shortness of breath in a 51 year old woman

Shortness of breath in a 51 year old woman

Sean Coffey FRACPGerard Wilkins FRACP Bernard Prendergast FESC

Dunedin Hospital, New Zealand andJohn Radcliffe Hospital, Oxford, United Kingdom

Our patient – medical history and examination

• 51 year old woman• Progressive shortness of breath on exertion for 2 yrs• No angina, syncope or other cardiovascular

symptoms• Hypertension for 6 years• Beta-blocker for 5 years

Our patient – medical history and examination

• No other significant past medical history• Sinus bradycardia 50 beats/minute• No murmurs noted• No other significant findings

Our patient - echocardiography

Parasternal long axis - systole

Parasternal long axis - diastole

Parasternal short axis - diastole

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What is your diagnosis?

• Myxomatous mitral valve?

• Mitral annular dilatation?

• Rheumatic mitral valve?

• Mitral valve endocarditis?

• Mitral annular calcification?

What is your diagnosis?

• Myxomatous mitral valve?

• Mitral annular dilatation?

• Rheumatic mitral valve

• Mitral valve endocarditis?

• Mitral annular calcification?

Morphological features of rheumatic mitral stenosis1

• Anterior mitral valve leaflet thickening ≥5 mm (for those older than 40 years)

• Chordal thickening

• Restricted leaflet motion (e.g. due to commissural fusion or chordal shortening)

• Excessive leaflet tip motion during systole (due to elongation of the chords, resulting in regurgitation)

1. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease—an evidence-based guideline. Reményi, B. et al. Nat. Rev. Cardiol. 9, 297–309 (2012).

Echo assessment of mitral stenosis1

• Degree and location of calcification• Mitral valve area according to:

• 2D planimetry (reference method)• Pressure half-time• (Continuity equation and proximal isovelocity surface area) -

level 2 recommendations

• Mean transvalve gradient• Pulmonary artery pressure• Left atrial size• Presence or absence of rheumatic features on other

valves

1. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Baumgartner, H. et al. Eur J Echocardiogr 10, 1–25 (2009).

Echo assessment of mitral stenosis

• Suitability for percutaneous valvuloplasty can be assessed by transthoracic echocardiography

• The Wilkins score1 is based on• leaflet mobility• leaflet thickening• calcification• subvalvular thickening

• The Cormier score2 is based on• subvalvular thickening • finding of any calcification on fluoroscopy

1. Percutaneous balloon dilatation of the mitral valve: an analysis of echocardiographic variables related to outcome and the mechanism of dilatation. Wilkins, GT et al. Br Heart J 60, 299-308, (1988).

2. Evaluation by two-dimensional and Doppler echocardiography of the results of percutaneous mitral valvuloplasty. Cormier, B. et al. Arch Mal Coeur Vaiss 82, 185-191, (1989).

Grading of severity of mitral stenosis1

Mild Moderate Severe

Specific finding

Valve area (cm2) > 1.5 1.0 – 1.5 < 1.0

Supportive findings

Mean gradient (mmHg)* < 5 5 – 10 > 10

Pulmonary artery pressure (mmHg) < 30 30 – 50 > 50


* Mean gradient applicable at heart rates between 60 and 80 bpm and in sinus rhythm

Our patient - mitral valve Doppler

E velocity: 1.59 m/sPeak gradient: 10.1mmHg

Half maximum pressure = 0.707 x maximum velocity= 1.12 m/s

Pressure half time (PHT) = time for pressure to decrease to half maximum pressure= 348 ms

Mitral valve area in cm2 (by PHT)= 220 ms / PHT= 0.64 cm2 i.e. severe mitral stenosis

NB: Pressure gradients are highly flow dependent, and lower during long diastolic intervals. Mean gradient would only classify this as moderate mitral stenosis.

Additional imaging

• When is transoesophageal echo indicated?1

• To look for left atrial thrombus• Before percutaneous mitral commissurotomy (PMC)• After an embolic event

• Poor transthoracic images

• When is stress echo indicated?2

• Level 2 recommendation for• Equivocal symptoms• Symptoms out of proportion to degree of stenosis

1. Guidelines on the management of valvular heart disease (version 2012). Vahanian, A. et al. Eur Heart J 33, 2451-2496, (2012).


Our patient - transthoracic echo report

• Mitral valve area (planimetry) – 1.1 cm2

• Mitral valve area (PHT) – 0.64 cm2

• Mean gradient – 6 mmHg (but unreliable due to bradycardia)

• Pulmonary artery pressure – 24mmHg + right atrial pressure

• Left atrial 2D dimension – 5.3cm• Left atrial volume index – 62 ml/m2 • Also• No other affected valves• Normal left ventricular systolic function

What is your management?

• Open surgical mitral commissurotomy?

• Percutaneous mitral commissurotomy?

• Conservative management?

• Anticoagulation with Factor Xa inhibitor?

• Anticoagulation with warfarin?

(choose as many options as required)

How should this woman be managed?

• Open surgical mitral commissurotomy?

• Percutaneous mitral commissurotomy

• Conservative management?

• Anticoagulation with Factor Xa inhibitor?

• Anticoagulation with warfarin

When is intervention indicated?1

• Valve area ≤ 1.5cm2 and • Symptoms or• In patients suitable for percutaneous mitral

commissurotomy (PMC)• Symptoms produced by exercise testing or• High risk of embolism or haemodynamic decompensation

• High embolic risk if• Previous embolism, dense spontaneous contrast (SEC) in left atrium, or

recent or paroxysmal atrial fibrillation

• High risk of haemodynamic decompensation if• Systolic pulmonary artery pressure > 50mmHg at rest, need for major

non-cardiac surgery, or desire for pregnancy


Which intervention should be used?1

• PMC should be chosen unless there are• Unfavourable anatomical characteristics• Wilkins score > 8, Cormier score 3, very small mitral valve

area, severe tricuspid regurgitation • Unfavourable clinical characteristics• Old age, history of commissurotomy with persistent

commissural opening, NYHA class IV, permanent atrial fibrillation, severe pulmonary hypertension


Which intervention should be used?1

• Even if anatomy is unfavourable, PMC can be considered as initial treatment if clinical characteristics are favourable.

• Contraindications to PMC• Left atrial thrombus• More than mild mitral regurgitation• Severe or bicommissural calcification• Absence of commissural fusion• Severe concomitant aortic valve disease, or severe combined tricuspid

stenosis and regurgitation• Concomitant coronary artery disease requiring bypass surgery


Our patient - decision making

• Anatomy was not favourable for PMC• Reduced mobility of base and mid-leaflets• Calcification extending into mid-leaflet• Wilkins score 10, Cormier score 3

• But, favourable clinical characteristics• Relatively young age• No prior commissurotomy• NYHA II• No atrial fibrillation• No pulmonary hypertension

Our patient – PMC

PMC was performed under local anaesthetic, and using fluoroscopy and echocardiographic guideance. A Mullins sheath was advanced from the femoral vein to the right atrium.

The interatrial septum was crossed with a Brockenbrough needle. An Inoue wire was delivered to the left atrium and looped, allowing removal of the Mullins sheath.

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Our patient - PMC

The mitral valve was crossed and the Inoue Balloon partially inflated to expand the distal portion of the balloon.

The balloon was then pulled back against the mitral valve and fully inflated, completing commisurotomy.

When is anticoagulation indicated?

• Mitral stenosis carries a high risk of thromboembolism, even in sinus rhythm

• Anticoagulation is indicated1

• In patients with AF• In patients in sinus rhythm with any of the following

features:• Previous history of thromboembolism• Thrombus visible in left atrium• Spontaneous echo contrast (SEC) in the left atrium• Severely dilated left atrium • M-mode dimension > 5.0 cm or LA volume index > 60ml/m2

• Factor Xa and direct thrombin inhibitors are not indicated for use in these settings


Our patient - progress

• No complications following PMC

• Echo prior to discharge• Mitral valve area (planimetry) 1.6cm2

• Mild mitral regurgitation unchanged

• Discharged from hospital the day after PMC

• Exercise capacity increased to previous levels at 1 year follow-up

What are the outcomes after PMC?

• In one large series1, 89% of patients had a good immediate result after PMC, defined as mitral valve area ≥1.5 cm2 and no more than mild MR

• Early serious adverse events were uncommon• In-hospital death 0.4%• Embolic stroke 0.3%• Moderate or severe MR 3.4%

• 20 year results related to immediate results• Poor immediate result: 5% good long term result (free at 20 years from

cardiovascular death, mitral intervention, or NYHA III or IV heart failure)• Good immediate result: 33% good long term result

• Even in the group with good immediate results, valve area and pressure gradient measured after PMC predict outcomes 20 years later

1. Late Results of Percutaneous Mitral Commissurotomy up to 20 Years. Development and Validation of a Risk Score Predicting Late Functional Results From a Series of 912 Patients. Bouleti, C. et al. Circulation 125, 2119-2127, (2013).

Take home messages

• Patients with rheumatic heart disease may have no history of rheumatic fever

• Severity of mitral stenosis is assessed primarily using mitral valve area measured by planimetry and pressure half time

• Pressure gradients can be misleading in the setting of high or low heart rates, and in patients with atrial fibrillation

• Percutaneous mitral commissurotomy should be considered the first line treatment in patients with symptoms and mitral valve area < 1.5 cm2

• Anticoagulation should be considered for patients with mitral stenosis with high risk features for thromboembolism (even if in sinus rhythm)

• Early results of percutaneous mitral commissurotomy predict results up to 20 years later

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shortness of breath in a 51 year old woman

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