Should we rely on Doppler measurements in assessment of degenerative mitral stenosis?

    Authors

    Keywords

    mitral stenosis, Doppler echocardiography, 3D echocardiography

    DOI

    https://doi.org/10.15836/ccar2017.125

    Full Text

    **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.

    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
    Cardiologia Croatica
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    Should we rely on Doppler measurements in assessment of degenerative mitral stenosis?

    Extended Abstract
    Issue4
    Published
    Pages125-126
    PDF via DOIhttps://doi.org/10.15836/ccar2017.125
    mitral stenosis
    Doppler echocardiography
    3D echocardiography

    Authors

    Zvonimir Ostojić*ORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Vlatka Rešković LukšićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Jadranka Šeparović HanževačkiORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    *Correspondence email: ostojiczvonimir@gmail.com

    Full Text

    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; p<0.001), with more pronounced risk factors for worse cardiovascular outcome (more hyperlipidemia, worse renal function, and coronary artery disease). Patients with RMS (N=47) had significantly higher rate of atrial fibrillation (47 vs. 35%; p=0.005). According to echocardiographic data patients with DMS had significantly higher left ventricular mass and increased relative wall thickness. They also had more sever and pronounced mitral annular calcification spread to both cusps. Patients with RMS had significantly larger left atrium area (LAA). In line with degenerative process, significant aortic stenosis (AS), defined to be at least moderate in severity, was more common in DMS group with no significant difference in other concomitant valve pathology (Table 1). Total 35 patients had MVA assessed using 3D planimetry. There was a significant difference in MVA when measured by PHT according to other methods irrespectively of MS etiology. In all cases MS was underestimated by PHT (Table 2).

    Table 1: Echocardiographic findings depending on etiology of mitral stenosis.

    IVSd (cm)1
    Degenerative
    1.38±0.35
    Rheumatic
    1.14±0.25
    P
    <0.001
    LVIDd (cm)2
    Degenerative
    4.93±0.68
    Rheumatic
    5.06±0.59
    P
    0.36
    LVPWd (cm)3
    Degenerative
    1.22±0.30
    Rheumatic
    1.02±0.21
    P
    <0.001
    Left ventricular mass (g)
    Degenerative
    267.37±89.11
    Rheumatic
    212.14±58.46
    P
    <0.001
    Relative wall thickness
    Degenerative
    0.51±0.15
    Rheumatic
    0.41±0.1
    P
    <0.001
    Ejection fraction
    Degenerative
    56±8
    Rheumatic
    55±7.6
    P
    0.58
    Mitral annular calcification4
    Degenerative
    2.45
    Rheumatic
    1.46
    P
    <0.001
    Mean pressure gradient
    Degenerative
    5.89±2.91
    Rheumatic
    7.9±4.8
    P
    0.02
    Maximal pressure gradient
    Degenerative
    14.21±5.4
    Rheumatic
    18±8.3
    P
    0.01
    MVA PHT5
    Degenerative
    1.92±0.76
    Rheumatic
    1.55±0.38
    P
    0.02
    MVA VTI6
    Degenerative
    1.26
    Rheumatic
    1.26
    P
    0.07
    LAA7
    Degenerative
    34.24±7.6
    Rheumatic
    42.77±17.23
    P
    0.004
    MI ≥28
    Degenerative
    11 (29%)
    Rheumatic
    20 (42%)
    P
    0.19
    AS ≥29
    Degenerative
    30 (79%)
    Rheumatic
    15 (32%)
    P
    <0.001
    AI ≥210
    Degenerative
    5 (13%)
    Rheumatic
    10 (21%)
    P
    0.32
    TI ≥211
    Degenerative
    8 (21%)
    Rheumatic
    16 (34%)
    P
    0.18
    PH12
    Degenerative
    48±18
    Rheumatic
    55±22
    P
    0.2
    TAPSE13
    Degenerative
    17.8±4.8
    Rheumatic
    17.7±5.3
    P
    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.

    p value
    PHT (2) 1.83±0.64 — VTI3 1.46±0.49
    p=0.019
    PHT 1.83±0.64 — 3D TTE4 1.32±0.45
    p=0.013
    PHT 1.83±0.64 — 3D TOE5 1.20±0.42
    p<0.001
    VTI 1.46±0.49 — 3D TTE 1.32±0.45
    p=0.557
    VTI 1.46±0.49 — 3D TOE 1.20±0.42
    p=0.074
    3D TTE 1.32±0.45 — 3D TOE 1.20±0.42
    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.

    Literature

    1. 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.DOI
    2. 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.DOI