Authors

• Zvonimir Ostojić — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0003-1762-9270
• Vlatka Rešković Lukšić — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-4721-3236
• Jadranka Šeparović Hanževački — University Hospital Centre Zagreb, Zagreb, Croatia — ORCID: 0000-0002-3437-6407

Abstract

**Introduction**: Compared to rheumatic mitral stenosis (RMS), degenerative mitral stenosis (DMS) is usually described as less sever. For the severity assessment echocardiographic Doppler parameters are often used, despite the well known possibility of DMS severity underestimation due to the influence myocardial diastolic function and concomitant valve patohlogy. (1, 2) The aim of this study was to compare severity of DMS compared to RMS and to determine whether Doppler parameters underestimate severity of DMS compared to other echocardiographic measurements. **Methods**: We preformed a single center, retrospective, observational study including all patients who were diagnosed with mitral stenosis in past three years. Data were reanalyzed using fully digital echocardiographic database and hospital charts. Mitral stenosis (MS) was defined as turbulent flow with mean diastolic gradient >2 mmHg across mitral valve (MV) in conjunction with morphologic changes. In patients who had 3D examinations made, mitral valve area (MVA) was calculated according to pressure half time (PHT), continuity equation, 3D transthoracic echocardiography, and 3D transoesophageal echocardiography. **Results**: Patients with DMS (N=38, female N=23; 60.5%) compared to patients with RMS were significantly older (80±9.4 vs. 67±7.1; p1** | 1.38±0.35 | 1.14±0.25 | 2** | 4.93±0.68 | 5.06±0.59 | 0.36 | | **LVPWd (cm)3** | 1.22±0.30 | 1.02±0.21 | 4** | 2.45 | 1.46 | 5** | 1.92±0.76 | 1.55±0.38 | 0.02 | | **MVA VTI6** | 1.26 | 1.26 | 0.07 | | **LAA7** | 34.24±7.6 | 42.77±17.23 | 0.004 | | **MI ≥28** | 11 (29%) | 20 (42%) | 0.19 | | **AS ≥29** | 30 (79%) | 15 (32%) | 10** | 5 (13%) | 10 (21%) | 0.32 | | **TI ≥211** | 8 (21%) | 16 (34%) | 0.18 | | **PH12** | 48±18 | 55±22 | 0.2 | | **TAPSE13** | 17.8±4.8 | 17.7±5.3 | 0.9 | [†] 1Intraventricular septal width in diastole; 2Left ventricle internal dimension in diastole; 3Left ventricle posterior wall width in diastole; 4Mitral annulus calcification: 1- annular calcification; 2- calcification extend 1/2 of mitral cusp; 5Mitral valve area calculated using pressure half time; 6Mitral valve area calculated using velocity time integral; 7Left atrium area; 8Mitral insufficiency at least moderate in severity; 9Aortic stenosis at least moderate in severity; 10Aortic insufficiency at least moderate in severity; 11Tricuspid insufficiency at least moderate in severity; 12Systolic pressure in pulmonary artery; 13Tricuspid annular plane systolic excursion. ### Table 2: Comparison of calculated mitral valve area with different echocardiographic methods. | **MVA** (1) **calculation** | PHT (2) 1.83±0.64 — VTI3 1.46±0.49 | PHT 1.83±0.64 — 3D TTE4 1.32±0.45 | PHT 1.83±0.64 — 3D TOE5 1.20±0.42 | VTI 1.46±0.49 — 3D TTE 1.32±0.45 | VTI 1.46±0.49 — 3D TOE 1.20±0.42 | 3D TTE 1.32±0.45 — 3D TOE 1.20±0.42 | | --- | --- | --- | --- | --- | --- | --- | | **p value** | p=0.019 | p=0.013 | p<0.001 | p=0.557 | p=0.074 | p=0.491 | [†] 1Mitral valve area; 2Pressure half time; 3Velocity time integral; 43 dimensional transthoracic echocardiography; 53 dimensional transesophageal echocardiography **Conclusion**: As expected, patients with DMS are older, with higher rate of comorbidities and higher prevalence of significant AS. On the other hand, patients with RMS had larger LAA and more often AF. Our results indicate that Doppler assessment of MS, using PHT, significantly underestimates severity of MS in DMS patients when compared with other methods, especially 3D planimetry. Furthermore, the same observations are described in our group of patients with RMS. In our opinion, cause of misleading PHT measurement might be of different cause between groups, but this requires further studies.

Keywords

mitral stenosis, Doppler echocardiography, 3D echocardiography

DOI

Literature

1. Oktay AA, Gilliland YE, Lavie CJ, Ramee SJ, Parrino PE, Bates M, et al. Echocardiographic Assessment of Degenerative Mitral Stenosis: A Diagnostic Challenge of an Emerging Cardiac Disease. Curr Probl Cardiol. 2017 Mar;42(3):71–100. https://doi.org/10.1016/j.cpcardiol.2017.01.002
2. Pasca I, Dang P, Tyagi G, Pai RG. Survival in Patients with Degenerative Mitral Stenosis: Results from a Large Retrospective Cohort Study. J Am Soc Echocardiogr. 2016 May;29(5):461–9. https://doi.org/10.1016/j.echo.2015.12.012