Persistence Pulmonal Hypertension After Balloon Mitral Valvuiloplasty
AbstractBackground.Pulmonary hypertension frequently complicates mitral stenosis. Increased pulmonary artery pressure results from raised left atrial pressure, pulmonary arteriolar vasoconstriction, and obliterative changes in the pulmonary vascular bed, and usually responds to relief of mitral stenosis. However, severe pulmonary hypertension may persist after mechanical relief of mitral stenosis.
Methods.A case cross sectional study was conducted in mitral stenosis patients to study the immediate effect of BMV for severe pulmonary hypertension. Pulmonary hypertension was assessed by echocardiography before procedur and 24 – 72 hours after procedure. Analysis was done to assess the relation of age, gender, left atrial size, gradient across mitral valve, mitral valve area and systolic PA pressure before procedure on the persistency of severe pulmonary hypertension.
Results.There were 183 patients with mitral stenosis were found in January 2007 – December 2008. Seventy three were severe pulmonary hypertension (systolic PAP = 80 mmHg) and 61 patients were mild – moderate pulmonary hypertension ( systolic PAP < 80 mmHg). Only 54 patients were fulfilling study criteria. Of 54 cases included to analysis, 66.7% were female, 70.4% were in sinus rhytm and had age of 35.44 ± 10.55 yo.
The mean mitral valve gradient (MVG) decreased from 18.53 ± 6.40 to 8.50 ± 4.84 mm Hg (p< 0.001). Mitral valve area (MVA) increased from 0.76 ± 0.26 to 1.36 ± 0.36 cm 2 (p < 0.02). LA diameter decreased from 52.87 ± 7.14 to 49.13 ± 7.35 mm (p = 0.01). The pulmonary artery systolic pressure decreased from 100.48 ± 15.77 to 79.83 ± 17.49 mm Hg (p< 0.001). Systolic PAP > 95 mmHg was associated with persistency of PH in mitral stenosis patients with 58% sensitivity and 30% specificity.
Conclusions.The degree of Systolic PAP before BMV is associated with persistency of severe pulmonary hypertension. Systolic PAP > 95 mmHg was associated with persistency of PH in mitral stenosis patients with 58% sensitivity and 70% specificity.
Marijon E, Celermajer DS, Ou Phalla, Ferreira B, Mocumbi AO, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med 2007;357:470-6.
Richards DW. The J. Burns Amberson Lecture: the right heart and the lung. Am Rev Respir Dis 1966;94:691-702.
Rubenfire M, Bayram M, Word ZH. Pulmonary Hypertension in the Critical Care Setting: Classification, Pathophysiology, Diagnosis, and Management. Crit Care Clin J 2007;23:801-834.
Richards DW. Nobel lecture: the contributions of right heart catheterization to physiology and medicine with some observations of the physiopathology of pulmonary heart disease. In: Nobel lectures: physiology or medicine. Amsterdam: Elsevier Publishing; 1964. Available from: http://nobelprize.org/medicine/laureates/1956/richards-lecture.html
Mubeen M, Sing AK, Agarwal SK, Pillai J, Kapoor S, Srivastava AK. Mitral Valve Replacement in Severe Pulmonary Arterial Hypertension. The Journal of Thoracic and Cardiovascular Surgery,1988;96:39-43.
Bach DS, Eagle KA. Valvular heart disease. In : Kelly’s Textbook of Internal Medicine, 4th Ed. 2002;77.p. 91.
Freeman G L, Oblouk G. Valvular heart disease. In : Hemodynamic monitoring, invasive and noninvasive clinical application. Third edition. Elsevier Saunder Company. 2004;20:574-83.
Brice E A, Commerford P J. Rheumatic fever and valvular heart disease. In : Rosendorff. editor. Essential cardiology principles and practice,second edistion. Humana press.2005;30:548-9.
Tuder RM, Marecki JC, Richtera A, Fijalkowska I, Flores S. Pathology of Pulmonary Hypertension. Clin Chest Med J 2007;28:23-42.
Cournand AF. Control of the pulmonary circulation in man with some remarks on methodology. Nobel lecture, December 11, 1956. In: Nobel lectures, physiology or medicine. Amsterdam: Elsevier Publishing; 1964. Available from: http://nobelprize.org/medicine/laureates/1956/cournandlecture.
Harvey F, Richard EL, William K N. Hemodynamic Studies Before and After Instrumental Mitral Commissurotomy: A Reappraisal of the Pathophysiology of Mitral Stenosis and the Efficacy of Mitral Valvotomy. Circulation 1968;38;261-276.
Messika-Z D, Agnes C, Eric B, Bertrand C, Bernard I, Alec V. Evaluation of mitral valve area by the proximal isovelocity surface area method in mitral stenosis: Could it be simplified? Eur J Echocardiography. 2007;8:116-121.
Carroll JD, Feldman T. Percutaneous mitral balloon valvotomy and the new demographics of mitral stenosis. JAMA 1993; 270:1731-6.
Purnomo H. Valve disease. In : The 7 th symposium on clinical cardiology and ECG course 2007. PLD 2007:50-5.
Bonow RO, Carabello B, de Leon AC Jr, et al. 2008 Focused update Incorporated Into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management on Management of Patients with Valvular Heart Disease). Circulation 2008;118;e523-e661
Noor A, Saghir T, Shah-e-Zaman K. Determinants of Decrease in Pulmonary Hypertension Following Percutaneous Transvenous Mitral Commissurotomy. Journal of The College of Physicians and Surgeons Pakistan 2009;19(2):81-5
Burger W, Kneissl GD, Kober G, Schräder R. Effect of balloon valvuloplasty for mitral stenosis on right ventricular function. Am J Cardiol 1993;71:994-996.
Barst RJ. PDGF signaling in pulmonary arterial hypertension. J. Clin. Invest. 2005;115:2691-4.
Porte JM, Cormier B, Iung B, et al. Early assessment by transesophageal echocardiography of left atrial appendage function after percutaneous mitral commissurotomy. Am J Cardiol 1996;77:72-6.
Vahanian A. Balloon valvuloplasty. Eur Heart J 2001;85: 223-8.
Gurbanov E, Shiliang X. The key role of apoptosis in the pathogenesis and treatment of pulmonary hypertension. European Journal of Cardio-thoracic Surgery 2006;30:499-507.
Humbert M, Sitbon O, Simonneau G. Drug therapy : Treatment of Pulmonary Arterial Hypertension. N Engl J Med 2004;351: 1425-36.
ChinK M, Rubin LJ. Pulmonary Arterial Hypertension. JACC, 2008;22:1527-38.
Maoqin S, Guoxiang H, Zhiyuan S, Luxiang C, Houyuan H, Liangyi S, Ling Z,Guoqiang Z. The clinical and hemodynamic results of mitral balloon valvuloplasty for patients with mitral stenosis complicated by severe pulmonary hypertension. European Journal of Internal Medicine 2005;16:413-18.
Fawzy ME, Hegazy H, Shoukri M, El Shaer F, El Dali E, Al-Amri M.Long-term clinical and echocardiographic results after successful mitral balloon valvotomy and predictors of long-term outcome. European Heart Journal 2005;26:1647-52.
Mehta D, Ghosh J. Management of Atrial Fibrillation with Reference to Valvular Heart Disease Indian Heart J 2002;54: 312-320.
Hannoush H, Fawzy ME, Stefadouros M, Moursi M, Chaudhary MA, Dunn B. Regression of significant tricuspid regurgitation after mitral valvotomy for severe mitral stesnosis. Am Heart J 2004;148:865-70.
Krasuski RA, Assar MD, Wang A, Kisslo KB, Pierce C, Harrison KJ, Bashore TM. Usefulness of Percutaneous Balloon Mitral Commissurotomy in Preventing the Development of Atrial Fibrillation in Patients With Mitral Stenosis. Am J Cardiol 2004 ;93:936-39.
Diker E, Aydogdu S, Ozdemir M, Kural T, Polat K, Cehreli S, et al.Prevalence and predictors of atrial fibrillation in rheumatic valvular heart disease. Am J Cardiol 1996;77:96-98.
Krishnamoorthy KM, Dash PK, Radhakrishnan S, Shrivastava S. Response of Different Grades of Pulmonary Artery Hypertension to Balloon Mitral Valvuloplasty. American Journal of Cardiology 2002;90:1170-3.
Ali HH, Shams-Eddin H, Abd-Elsayed AA, Maghraby MH.Echocardiographic assessment of mitral valve morphology after Percutaneous Transvenous Mitral Commissurotomy (PTMC). Cardiovascular Ultrasound 2007;5:1-8.
Harikrishnan S, Chandrasekharan C K. Pulmonary Hyper-tension in Rheumatic Heart Disease. PVRI REVIEW 2009;1:13-19.
Umesan CV, Kapoor A, Sinha N, Kumar AS, Goel PK. Effect of Inoue ballon mitral valvotomy on severe pulmonary arterial hypertension in 315 patients with rheumatic mitral stenosis : immediate and long-term results. J Heart Valve Dis 2000;9:609 -15.
Rich S, Rabinovitch M. Diagnosis and Treatment of Secondary (Non–Category 1) Pulmonary Hypertension. Circulation 2008;118:2190-99.
Evans W, Short DS. Pulmonary hypertension in mitral stenosis. Cardiac department of the London Hospital 1957:457-72.
Ehud Schwammenthal, Zvi Vered, Oren Agranat, Elieser Kaplinsky, Babeth Rabinowitz and Micha S. Feinberg. Impact of Atrioventricular Compliance on Pulmonary Artery Pressure in Mitral Stenosis: An Exercise Echocardiographic Study. Circulation 2000;102:2378-84.
PDF (Bahasa Indonesia) downloads: 659
Authors who publish with this journal agree to the following terms:
- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).