Diagnosis and differential therapy of mitral stenosis
Clinical symptoms and diagnostic findings in patients with mitral stenosis are usually determined by the extent of the stenosis. Compared to a normal mitral valve area (MVA) of > 4 cm2, MVA in patients with severe mitral stenosis is usually reduced to < 1.5 cm2. In older patients symptoms are...
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Published in | Herz Vol. 23; no. 7; pp. 420 - 428 |
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Format | Journal Article |
Language | German English |
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01.11.1998
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Abstract | Clinical symptoms and diagnostic findings in patients with mitral stenosis are usually determined by the extent of the stenosis. Compared to a normal mitral valve area (MVA) of > 4 cm2, MVA in patients with severe mitral stenosis is usually reduced to < 1.5 cm2. In older patients symptoms are frequently influenced by concomitant diseases (e.g. atrial fibrillation, arterial hypertension or lung disease). An important diagnostic element besides anamnesis, auscultation, ECG and chest X-ray is echocardiography, which is required in order to measure non-invasively and reliably the mitral valve gradient (MVG), the MVA and morphologic changes to the valves, as well as concomitant valvular disease, ventricular functions and, where appropriate, left-atrial thrombi. In addition to the surgical treatment of patients with severe mitral stenosis, which has been an established procedure for 50 years, percutaneous balloon mitral valvuloplasty (MVP) has recently established itself as an alternative option. At the current time, the Inoue technique seems to display the most advantages. Following transseptal puncture, the Inoue balloon is guided transvenously into the left atrium and then into the left ventricle using a special support wire. The balloon is short and soft. Its special unfolding character enables it to be placed securely in the mitral valve without any risk of ventricular perforation (Figure 1). As with surgical commissurotomy, balloon valvuloplasty leads to a separation of fused commissures. This results in a significant reduction of MVG, accompanied by an increase in the MVA (Figure 2). The results and success of MVP are influenced by the morphology of the valves and the changes to the subvalvular apparatus. In randomized studies, the results of surgical commissurotomy were comparable with those of balloon mitral valvulotomy. In our hospital, an increase in MVA from 1.0 to 1.8 cm2 could be achieved in 899 patients (mean age 56 +/- 3 years). In younger patients with less significantly changed valves, the results were correspondingly more favorable than in older patients (Figure 3). Provided valve morphology is suitable, a relapse following previous surgical commissurotomy is not a contraindication for MVP. The MVP complication rate is very low in skilled hands: mortality is below 1%; mitral insufficiency occurs in 3 to 10% of interventions; we observed a severe mitral insufficiency in 5% of our patient group. Thromboembolic complications may be prevented after exclusion of atrial thrombi by transesophageal echocardiography. The occurrence of a hemodynamically significant atrial septum defect is a very rare event. The mid-term results (5 to 10 years) and the low restenosis rate following MVP in patients with suitable valves are comparable with those of surgical commissurotomy. In older patients with considerably changed, calcified and fibrotic valves, restenosis may be expected within 1 to 5 years. In these patients MVP represents no more than a palliative intervention in order to prolong the point of surgery, for example in patients where a concomitant aortic valve disease in itself is not yet an indication for surgery. Special indications are to be found in young patients with severe mitral stenosis yet few symptoms, in pregnant females and in emergency situations, as well as in patients with Grade II mitral stenosis with intermittent atrial fibrillation. Catheter therapy is much less invasive than surgery. In case of failure the patient still has the option of surgical therapy. Patients with morphologically significantly altered valves usually receive a valve replacement since an unsuccessful reconstruction would lead to a second operation within a very short time interval. Contraindications for MVP are thrombi in the left atrium, a previously existing > Grade II mitral regurgitation and marked, degenerative destruction of the subvalvular apparatus or extensive calcification of the valves. MVP thus represents a significant addi |
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AbstractList | Clinical symptoms and diagnostic findings in patients with mitral stenosis are usually determined by the extent of the stenosis. Compared to a normal mitral valve area (MVA) of > 4 cm2, MVA in patients with severe mitral stenosis is usually reduced to < 1.5 cm2. In older patients symptoms are frequently influenced by concomitant diseases (e.g. atrial fibrillation, arterial hypertension or lung disease). An important diagnostic element besides anamnesis, auscultation, ECG and chest X-ray is echocardiography, which is required in order to measure non-invasively and reliably the mitral valve gradient (MVG), the MVA and morphologic changes to the valves, as well as concomitant valvular disease, ventricular functions and, where appropriate, left-atrial thrombi. In addition to the surgical treatment of patients with severe mitral stenosis, which has been an established procedure for 50 years, percutaneous balloon mitral valvuloplasty (MVP) has recently established itself as an alternative option. At the current time, the Inoue technique seems to display the most advantages. Following transseptal puncture, the Inoue balloon is guided transvenously into the left atrium and then into the left ventricle using a special support wire. The balloon is short and soft. Its special unfolding character enables it to be placed securely in the mitral valve without any risk of ventricular perforation (Figure 1). As with surgical commissurotomy, balloon valvuloplasty leads to a separation of fused commissures. This results in a significant reduction of MVG, accompanied by an increase in the MVA (Figure 2). The results and success of MVP are influenced by the morphology of the valves and the changes to the subvalvular apparatus. In randomized studies, the results of surgical commissurotomy were comparable with those of balloon mitral valvulotomy. In our hospital, an increase in MVA from 1.0 to 1.8 cm2 could be achieved in 899 patients (mean age 56 +/- 3 years). In younger patients with less significantly changed valves, the results were correspondingly more favorable than in older patients (Figure 3). Provided valve morphology is suitable, a relapse following previous surgical commissurotomy is not a contraindication for MVP. The MVP complication rate is very low in skilled hands: mortality is below 1%; mitral insufficiency occurs in 3 to 10% of interventions; we observed a severe mitral insufficiency in 5% of our patient group. Thromboembolic complications may be prevented after exclusion of atrial thrombi by transesophageal echocardiography. The occurrence of a hemodynamically significant atrial septum defect is a very rare event. The mid-term results (5 to 10 years) and the low restenosis rate following MVP in patients with suitable valves are comparable with those of surgical commissurotomy. In older patients with considerably changed, calcified and fibrotic valves, restenosis may be expected within 1 to 5 years. In these patients MVP represents no more than a palliative intervention in order to prolong the point of surgery, for example in patients where a concomitant aortic valve disease in itself is not yet an indication for surgery. Special indications are to be found in young patients with severe mitral stenosis yet few symptoms, in pregnant females and in emergency situations, as well as in patients with Grade II mitral stenosis with intermittent atrial fibrillation. Catheter therapy is much less invasive than surgery. In case of failure the patient still has the option of surgical therapy. Patients with morphologically significantly altered valves usually receive a valve replacement since an unsuccessful reconstruction would lead to a second operation within a very short time interval. Contraindications for MVP are thrombi in the left atrium, a previously existing > Grade II mitral regurgitation and marked, degenerative destruction of the subvalvular apparatus or extensive calcification of the valves. MVP thus represents a significant addi Clinical symptoms and diagnostic findings in patients with mitral stenosis are usually determined by the extent of the stenosis. Compared to a normal mitral valve area (MVA) of > 4 cm super(2), MVA in patients with severe mitral stenosis is usually reduced to < 1.5 cm super(2). In older patients symptoms are frequently influenced by concomitant diseases (e. g. atrial fibrillation, arterial hypertension or lung disease). An important diagnostic element besides anamnesis, auscultation, ECG and chest X-ray is echocardiography, which is required in order to measure non-invasively and reliably the mitral valve gradient (MVG), the MVA and morphologic changes to the valves, as well as concomitant valvular disease, ventricular functions and, where appropriate, left-atrial thrombi. In addition to the surgical treatment of patients with severe mitral stenosis, which has been an established procedure for 50 years, percutaneous balloon mitral valvuloplasty (MVP) has recently established itself as an alternative option. At the current time, the Inoue technique seems to display the most advantages. Following transseptal puncture, the Inoue balloon is guided transvenously into the left atrium and then into the left ventricle using a special support wire. The balloon is short and soft. Its special unfolding character enables it to be placed securely in the mitral valve without any risk of ventricular perforation (Figure 1). As with surgical commissurotomy, balloon valvuloplasty leads to a separation of fused commissures. This results in a significant reduction of MVG, accompanied by an increase in the MVA (Figure 2). The results and success of MVP are influenced by the morphology of the valves and the changes to the subvalvular apparatus. In randomized studies, the results of surgical commissurotomy were comparable with those of balloon mitral valvulotomy. In our hospital, an increase in MVA from 1.0 to 1.8 cm super(2) could be achieved in 899 patients (mean age 56 plus or minus 3 years). In younger patients with less significantly changed valves, the results were correspondingly more favorable than in older patients (Figure 3). Provided valve morphology is suitable, a relapse following previous surgical commissurotomy is not a contraindication for MVP. The MVP complication rate is very low in skilled hands: mortality is below 1%; mitral insufficiency occurs in 3 to 10% of interventions; we observed a severe mitral insufficiency in 5% of our patient group. Thromboembolic complications may be prevented after exclusion of atrial thrombi by transesophageal echocardiography. The occurrence of a hemodynamically significant atrial septum defect is a very rare event. The mid-term results (5 to 10 years) and the low restenosis rate following MVP in patients with suitable valves are comparable with those of surgical commissurotomy. In older patients with considerably changed, calcified and fibrotic valves, restenosis may be expected within 1 to 5 years. In these patients MVP represents no more than a palliative intervention in order to prolong the point of surgery, for example in patients where a concomitant aortic valve disease in itself is not yet an indication for surgery. Special indications are to be found in young patients with severe mitral stenosis yet few symptoms, in pregnant females and in emergency situations, as well as in patients with Grade II mitral stenosis with intermittent atrial fibrillation. Catheter therapy is much less invasive than surgery. In case of failure the patient still has the option of surgical therapy. Patients with morphologically significantly altered valves usually receive a valve replacement since an unsuccessful reconstruction would lead to a second operation within a very short time interval. Contraindications for MVP are thrombi in the left atrium, a previously existing > Grade II mitral regurgitation and marked, degenerative destruction of the subvalvular apparatus or extensive calcification of the valves. MVP thus represents a significant addition to the spectrum of percutaneous treatments for cardiologic clinical pictures.Original Abstract: Klinische Symptome und diagnostische Befunde bei Patienten mit Mitralstenose werden in der Regel vom Ausmas der Stenose bestimmt. Bei einer normalen Mitralklappenoffnungsflaeche von ueber 4 cm super(2) ist bei Patienten mit hohergradiger Mitralstenose die Mitralklappenoffnungsflaeche meist auf < 1,5 cm super(2) reduziert. Bei aelteren Patienten beeinflussen Begleiterkrankungen haeufig die Symptomatik (zum Beispiel Vorhofflimmern, arterielle Hypertonie und Lungenerkrankungen). Wichtigster Bestandteil der Diagnostik neben Anamnese, Auskultation, EKG und Rontgenaufnahmen des Thorax ist die Echokardiographie, um nichtinvasiv zuverlaessig Mitralklappengradienten, Mitralklappenoffnungsflaeche und morphologische Veraenderungen der Klappen sowie begleitende Vitien, Ventrikelfunktionen und eventuelle linksatriale Thromben zu erfassen. Neben den seit 50 Jahren bewaehrten chirurgischen Behandlungsverfahren bei Patienten mit hochgradiger Mitralstenose hat sich in den letzten Jahren die perkutane Ballonmitralvalvuloplastie etabliert. Zum gegenwaertigen Zeitpunkt scheint die Inoue-Technik die meisten Vorteile aufzuweisen. Nach transseptaler Punktion wird der Inoue-Ballon transvenos ueber einen speziellen Wechseldraht in den linken Vorhof und nachfolgend in den linken Ventrikel vorgebracht. Eine spezielle Entfaltungscharakteristik erlaubt eine sichere Plazierung im Bereich der Mitralklappe ohne Gefahr von Ventrikelrupturen durch den Ballon (Abbildung 1); spezielle im Ventrikel liegende steife Unterstuetzungsdraehte sind nicht erforderlich, so das mit dieser Methode bisher keine Vetrikelrupturen Beschrieben wurden. Wie bei einer chirurgischen Kommissurotomie fuehrt die Ballonvalvuloplastie zu einer Separation der verwachsenen Kommissuren. Es kommt zu einer deutlichen Reduktion des Mitralklappengradienten mit begleitender Zunahme der Mitralklappenoffnungsflaeche (Abbildung 2). Die Ergebnisse und Erfolge der Ballonmitralvalvuloplastie werden stark von der Morphologie der Klappen und der Veraenderungen des subvalvulaeren Apparates bestimmt. In randomisierten Studien waren die Ergebnisse der chirurgischen Kommissurotomie mit denen der Ballonmitralvalvulotomie vergleichbar. In unserer Klinik wurde bei 899 Patienten mit einem mittleren Alter von 56 plus or minus 3 Jahren eine Zunahme der Klappenoffnungsflaeche von 1,0 auf 1,8 cm super(2) erzielt. Bei juengeren Patienten mit weniger stark veraenderten Klappen waren die Ergebnisse entsprechend guenstiger als bei aelteren Patienten (Abbildung 3); auch ein Rezidiv nach vorausgegangener chirurgischer Kommissurotomie stellt bei geeigneter Klappenmorphologie keine Kontraindikation fuer eine Ballonmitralvalvuloplastie dar. Die Komplikationsrate ist in geuebter Hand sehr niedrig: Die Letalitaet liegt. unter 1%; mit dem Auftreten einer schweren Mitralinsuffizienz mus bei 3 bis 10% der Eingriffe gerechnet werden; in unserem Kollektiv haben wir eine hohergradige Mitralinsuffizienz bei 5% der Eingriffe beobachtet. Thromboembolische Komplikationen lassen sich mit Ausschlus von Vorhofthromben durch eine transosophagiale Echokardiographie verhindern. Das Auftreten eines haemodynamisch bedeutsamen Vorhofseptumdefekts ist eine Ausnahme. Die mittelfristigen Ergebnisse (fuenf bis zehn Jahre) und die niedrige Restenosierungsrate nach Ballonmitralvalvuloplastie bei Patienten mit geeigneten Klappen sind denen der operativen Kommissurotomie vergleichbar. Bei aelteren Patienten mit stark veraenderten, verkalkten und fibrosierten Klappen ist mit einer Restenosierung innerhalb von ein bis fuenf Jahren zu rechnen; bei diesen Patienten stellt die Ballonmitralvalvuloplastie nur einen palliativen Eingriff dar, um den Operationszeitpunkt hinauszuzogern, zum Beispiel bei Patienten mit einem begleitenden Aortenklappenvitium, das allein noch keine Operationsindikation darstellt. Besondere Indikationen ergeben sich bei jungen, noch wenig symptomatischen Patienten mit hochgradiger Mitralstenose, bei Schwangeren und in Notfallsituationen sowie bei Patienten mit Mitralstenose vom Schweregrad II mit intermittierendem Vorhofflimmern. Im Vergleich zur operativen Behandlung ist die Kathetertherapie sehr viel weniger invasiv; da die Letalitaet ausgesprochen niedrig ist, bleibt den Patienten auch im Fall eines Miserfolgs die Moglichkeit der operativen Therapie. Dem ist gegenueberzustellen, das Patienten mit morphologisch staerker veraenderten Klappen bei der Operation in der Regel einen Klappenersatz erhalten, da durch eine mislungene Rekonstruktion kurzfristig eine Zweitoperation erforderlich wuerde. Kontraindikationen der Ballonmitralvalvuloplastie sind Thromben im linken Vorhof, eine vorbestehende Mitralinsuffizienz > Grad II und ausgepraegte destruktive Veraenderungen oder fortgeschrittene Verkalkungen der Klappen. Somit stellt die Ballonmitralvalvuloplastie eine bedeutsame Erweiterung des Spektrums perkutaner Behandlungsverfahren kardiologischer Krankheitsbilder dar. |
Author | Schmidt, H K Mannebach, H Bogunovic, N Fassbender, D Seggewiss, H |
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SubjectTerms | Angioplasty, Balloon, Coronary - trends Catheterization - trends Humans Mitral Valve Stenosis - diagnosis Mitral Valve Stenosis - therapy |
Title | Diagnosis and differential therapy of mitral stenosis |
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