The investigation of the calcium metabolism changes in rheumatic mitral valve patients

Objectives: Rheumatic mitral valve disease (RMVD) is associated with autoimmune heart valve injury. Parathyroid hormone (PTH) and vitamin D are two essential molecules that have effects on the immune system. In this study, we aimed to evaluate the relationship between PTH and vitamin D in patients with RMVD. Patients and Methods: We investigated 81 patients with RMVD and 75 healthy subjects. According to Wilkins score, baseline clinical, laboratory, and echocardiographic parameters were recorded, and all RMVD patients were analyzed. Multivariate logistic regression analysis was performed between the groups. Results: Vitamin D levels were significantly low in the RMVD group. Patients were stratified according to Wilkins score [Wilkins score < 7 (n:50) vs. Wilkins score 7 (n:31)]. Age, BMI, and PTH were significantly higher, and mitral valve area was significantly lower in Wilkins score 7 patients. In multivariate analysis, age (OR: 1.052; 95% CI 1.005-1.100, p=0.028) and PTH (OR: 1.017; 95% CI 1.000-1.033, p=0.047) were found to be independent predictors of high Wilkins score. Conclusion: This study showed that vitamin D levels were low in patients with RMVD. According to the Wilkins score, PTH levels were significantly high in patients with high Wilkins score. The contrary changes in PTH and vitamin D levels may trigger inflammation and be responsible for valve damage.

Measurement of Mitral Valve Area By Direct Three Dimensional Planimetry Compared To Multiplanar Reconstruction In Patients With Rheumatic Mitral Stenosis

Background: Mitral valve area (MVA) measurement by three-dimensional transesophageal echocardiography (3D-TEE) has a crucial role in the evaluation of mitral stenosis (MS) severity. Three-dimensional direct (3D-direct) planimetry has been proposed as a new technique to measure mitral valve area. This study aimed to compare the 3D-direct mitral valve planimetry to conventional three-dimensional multiplanar reconstruction (3D-MPR) in severe mitral stenosis (MS) using 3D-TEE.Methods: 149 patients with severe MS who were referred for percutaneous transmitral commissurotomy (PTMC), prospectively recruited. All patients underwent 2D transthoracic echocardiography (2D-TTE) and 3D-TEE in a single session before PTMC. During 2D-TTE planimetry, pressure half time (PHT), and proximal isovelocity surface area (PISA) were applied to measure the MVA. Transmitral mean pressure gradient (MPG) was measured. During 3D-TEE, MVA planimetry was carried out with both 3D-direct and 3D-MPR methods. 3D-direct was applied from both atrial and ventricular views. The consistency of MVA measurements with 3D-direct, 3D-MPR, and 2D-TTE methods was statistically investigated.Results: Our sample consisted of 109 (73.2%) women and 40 (26.8%) men. The mean age was 51.75 ± 9.81 years. The agreement between 3D-direct and 3D-MPR planimetry was significant and moderate (0.99 ± 0.29 cm2 vs. 1.12 ± 0.26 cm2, Intraclass Correlation = 0.716, p value =0.001).The accuracy of the 3D-direct method reduced significantly compared to the MPR method at MVA > 1.5 cm2. The maximum difference between two methods was observed in cases with MVAs larger than 1.5 cm2. MVA measured with the 3D-MPR method was significantly correlated with a 2D-TTE method, with a moderate agreement (Intraclass Correlation = 0.644, p value = 0.001). Also, 2D-TTE and 3D-direct TEE techniques yielded significantly consistent measurements of the MVA (1.06 ± 0.026 cm2 vs. 0.99 ± 0.29 cm2, Intraclass Correlation = 0.787, p value = 0.001); however, with a slight overestimation of the MVA by the former with a net difference of 0.06 ± 0.013 cm2. Mitral valve pressure gradient (MPG) had no significant correlation with planimetry results. A significant inverse correlation was seen between the MVA and pulmonary arterial systolic pressure.Conclusion: 3D-direct planimetry has an acceptable agreement with 3D-MPR planimetry at MVA less than 1.5 cm2, but their correlation decreases significantly at MVA above 1.5 cm2. 3D-direct planimetry underestimates MVA compared to 3D-MPR, especially at MVA above 1.5 cm2. The 2D-TTE planimetry has generally acceptable accuracy, but its correlation to the 3D-TEE methods is significantly reduced in cases with moderate to severe MS (i.e. MVA> 1.0cm2).

Assessment of mitral valve area by 3D planimetry after percutaneous mitral valve repair

Background Percutaneous mitral valve (MV) repair has become an effective therapeutic alternative to MV surgery in high-risk surgical patients with severe MR. Persistent pulmonary hypertension after mitral valve replacement has shown an increased risk of morbidity and mortality. Improvement of pulmonary systolic arterial pressure (PSAP) post-MitraClip has been reported, however relative mitral stenosis may hamper this benefit. Few data is available regarding the best echocardiographic parameter to determine mitral stenosis after the procedure. Purpose To evaluate the correlation between the residual mitral valve area (MVA) by 3D planimetry, the pressure half time (PHT) and the transmitral gradient after percutaneous edge-to-edge mitral repair. Methods This is a single-center, retrospective study. We enrolled 88 consecutive patients who underwent a percutaneous MV repair with the MitraClip system between 2010 and 2020 at our tertiary university hospital, with eligibility evaluation by transesophageal echocardiogram (TEE). All patients had moderate to severe (3+) or severe (4+) primary or secondary MR. Results The mean age was 76.2±10.4 years and 64.8% of the patients were male. Above 88% of patients were in New York Heart Association class III/IV. Baseline 3D planimetry MVA was 5.3±1.4cm2 and mean gradient pre-implantation was 1.8±0.8mmHg. After the procedure, MVA reduced to 2.9±0.8cm2 and mean gradient was 2.8±1.4mmHg. Both 3D planimetry and mean gradient were very significantly correlated (r −0.5; p&lt;0.001) (Figure 1), whereas no correlation was note between mean gradient and PHT (r 0.17; p=0.117) Conclusion After MitraClip implantation, the assessment of mitral valve area by 3D planimetry is significantly correlated with the transmitral mean gradient, unlike PHT. FUNDunding Acknowledgement Type of funding sources: None. Figure 1. Correlation of post-procedural 3D MVA and transmitral mean gradient

Correlation between mitral CT calcium score and Wilkin's score in rheumatic mitral stenosis: added value of cardiac CT

Introduction Wilkin's score, as one of the predictors used to determine the transcatheter or surgical approach may be lacking in objectivity because of potential inter-observer variability. Materials and methods A cross-sectional pilot study was done to assess the correlation between Wilkin's score and Wilkin's Calcium score to the result of the Mitral Computed Tomography Calcium Score. Result Mitral computed tomography calcium score has moderate to strong correlation to Wilkin's calcium score (Correlation 0.738 (Strong correlation), p 0.01) and Wilkin's score (Correlation 0.626 (Moderate correlation), p 0.039). Two of the samples showed zero calcium ct score; however, they scored two in Wilkin's calcium score. Meanwhile, mitral computed tomography calcium score has a weak correlation to the mitral valve area (Correlation −0.294 (Weak correlation), p 0.38 – Statistically not significant). Instead, Wilkin's Calcium Score and Wilkins Score have moderate to strong correlation to the mitral valve area (Correlation −0.609 (Moderate correlation), p 0.047; Correlation −0.722 (Strong correlation), p 0.012). Conclusion Mitral CT calcium score may be incorporated or complement the Wilkin's Score to assess the viability of using percutaneous balloon mitral valvuloplasty (PBMV) as the treatment of choice for mitral stenosis. This is a consideration that Mitral CT calcium score is free from inter-observer variability and thus becomes a gold standard to assess calcium content in the mitral valve. FUNDunding Acknowledgement Type of funding sources: None.

Impact of Left Atrial Volume Index on Discrepancy in Mitral Valve Area Assessed by Two-Dimensional Planimetry and Three-Dimensional Multi-Planar Reconstruction Technique

Background: Mitral valve area (MVA) is technically measured using both two-dimensional (2D) planimetry and three dimensional multi planar reconstruction (3D-MPR) techniques; however, studies have always overestimated MVA using the former method. Objectives: This study aimed to assess the correlation between MVA assessed by 2D and 3D techniques and the impact of left atrial volume index (LAVI) on the discrepancy between MVA assessed by two echocardiography techniques. Methods: The data of 75 patients with moderate to severe mitral stenosis assessed by both 2D planimetry and 3D-MPR techniques were retrospectively reviewed. Clinical and echocardiographic variables were evaluated. Left atrial (LA) volume was determined using biplane area-length method. Results: The mean MVA assessed by the 2D and 3D techniques was 1.03±0.24 cm2 and 0.99±0.25 cm2 with a mean discrepancy of 0.04±0.15 cm2, respectively. A strong association was observed between the MVA values assessed by 2D planimetry and 3D-MPR methods (r coefficient = 0.817, P<0.001) indicating a slight discrepancy between the two techniques in assessing MVA measure. The pointed discrepancy was affected by none of the baseline characteristics and LAVI value. There was an adverse association between LAVI value and MVA measured by both 2D planimetry (r coefficient = -0.291, P= 0.011) and 3D-MPR (r coefficient=-0.260, P=0.024). Conclusion: In contrast to the left atrial dimension, the discrepancy in MVA values assessed by 2D planimetry and 3D-MPR is not influenced by LAVI adjusted for baseline parameters.

Mid-term (up to 12 years) clinical and echocardiographic outcomes of percutaneous transvenous mitral commissurotomy in patients with rheumatic mitral stenosis

Background Rheumatic heart disease (RHD) is still a concerning issue in developing countries. Among delayed RHD presentations, rheumatic mitral valve stenosis (MS) remains a prevalent finding. Percutaneous transvenous mitral commissurotomy (PTMC) is the intervention of choice for severe mitral stenosis (MS). We aimed to assess the mid-term outcome of PTMC in patients with immediate success. Methods In this retrospective cohort study, out of 220 patients who had undergone successful PTMC between 2006 and 2018, the clinical course of 186 patients could be successfully followed. Cardiac-related death, undergoing a second PTMC or mitral valve replacement (MVR) were considered adverse cardiac events for the purpose of this study. In order to find significant factors related to adverse cardiac outcomes, peri-procedural data for the studied patients were collected.The patients were also contacted to find out their current clinical status and whether they had continued secondary antibiotic prophylaxis regimen or not. Those who had not suffered from the adverse cardiac events were additionally asked to undergo echocardiographic imaging, in order to assess the prevalence of mitral valve restenosis, defined as mitral valve area (MVA) < 1.5 cm2 and loss of ≥ 50% of initial area gain. Results During the mean follow-up time of 5.69 ± 3.24 years, 31 patients (16.6% of patients) had suffered from adverse cardiac events. Atrial fibrillation rhythm (p = 0.003, HR = 3.659), Wilkins echocardiographic score > 8 (p = 0.028, HR = 2.320) and higher pre-procedural systolic pulmonary arterial pressure (p = 0.021, HR = 1.031) were three independent predictors of adverse events and immediate post-PTMC mitral valve area (IMVA) ≥ 2 cm2 (p < 0.001, HR = 0.06) was the significant predictor of event-free outcome. Additionally, follow-up echocardiographic imaging detected mitral restenosis in 44 patients (23.6% of all patients). The only statistically significant protective factor against restenosis was again IMVA ≥ 2 cm2 (p = 0.001, OR = 0.240). Conclusion The mid-term results of PTMC are multifactorial and may be influenced by heterogeneous peri-procedural determinants. IMVA had a great impact on the long-term success of this procedure. Continuing secondary antibiotic prophylaxis was not a protective factor against adverse cardiac events in this study. (clinicaltrial.gov registration: NCT04112108).

Two-dimensional-Wilkins and real-time transesophageal three-dimensional scoring systems: Which one is preferred to mitral valve morphological assessment?

Background To quantify valvular morphological assessment, some two-dimensional (2D) and three-dimensional (3D) scoring systems have been developed to target the patients for balloon mitral valvuloplasty; however, each scoring system has some potential limitations. To achieve the best scoring system with the most features and the least restrictions, it is necessary to check the degree of overlap of these systems. Also the factors related to the accuracy of these systems should be studied. We aimed to determine the correlation between the 2D Wilkins and real-time transesophageal three-dimensional (RT3D-TEE) scoring systems. Methods This cross-sectional study was performed on 156 patients with moderate to severe mitral stenosis who were candidates for percutaneous balloon valvuloplasty. To morphologic assessment of mitral valve, patients were examined by 2D-transthoracic echocardiography and RT3D-TEE techniques on the same day. Results A strong association was found between total Wilkins and total RT3D-TEE scores (r = 0.809, p < 0.001). The mean mitral valve area assessed by the 2D and 3D was 1.07 ± 0.25 and 1.03 ± 0.26, respectively, indicating a mean difference of 0.037 cm2 (p = 0.001). We found a strong correlation between the values of mitral valve area assessed by 2D and 3D techniques (r = 0.846, p < 0.001). Conclusion There is a high correlation between the two scoring systems in terms of evaluating dominant morphological features. Partially, mitral valve area overestimation in the 2D-transthoracic echocardiography and its inability to assess commissural involvement as well as its dependence on patient age were exceptions in this study.