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      Radius of proximal isovelocity surface area in the assessment of rheumatic mitral stenosis: Connecting flow to anatomy and hemodynamics

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          Abstract

          Background

          Echocardiographic assessment of left atrial pressure (LAP) in mitral stenosis (MS) is controversial. We sought to examine the role of the radius of the proximal isovelocity surface area (PISA-r) in the assessment of the hemodynamic status of MS after fixing the aliasing velocity (Val).

          Methods and results

          We studied 42 candidates of balloon mitral valvuloplasty (BMV), for whom pre-BMV echocardiography was done and LAP invasively measured before dilatation. PISA-r was calculated after fixing aliasing velocity to 33 cm/s. In addition, the ratio IVRT/Te’–E was also measured, where IVRT was isovolumic relaxation time, and Te’–E was the time difference between the onset of mitral flow E-wave and mitral annular early diastolic velocity. IVRT/Te’–E and PISA-r showed a strong correlation with LAP (r = −0.715 and −0.637, all p < 0.001) and with right-sided pressures. In addition, PISA-r correlated with mitral valve area by planimetry method (MVA) and with left ventricular outflow tract stroke volume (r = 0.66 and 0.71, all p < 0.001). Receiver operator characteristic curve (ROC-curve) showed that PISA-r was not inferior to IVRT/Te’–E in differentiating LAP ⩾25 from <25 mmHg.

          Conclusion

          Provided that Val is set to a constant of 33 cm/s, PISA-r can assess the hemodynamic status of MS, and seems a simple alternative to the tedious IVRT/Te’–E for estimation of LAP.

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          Most cited references26

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          Modern management of mitral stenosis.

          Blase Carabello (2005)
          Article 0 comments Cited 34 times – based on 0 reviews     Review now
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            Doppler estimation of left ventricular filling pressures in patients with mitral valve disease.

            Sherif Nagueh, G Lawrie, M McCulloch … (2005)
            Conventional Doppler measurements have limitations in the prediction of left atrial pressure (LAP) in patients with mitral valve disease (MVD), given the confounding effect of valve area, left ventricular (LV) relaxation, and stiffness. However, the time interval between the onset of early diastolic mitral inflow velocity (E) and annular early diastolic velocity (Ea) by tissue Doppler imaging (TDI), T(E-Ea), which is well related to the time constant of LV relaxation (tau) in canine and clinical studies, is not subject to these variables. We therefore undertook this study to test its usefulness in a patient population. Two-dimensional Doppler and TDI echocardiography were performed simultaneously with right-heart catheterization in 51 consecutive patients (mean+/-SD age, 64+/-11 years) with MVD: 35 with moderately severe to severe mitral regurgitation (MR) and 16 with moderate to severe mitral stenosis (MS). Among several Doppler measurements, only the mitral E/A ratio, isovolumetric relaxation time (IVRT), and pulmonary venous Ar duration had significant relations with mean pulmonary capillary wedge pressure (PCWP). The ratio of IVRT to T(E-Ea) (for MR, r=-0.92; for MS, r=-0.88; both P or =5 mm Hg. A similar correlation was noted in 13 patients with atrial fibrillation (r=-0.92, P<0.01) and in a prospective group of 14 patients with MR (r=-0.93, P<0.001). The ratio of IVRT to T(E-Ea) or to tau can be readily applied for estimating mean PCWP in patients with MVD and can track changes in PCWP after valve surgery.
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              Impact of atrioventricular compliance on pulmonary artery pressure in mitral stenosis: an exercise echocardiographic study.

              O Agranat, B Rabinowitz, Stanley Feinberg … (2000)
              The decay of the pressure gradient across a stenotic mitral valve is determined by the size of the orifice and net AV compliance (C(n)). We have observed a group of symptomatic patients, usually in sinus rhythm, characterized by pulmonary hypertension (particularly during exercise) despite a relatively large mitral valve area by pressure half-time. We speculated that this discrepancy was due to low atrial compliance causing both pulmonary hypertension and a steep decay of the transmitral pressure gradient despite significant stenosis. We therefore tested the hypothesis that C(n) is an important physiological determinant of pulmonary artery pressure at rest and during exercise in mitral stenosis. Twenty patients with mitral stenosis were examined by Doppler echocardiography. C(n), calculated from the ratio of effective mitral valve area (continuity equation) and the E-wave downslope, ranged from 1.7 to 8.1 mL/mm Hg. Systolic pulmonary artery pressure (PAP) increased from 43+/-12 mm Hg at rest to 71+/-23 mm Hg (range, 40 to 110 mm Hg) during exercise. There was a particularly close correlation between C(n) and exercise PAP (r=-0.85). Patients with a low compliance were more symptomatic (P<0.025). Catheter- and Doppler-derived values for C(n), determined in 10 cases, correlated well (r=0.79). C(n), which can be noninvasively assessed, is an important physiological determinant of PAP in mitral stenosis. Patients with low C(n) represent an important clinical entity, with symptoms corresponding to severe increases in PAP during stress echocardiography.
              Article 0 comments Cited 19 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Alaa Mabrouk Salem Omar
                Journal
                Journal ID (nlm-ta): J Saudi Heart Assoc
                Journal ID (iso-abbrev): J Saudi Heart Assoc
                Title: Journal of the Saudi Heart Association
                Publisher: Elsevier
                ISSN (Print): 1016-7315
                ISSN (Electronic): 2212-5043
                Publication date PMC-release: 12 March 2015
                Publication date (Print): October 2015
                Publication date (Electronic): 12 March 2015
                Volume: 27
                Issue: 4
                Pages: 244-255
                Affiliations
                [a ]Department of Internal Medicine, Medical Division, National Research Centre, Dokki, Cairo, Egypt
                [b ]Department of Cardiology, Ain Shams University, Abbasiya, Cairo, Egypt
                Author notes
                [* ]Corresponding author at: Department of Internal Medicine, Medical Division, National Research Centre, El Buhouth St., Dokki, Cairo 12311, Egypt. Tel.: +20 2 33371362; fax: +20 2 33370931. alaahoda2001@ 123456gmail.com
                Article
                Publisher ID: S1016-7315(15)00007-X
                DOI: 10.1016/j.jsha.2015.03.001
                PMC ID: 4614900
                PubMed ID: 26557742
                SO-VID: 0d155a08-aa63-403c-b416-d937976259c3
                Copyright © © 2015 The Authors
                License:

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 8 February 2015
                Date accepted : 3 March 2015
                Categories
                Subject: Full Length Article

                Keywords: mitral stenosis,mitral valve area,left atrial pressure,proximal isovelocity surface area
                Data availability:
                Keywords: mitral stenosis, mitral valve area, left atrial pressure, proximal isovelocity surface area

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