloon valvotomy increased from 0.80 ± 0.13 cm2 to 1.65 ± 0.36 cm2 as measured by echocardiography. Pre procedure PTMC the mean MVA (PHT) was 0.80 ± 0.25 cm2 and MLS index was 5.75 to 6.25 mm. and after the procedure (PTMC) the mean MVA (PHT) was 1.65 ± 0.36 cm2 and Mitral leaflet separation index (MLSI) was 10.22 to 15.55 mm.  In our study we noted, better correlation between the measured mitral valve area by echocardiography and mitral leaflet separation index (MLSI) (r = 0.36, p= 0.0132) and also between MVA (PHT) and mitral leaflet separation index (MLSI) (r = 0.54, p = 0.0001).

Conclusion: By using simple non invasive, easily available echocardiography method, the mitral leaflet separation index (MLSI) we can assess the severity of mitral stenosis before and after Percutaneous balloon mitral commissurotomy (PTMC).

References

  1. Padmavathi S. Present status of Rheumatic fever and rheumatic heart disease in India. Indian Heart Journal 1995;47: 395-398.
  2. Padmavathi S. Rheumatic fever and rheumatic heart disease in India at the turn of the Century. Indian Heart Journal 2002; 53: 35-37.
  3. Rheumatic fever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva 29 October - 1 November 2001. WHO technical report series; 923.Geneva: World Health Organisation, 2004.
  4. WHO Technical Report, Series. Rheumatic fever and rheumatic heart disease: 1 November 2001. Geneva: WHO; 200
  5. IB Vijayalakshmi. Rheumatic Fever, Rheumatic Heart Disease Registry and Control Program. IB Vijayalakshmi ed. Acute Rheumatic Fever and Chronic Rheumatic Heart disease. 2011. Jaypee Brothers Medical Publishers. India. P324-336.
  6. Mishra TK, Acute Rheumatic Fever and Rheumatic Heart Disease: Current Scenario. Indian Academy of Clinical Medicine 2007;8:324-30.
  7. Ntusi NB, Mayosi BM. Epidemiology of heart failure in sub-Saharan Africa. Expert Rev Cardiovasc Ther. 2009;7:169.
  8. Vijayalakshmi IB, Mithravinda J, Deva AN. The role of echocardiography in diagnosing carditis in the setting of acute rheumatic fever. Cardiol Young 2005; 15: 583–588
  9. Bocchi EA, Guimaraes G, Tarasoutshi F, et al.. Cardiomyopathy: adult valve disease and heart failure in South America. Heart. 2009;95:181.
  10. Olson LJ, Subramanian R, Ackermann DM, et al.. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clin Proc. 1987;62:22.
  11. Horstkotte D, Niehues R, Strauer BE. Pathomorphological aspects: aetiology and natural history of acquired mitral valve stenosis. Eur Heart J. 1991;12:55.
  12. Carroll JD, Feldman T. Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis. JAMA. 1993;270:1731.
  13. Inoue K, Owaki T, Nakamura T, et al.. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg. 1984;87:394.
  14. Lock JE, Khalilullah M, Shrivastava S, et al.. Percutaneous catheter commissu-rotomy in rheumatic mitral stenosis. N Engl J Med. 1985;313:1515.
  15. Otto CM. Valvular heart disease: mitral stenosis. Philadelphia Saunders. Vol.252, 2nd ed. 2004. p. 255.
  16. Bonow RO, Carabello BA, Chatterjee K, et al.. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): Developed in collaboration with the Society of Cardiovascular Anesthesiolo-gists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation. 2006;114:184.
  17. Inoue K, Feldman T. Percutaneous transvenous mitral commissurotomy using Inoue balloon catheter. Cathet Cardiovasc Diagn. 1993;28:119.
  18. Wilkins GT, Weyman AE, Abascal VM, et al.. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardio-graphic variables related to outcome and the mechanism of dilatation. Br Heart J. 1988;60:299.
  19. Feigenbaum H, Armstrong WF, Ryan T, et al. Feigenbaum’s Echocardiography. Mitral valve disease. Lippincott Williams & Wilkins. Vol. 11, 6th ed.; 2005. p.30
  20. Vahanian A, Baumgartner H, Bax J, et al.. Guidelines on the management of valvular heart disease: the Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J. 2007;28:230.
  21. Messika-Zeitoun D, Lung B, Brochet E, Himbert D, et al. Evaluation of mitral stenosis. Arch Cardiovasc Dis. 2008; 653:63.
  22. Rifaie O, Abdel-Dayem MK, Ramzy A, Ezz-El-Din H, et al. Percutaneous mitral valvotomy versus closed surgical commissurotomy: up to 15 years of follow-up of a prospective randomized study. J Cardiol. 2009; 53:28–34.
  23. Faletra F, Pezzano Jr A, Fusco R, Mantero A, et al.. Measurement of mitral valve area in mitral stenosis: four echocardiographic methods compared with direct measurement of anatomic orifices. J Am Coll Cardiol. 1996;28:1190.
  24. Seow SC, Koh LP, Yeo TC. Hemodynamic significance of mitral stenosis: use of a simple, novel index by 2- dimensional echocardiography. J Am Soc Echocardiogr. 2006;19:102–106.
  25. Fisher ML, Parisi AF, Plotnick GD, DeFelice CE, et al.. Assessment of severity of mitral stenosis by echocardiographic leaflet separation-. Intern Med. 1979;139:402.
  26. Holmin C, Messika-Zeitoun D, Mezalek AT, Brochet E, et al.. Mitral leaflet separation index: a new method for the evaluation of the severity of mitral stenosis? Usefulness before and after percutaneous mitral commissurotomy. J Am Soc Echocardiogr. 2007;1119:24.
  27. Duggal B, Bajaj M, Prabhu S, Mathew M. The mitral leaflet separation index for assessment mitral stenosis during percutaneous mitral commissurotomy: validation of the index in the immediate post PMC period. Echocardiography. 2012;9:10
  28. Fawzy ME, Shoukri M, Al Buraiki J, Hassan W, et al.. Seventeen years’ clinical and echocardiographic follow up of mitral balloon valvuloplasty in 520 patients, and predictors of long-term outcome. J Heart Valve Dis. 2007;16 (454):60.
  29. Boscarini M, Repetto S, Secchin G, Stifani A, et al.. Percutaneous mitral commissu-rotomy: immediate and short-term result. G Ital Cardiol. 1991;21 (1185):94.

Corresponding Author

Dr Ravishankar Govindarajulu

Professor of Cardiology, Institute of Cardiology, Madras Medical College, Chennai, India