Rheumatic Mitral Stenosis

Background: Rheumatic fever in childhood is the most common cause of Mitral Stenosis in developing countries. The disease is characterized by damaged and deformed mitral valves predisposing them to scarring and narrowing (stenosis) that results in left atrial hypertrophy followed by heart failure. Presently, echocardiography is the main imaging technique used to diagnose Mitral Stenosis. Despite the high prevalence and increased morbidity, no biochemical indicators are available for prediction, diagnosis and management of the disease. Adopting a proteomic approach to study Rheumatic Mitral Stenosis may therefore throw some light in this direction. In our study, we undertook plasma proteomics of human subjects suffering from Rheumatic Mitral Stenosis (n = 6) and Control subjects (n = 6). Six plasma samples, three each from the control and patient groups were pooled and subjected to low abundance protein enrichment. Pooled plasma samples (crude and equalized) were then subjected to in-solution trypsin digestion separately. Digests were analyzed using nano LC-MS E . Data was acquired with the Protein Lynx Global Server v2.5.2 software and searches made against reviewed Homo sapiens database (UniProtKB) for protein identification. Label-free protein quantification was performed in crude plasma only. Results: A total of 130 proteins spanning 9 – 192 kDa were identified. Of these 83 proteins were common to both groups and 34 were differentially regulated. Functional annotation of overlapping and differential proteins revealed that more than 50% proteins are involved in inflammation and immune response. This was corroborated by findings from pathway analysis and histopathological studies on excised tissue sections of stenotic mitral valves. Verification of selected protein candidates by immunotechniques in crude plasma corroborated our findings from label-free protein quantification.

The Rheumatic mitral stenosis patients are more prone to develop pulmonary dysfunction and the severity of mitral stenosis may influence the degree of lung function impairment. The clinical and haemodynamic features of mitral stenosis are influenced importantly by the level of the pulmonary arterial pressure. Fibrous thickening of the walls of the alveoli and pulmonary capillaries occur commonly in mitral stenosis. Pulmonary function abnormalities, like vital capacity, total lung capacity, maximum breathing capacity, and oxygen uptake per unit of ventilation are reduced. Airway resistance is abnormally increased and diffusion capacity is also reduced. These changes in the lungs are due, to increased transudation of fluid from the pulmonary capillaries into the interstitial and alveolar spaces. However, the increased capacity of the pulmonary lymphatic system to drain excess fluid retards the development of alveolar edema.

Mitral valve disease is a common cause of morbidity and mortality in patient over age of 65. Physical findings and natural history of rheumatic mitral stenosis may differ in older and younger patients. In addition, symptoms of mitral steno- sis may be masked or exacerbated by coexistent coronary artery disease, pulmo- nary disease, hypertension, and other systemic disorders that commonly occur in older adults [7]. According to previous published reports for the treatment of mitral stenosis, the mean age of the patients ranged from 15 to 56 years. One third of the patients who undergo percutaneous mitral valvotomy are >65 years old [8] [9]. In the present single center study that excluded the patients who had

I, Dr.P.RAMACHANDRAN, solemnly declare that this dissertation entitled, Echocardiographic Assessment of Pulmonary Artery Parameters Before and After Successful Percutaneous Transvenous mitral Commissurotomy in Rheumatic Mitral Stenosis” is a bonafide work done by me at the department of Cardiology, Madras Medical College and Government General Hospital during the period 2011 – 2014 under the guidance and supervision of the Professor and Head of the department of Cardiology of Madras Medical College and Government General Hospital, Professor M.S.Ravi M.D.D.M. This dissertation is submitted to The Tamilnadu Dr.M.G.R Medical University, towards partial fulfillment of requirement for the award of D.M. Degree (Branch-II) in Cardiology.

patients with AS. However, its clinical implication and outcome after aortic valve replacement were not systematic- ally evaluated. Some patients may have exaggerated the resting transmitral pressure gradients due to increases in stroke volume after aortic valve replacement. Further stress echocardiographic studies are required to determine whether reduced MVA could produce exercise-induced abnormal physiological fi ndings in patients after aortic valve replacement. Finally, we did not have any validation data regarding 3DTEE quanti fi cation of MAA such as cor- relation with surgical fi ndings, because no patients had undergone both aortic and mitral valve surgery. Further, a multimodality imaging study between 3DTEE and multide- tector CT should be required to validate the accuracy of 3DTEE measurements.

15. Kim JB, Ha JW, Kim JS, Shim WH, Kang SM, Ko YG, et al. Com- parison of long-term outcome after mitral valve replacement or repeated balloon mitral valvotomy in patients with restenosis af- ter previous balloon valvotomy. Am J Cardiol 2007;99:1571-4. 16. Kang DH, Park SW, Song JK, Kim HS, Hong MK, Kim JJ, et al.

Transesophageal echocardiography was then repeated in patients on anticoagulation who were on regular follow-up, and in whom percutaneous transvenous mitral commissurotomy could be considered. Of the 490 patients studied, 163 had left atrial body or left atrial appendage clots. A repeat transesophageal echocardiographic examination was done in 50 patients who had optimal anticoagulation for a period of 6 months. Only 2 of the 17 patients who had left atrial body clots had successful clot dissolution after long-term anticoagulation, while the left atrial appendage clots disappeared in 31 of 33 patients (p<0.001).

Due to rapid urbanisation and overcrowding, Rheumatic Mitral Stenosis remains an important public health concern in developing countries. PTMC has become the procedure of choice in symptomatic patients when the stenotic mitral valve is not heavily calcified and mitral regurgitation is not significant because it is cost effective and safe. This technique may also be used in patients with less favourable anatomic features, particularly in patients who are considered to be at high surgical risk such as pregnant women, very elderly patients, patients with associated Severe Ischemic heart disease or associated other co morbidities i.e., severe pulmonary, renal, or malignant diseases. The results of PTMC are equivalent to those of surgical, open commissurotomy and both give better results than closed mitral commissurotomy.

with high velocity flows on one end of the spectrum (velocities similar to or even exceeding, those observed in sinus rhythm,) and minimal to absent flow on the other end. This represents the wide continuum of LAA contractile contraction to complete paralysis of the appendage. Of mitral and Aortic valve disorders, rheumatic mitral stenosis is most commonly associated with thromboembolism, irrespective of co- existence of MR. AF increase the risk thromboembolism upto 18 times, thrombi associated with MS can be found on either the atrial wall or in its appendage. The Risk of thromboembolism in rheumatic valve stenosis is related to age and low cardiac output, yet it does not correlate well with left atrial size, mitral calcification or severity of mitral stenosis. The Association of MR with thromboembolism correlates with the co- existence of MS.

Introduction: Current echocardiographic parameters have a limitation in assessing mitral valve (MV) apparatus in rheumatic mitral stenosis (MS) pa- tient. In the current study, we use 2 dimensional (2D) longitudinal strain (S) and strain rate (Sr) imaging in evaluating the papillary muscle longitudinal strain (LS) as an objective and quantitative echocardiographic parameter with high reproducibility in the assessment of MV apparatus in patients with mild to moderate rheumatic MS with preserved ejection fraction (EF%). Patients and Method: The study included 40 patients with established diagnosis of MS subdivided in to 31 patients with moderate MS (mean age: 32 ± 5) and 9 patients with mild MS (mean age: 31 ± 6). 20 healthy individuals (mean age 31 ± 6) as a control for cases. The mitral valve area (MVA) was estimated us- ing planimetry and pressure half time (PHT) methods. 2D longitudinal sys- tolic S and Sr imaging was carried out for all participants from the apical long axis (LAX), 4 chamber (4C), 2 chamber (2C) views. Global longitudinal sys- tolic S and Sr were estimated by averaging the 3 apical views. Longitudinal myocardial strain of papillary muscle PMs was assessed by the use of the free strain method from apical 4 chamber view for the antrolateral papillary mus- cle (APM) and apical long axis view for postromedial papillary muscle (PPM). Results: Patients with MS had significantly decreased longitudinal LV systolic S and Sr in comparison with control group (p < 0.001) despite no significant differences in LV EF%, LVESD and LVEDD were determined between the 3 groups. APM-LS and PPM-LS had significantly decreased values in patient with MS in comparison with control group (p < 0.001). Conclusion: Patients with MS and preserved EF% had decreased APM-LS & PPM-LS in compari- son with control group, and had decreased longitudinal LV systolic S and Sr when compared with control group. 2D strain as well as Sr imaging might be a useful method for assessment of mitral valve apparatus in patients with MS & preserved EF%.

Background: Rheumatic heart disease (RHD) is a serious health concern in developing countries. Rheumatic mitral stenosis (RMS) is the most long-term sequel in RHD. The neutrophil to lymphocyte ratio (NLR) is a novel marker, and a higher NLR has been associated with poor clinical outcomes in various cardiovascular disorders. We evaluated the availability of NLR to predict severity of mitral stenosis (MS) in patients with RHD.

Since Inoue et al. introduced balloon mitral valvuloplasty BMV in 1984, this procedure has become the treatment of choice replacing surgical commissurotomy in most of cases [2]. Long-term outcome is favorable, with excellent survival rates without functional disability or need for repeat intervention [3] [4]. The results of BMV in those with adverse valve morphology and in young population are less predictable [5]-[8]. Percutane- ous mitral valvotomy is now the first therapeutical choice for treating mitral stenosis in selected patients [9]. An appropriately sized balloon catheter for a safe stepwise dilation procedure is selected in order to avoid iatrogenic severe mitral regurgitation (MR) during BMV. Various criteria have been proposed for ideal balloon sizing, de- pending on the patient’s height 10 body surface area (BSA), and mitral annulus size [10] [11]. The objective of this study was to describe early results and midterm clinical follow-up of PMV for treatment of rheumatic mitral stenosis in patients at younger age group than previous studies.

Percutaneous mitral balloon commissurotomy is an important treatment option. It is a safe procedure with excellent immediate results signifying that it is a treatment of choice for heterogeneous group of patients with rheumatic mitral stenosis. Exceptional immediate outcome was observed among those who had lower echocardiographic scores and those who were sinus rhythm at presentation. In addition to these, patients with mitral restenosis, pregnancy and majority of calcified valves had optimal result irrespective of age. PMBC in patient with Lutembacher’s syndrome, moderate mitral regurgitation, severe tricuspid regurgitation (TR), mitral stenosis with localized LA appendage clot and high-risk comorbid conditions like thrombocytopenia is feasible and showed satisfactory result in our study population.

Background: Valve-in-Valve (VIV) Transcatheter Aortic Valve Replacement (TAVR) is now the treatment of choice in high-surgical-risk patients with failing aortic bioprosthesis. Although less performed, VIV-Transcatheter Mitral Valve Replacement (TMVR) is a valid treatment option for selected high-risk patients with degenerated mitral bioprostheses. Several cases of elective ViV- TAVR and -TMVR have been reported but only few were performed in critical hemodynamic conditions.

This is to certify that the dissertation entitled “MITRAL VALVE REPLACEMENT WITH CHORDAL PRESERVATION A RETROSPECTIVE ANALYSIS OF OUT COME IN COMPARISON WITH CLASSICAL MITRAL VALVE REPLACEMENT” presented here is the original work done by Dr. N. Girish in the department of cardio thoracic surgery, Govt General Hospital ,Madras Medical college, Chennai 600003, in partial fulfillment of the University rules and regulations for the award of Mch Cardiothoracic degree under our guidance and supervision during the academic period from 2003-2005.

A 28-year-old Caucasian woman was referred to our institution in October 2006 with arthralgias and inter- mittent haemoptysis. She had a missed abortion earlier that year, when she was nine weeks pregnant. Labora- tory findings are shown in Table 1. The patient was diagnosed with primary APS. In November 2006 she presented with exertional dyspnoea and a blowing systo- lic murmur at the apex radiating to the left axilla. Transthoracic echocardiography (TTE) revealed mitral valve leaflet thickening with small vegetations on the edges of both leaflets (Fig 3A,B) and severe MR with backflow into the pulmonary veins (Fig 3C). Repeated blood cultures were negative and there was no other evidence of infectious endocarditis. Results of cardiac catheterization are shown in Table 1. The patient under- went mitral valve replacement in October 2007. Intrao- perative inspection revealed thickened and fibrotic

Currently, the most precise parameter in characterizing PPM is the EOAi [20], which is defined as the EOA of the prosthesis divided by the patient’s BSA. EOAi is in fact the only parameter found to consistently correlate with the postoperative gradient; therefore it is the most widely used. In Western countries, the predominant cause of mitral valve disease is degenerative mitral valve regurgitation. For this population, patients with mitral valve diseases usually have a larger left ventricle volume (left ventricular diastolic diameter) than the eastern Asian population; therefore, implantation of a large size prosthesis to avoid PPM will not have an obvious effect on left ventricular function. Hence, the parameter of EOAi has high feasibility in characterizing PPM for Western populations.

Asymptomatic patients with severe MR having excellent ventricular function (EF > 70%, ESD (end-systolic diameter) < 40 mm) can be safely followed by a “watchful waiting approach” until symptoms, LV dysfunction (EF ≤ 60%, ESD ≥ 45 mm) and pulmonary hypertension develops. Mitral valve surgery is the only treatment for MR which provides substantial relief of symptoms and prevent the development of heart failure [52]. The normal function of the mitral valve apparatus “primes” the left ven- tricle for normal contraction. Operative procedures may interfere the annular-chordal- papillary muscle continuity, results in postoperative LV dysfunction and so the preser- vation of these structures are now considered as a critical feature of MVR (mitral valve replacement) [53]. Reconstructive procedures are carried out in degenerative MR due to mitral valve prolapse and chordal rupture as well as in ischemic functional MR [54]. Percutaneous catheter-based mitral valve repair procedures such as leaflet edge-to-edge repair and mitral annular reduction are currently under clinical evaluation and the pre- liminary results are encouraging [55]. The severely deformed valves in rheumatic heart disease are not suitable for reconstructive surgery and they require MVR [56] and the operation should be desirable before they develop marked LV dysfunction [57] and se- rious symptoms since severe LV dysfunction(EF < 30%) may cause high perioperative mortality [58]. Excellent survival is observed in patients with ESD < 45 mm, EF ≥ 60% and the 5-year survival rate is 40% in ischemic MR and 75% in rheumatic MR. Inter- mediate outcome may occur when LV ESD is 45 - 52 mm and the ejection fraction be- tween 50% - 60%. Poor outcome is associated with values below these limits.

Beneficial Effects of ACE Inhibitors Severe Mitral Stenosis Med J Malaysia Vol 44 No 4 December 1989 Beneficial effects of ACE inhibitors severe mitral stenosis •In V J Sebastian BSc, MBBS, MRCP (UK),[.]

This is to certify that the dissertation titled “ CORRELATION BETWEEN MITRAL ANNULAR SYSTOLIC VELOCITY AND LEFT ATRIAL APPENDAGE FUNCTION IN MITRAL STENOSIS ” is the bonafide original work of Dr. M. S. SELVAKUMARAN, in partial fulfillment of the requirements for D.M. Branch-II (CARDIOLOGY) examination of THE TAMILNADU DR.M.G.R. MEDICAL UNIVERSITY to be held in August 2014.The period of post-graduate study and training was from August 2011 to July 2014.