© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12799
Echocardiography
ORIGINAL INVESTIGATION
The Effects of Successful Percutaneous Mitral Balloon Valvuloplasty on Acute and Intermediate Term Aortic Stiffness € kay Nar, M.D.,* Mustafa Kemal Erol, M.D.,† Selami Demirelli, M.D.,† Sinan Inci, M.D.,* Go Hakan Duman, M.D.,† Serkan Serdar, M.D.,† and Fatih Erol, M.D.† *Department of Cardiology, State Hospital Aksaray, Aksaray, Turkey; and †Department of Cardiology, Ataturk University Medical Faculty, Erzurum, Turkey
Aim: The aim of this study was to evaluate the effects of percutaneous mitral balloon valvuloplasty (PMBV) on short- and intermediate-term aortic stiffness in patients with mitral stenosis. Materials and Methods: This prospective study included 56 patients with critical mitral stenosis in normal sinus rhythm (68% female; mean age: 42 11 years) and 37 healthy controls. Aortic stiffness was measured using transthoracic echocardiography before PMBV, and 24–48 hours and 1 year post procedure. Results: Aortic strain and distensibility were significantly higher in the patients with mitral stenosis, both after PMBV and 1 year post procedure, whereas the aortic stiffness index (ASI) was significantly lower. There was also a significant decrease in mitral mean gradient (MMG) and systolic pulmonary artery pressure (sPAP) after PMBV, based on echocardiography and catheterization. Mitral valve area (MVA) significantly increased after PMBV. There was a significant correlation between change in ΔMVA and ΔMMG and aortic elastic properties. There was a significantly negative correlation between the ΔMVA and ΔΔ aortic stiffness (r = 0.62, P < 0.001), and a significantly positive correlation between ΔMMG and ΔASI (r = 0.60, P < 0.001). Conclusion: Mitral valve stenosis was associated with impaired aortic stiffness and following PMBV, aortic stiffness decreased during both the acute period and the intermediate period. (Echocardiography 2014;00:1–6) Key words: mitral stenosis, percutaneous intervention, transthoracic echocardiography
Several diseases are known to cause mitral valve stenosis (MS), of which rheumatic heart disease is the most prevalent. Rheumatic heart disease is a manifestation of rheumatic carditis, which occurs in 60–90% of patients with rheumatic fever. Rheumatic mitral stenosis is associated with extensive commissural fusion, a reduction in mitral valve area (MVA), and leaflet mobility.1 Percutaneous mitral balloon valvuloplasty (PMBV) is the most commonly used technique for treating patients with MS. Successful PMBV decreases pulmonary artery pressure, left atrial pressure, and the mean transmitral gradient. Aortic stiffness is a measure of the dilatation ability of the aortic wall against the pulse pressure.2,3 Impaired endothelial function increases aortic stiffness, which is an independent risk factor for cardiovascular mortality4,5; therefore, an increase in aortic stiffness was recently acknowledged to be a risk factor that requires medical Address for correspondence and reprint requests: Sinan _Inci, M.D., Aksaray State Hospital zafer mah. Nevsßehir cad. no: 117, Aksaray/Merkez, Turkey. Fax: 0903822122243; E-mail: [email protected]
intervention. At present, calculation of pulse wave velocity (PWV)6 and the aortic stiffness index (ASI) are commonly used noninvasive methods.7 Earlier studies have reported that there is a correlation between impaired arterial stiffness, and congestive heart failure,8 chronic kidney disease,9 aging,10 diabetes mellitus (DM),11 smoking,12 stent restenosis,13 cerebrovascular disease,14 and hypertension.15 An earlier study16 investigated the effect of PMBV on arterial stiffness in MS patients during the acute period. This study aimed to investigate the relationship between MS and aortic stiffness, and the effect of PMBV on aortic stiffness during the acute period and 1 year post procedure. To the best of our knowledge, this study is the first to investigate directly the relationship between MS and aortic stiffness. Materials and Methods: Participants: The study population included 56 patients (mean age: 42.7 11.6 years; 68% female) with isolated rheumatic MS that underwent PMBV. The 1
Inci, et al.
control group included 37 age- and sex-matched healthy volunteers. Indications for PMBV included New York Heart Association class II–IV, planimetered MVA ≤1.5 cm2, mitral regurgitation ≤2+, suitable valve morphology, and the absence of concomitant cardiovascular disease requiring surgical intervention. All the patients had sinus rhythm. Exclusion criteria were as follows: left ventricular ejection fraction 50% loss of MVA calculated after the procedure and/or MVA of 1.5 cm2. A major cardiovascular event was defined as mortality, a repeat PMBV, or the need for mitral valve replacement during the follow-up period. Statistical Analysis: Statistical analysis was performed using SPSS v.15.0 (SPSS, Inc., Chicago, IL, USA). Continuous variables are expressed as mean SD. Friedman’s test was used to compare consecutive measurements, and the Wilcoxon signed-rank test was used for post hoc analysis. Correlation analysis was performed using Pearson’s correlation coefficient. The level of statistical significance was set at P < 0.05. Results: Patients clinical, demographic, and transthoracic echocardiographic characteristics are shown in Table I. There were no significant differences in age, gender, systolic and diastolic blood pressure, ejection fraction, and left ventricular diastolic or systolic diameter between the MS and the control groups. The heart rate and pulmonary artery pressure in the MS group were higher
TABLE I Clinical, Demographic, and Transthoracic Echocardiographic Findings Mitral Stenosis (n = 56) Clinical, demographic, and transthoracic echocardiograph variables Age (years) Body mass index (kg/m2) Heart rate (beats/min) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Left ventricular diastolic diameter (mm) Left ventricular systolic diameter (mm) Ejection fraction (%) Aortic strain (%) Distensibility (cm2/dyne) Aortic stiffness index
42.4 28.7 84.8 111.6 70.8 46.2 29.4 64.4 9.4 4.5 7.5
11.4 5.0 7.2 13.3 9.9 4.5 5.6 5.1 2.5 1.4 2.1
Control Group (n = 37)
P
0.681 0.752
Echocardiography
ORIGINAL INVESTIGATION
The Effects of Successful Percutaneous Mitral Balloon Valvuloplasty on Acute and Intermediate Term Aortic Stiffness € kay Nar, M.D.,* Mustafa Kemal Erol, M.D.,† Selami Demirelli, M.D.,† Sinan Inci, M.D.,* Go Hakan Duman, M.D.,† Serkan Serdar, M.D.,† and Fatih Erol, M.D.† *Department of Cardiology, State Hospital Aksaray, Aksaray, Turkey; and †Department of Cardiology, Ataturk University Medical Faculty, Erzurum, Turkey
Aim: The aim of this study was to evaluate the effects of percutaneous mitral balloon valvuloplasty (PMBV) on short- and intermediate-term aortic stiffness in patients with mitral stenosis. Materials and Methods: This prospective study included 56 patients with critical mitral stenosis in normal sinus rhythm (68% female; mean age: 42 11 years) and 37 healthy controls. Aortic stiffness was measured using transthoracic echocardiography before PMBV, and 24–48 hours and 1 year post procedure. Results: Aortic strain and distensibility were significantly higher in the patients with mitral stenosis, both after PMBV and 1 year post procedure, whereas the aortic stiffness index (ASI) was significantly lower. There was also a significant decrease in mitral mean gradient (MMG) and systolic pulmonary artery pressure (sPAP) after PMBV, based on echocardiography and catheterization. Mitral valve area (MVA) significantly increased after PMBV. There was a significant correlation between change in ΔMVA and ΔMMG and aortic elastic properties. There was a significantly negative correlation between the ΔMVA and ΔΔ aortic stiffness (r = 0.62, P < 0.001), and a significantly positive correlation between ΔMMG and ΔASI (r = 0.60, P < 0.001). Conclusion: Mitral valve stenosis was associated with impaired aortic stiffness and following PMBV, aortic stiffness decreased during both the acute period and the intermediate period. (Echocardiography 2014;00:1–6) Key words: mitral stenosis, percutaneous intervention, transthoracic echocardiography
Several diseases are known to cause mitral valve stenosis (MS), of which rheumatic heart disease is the most prevalent. Rheumatic heart disease is a manifestation of rheumatic carditis, which occurs in 60–90% of patients with rheumatic fever. Rheumatic mitral stenosis is associated with extensive commissural fusion, a reduction in mitral valve area (MVA), and leaflet mobility.1 Percutaneous mitral balloon valvuloplasty (PMBV) is the most commonly used technique for treating patients with MS. Successful PMBV decreases pulmonary artery pressure, left atrial pressure, and the mean transmitral gradient. Aortic stiffness is a measure of the dilatation ability of the aortic wall against the pulse pressure.2,3 Impaired endothelial function increases aortic stiffness, which is an independent risk factor for cardiovascular mortality4,5; therefore, an increase in aortic stiffness was recently acknowledged to be a risk factor that requires medical Address for correspondence and reprint requests: Sinan _Inci, M.D., Aksaray State Hospital zafer mah. Nevsßehir cad. no: 117, Aksaray/Merkez, Turkey. Fax: 0903822122243; E-mail: [email protected]
intervention. At present, calculation of pulse wave velocity (PWV)6 and the aortic stiffness index (ASI) are commonly used noninvasive methods.7 Earlier studies have reported that there is a correlation between impaired arterial stiffness, and congestive heart failure,8 chronic kidney disease,9 aging,10 diabetes mellitus (DM),11 smoking,12 stent restenosis,13 cerebrovascular disease,14 and hypertension.15 An earlier study16 investigated the effect of PMBV on arterial stiffness in MS patients during the acute period. This study aimed to investigate the relationship between MS and aortic stiffness, and the effect of PMBV on aortic stiffness during the acute period and 1 year post procedure. To the best of our knowledge, this study is the first to investigate directly the relationship between MS and aortic stiffness. Materials and Methods: Participants: The study population included 56 patients (mean age: 42.7 11.6 years; 68% female) with isolated rheumatic MS that underwent PMBV. The 1
Inci, et al.
control group included 37 age- and sex-matched healthy volunteers. Indications for PMBV included New York Heart Association class II–IV, planimetered MVA ≤1.5 cm2, mitral regurgitation ≤2+, suitable valve morphology, and the absence of concomitant cardiovascular disease requiring surgical intervention. All the patients had sinus rhythm. Exclusion criteria were as follows: left ventricular ejection fraction 50% loss of MVA calculated after the procedure and/or MVA of 1.5 cm2. A major cardiovascular event was defined as mortality, a repeat PMBV, or the need for mitral valve replacement during the follow-up period. Statistical Analysis: Statistical analysis was performed using SPSS v.15.0 (SPSS, Inc., Chicago, IL, USA). Continuous variables are expressed as mean SD. Friedman’s test was used to compare consecutive measurements, and the Wilcoxon signed-rank test was used for post hoc analysis. Correlation analysis was performed using Pearson’s correlation coefficient. The level of statistical significance was set at P < 0.05. Results: Patients clinical, demographic, and transthoracic echocardiographic characteristics are shown in Table I. There were no significant differences in age, gender, systolic and diastolic blood pressure, ejection fraction, and left ventricular diastolic or systolic diameter between the MS and the control groups. The heart rate and pulmonary artery pressure in the MS group were higher
TABLE I Clinical, Demographic, and Transthoracic Echocardiographic Findings Mitral Stenosis (n = 56) Clinical, demographic, and transthoracic echocardiograph variables Age (years) Body mass index (kg/m2) Heart rate (beats/min) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Left ventricular diastolic diameter (mm) Left ventricular systolic diameter (mm) Ejection fraction (%) Aortic strain (%) Distensibility (cm2/dyne) Aortic stiffness index
42.4 28.7 84.8 111.6 70.8 46.2 29.4 64.4 9.4 4.5 7.5
11.4 5.0 7.2 13.3 9.9 4.5 5.6 5.1 2.5 1.4 2.1
Control Group (n = 37)
P
0.681 0.752
