Left Ventricular Remodeling Following Balloon Mitral Valvuloplasty in Rheumatic Mitral Stenosis: Magnetic Resonance Imaging Study

Amir Anwar Samaan, Karim Said, Wafaa El Aroussy, Mohammed Hassan, Soha Romeih, Amr El Sawy, Mohammed Eid Fawzy, Magdi Yacoub, Amir Anwar Samaan, Karim Said, Wafaa El Aroussy, Mohammed Hassan, Soha Romeih, Amr El Sawy, Mohammed Eid Fawzy, Magdi Yacoub

Abstract

Background: Rheumatic heart disease affects primarily cardiac valves, it could involve the myocardium either primarily or secondary to heart valve affection. The influence of balloon mitral valvuloplasty (BMV) on left ventricular function has not been sufficiently studied. Aim: To determine the influence of balloon mitral valvuloplasty (BMV) on both global and regional left ventricular (LV) function. Methods: Thirty patients with isolated rheumatic mitral stenosis (MS) were studied. All patients had cardiac magnetic resonance imaging (CMR) before, 6 months and 1 year after successful BMV. LV volumes, ejection fraction (EF), regional and global LV deformation, and LV late gadolinium enhancement were evaluated. Results: At baseline, patients had median EF of 57 (range: 45-69) %, LVEDVI of 74 (44-111) ml/m2 and LVESVI of 31 (14-57) ml/m2 with absence of late gadolinium enhancement in all myocardial segments. Six months following BMV, there was a significant increase in LV peak systolic global longitudinal strain (GLS) (-16.4 vs. -13.8, p < 0.001) and global circumferential strain (GCS) (-17.8 vs. -15.6, p = 0.002). At 1 year, there was a trend towards decrease in LVESVI (29 ml/m2, p = 0.079) with a significant increase in LV EF (62%, p < 0.001). A further significant increase, compared to 6 months follow up studies, was noticed in GLS (-17.9 vs. -16.4, p = 0.008) and GCS (-19.4 vs. -17.8 p = 0.03). Conclusions: Successful BMV is associated with improvement in global and regional LV systolic strain which continues for up to 1 year after the procedure.

Keywords: balloon mitral valvuloplasty; cardiac magnetic resonance imaging; left ventricular deformation; left ventricular function; left ventricular remodeling; mitral stenosis; myocardial tagging.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2021 Samaan, Said, Aroussy, Hassan, Romeih, El Sawy, Fawzy and Yacoub.

Figures

Figure 1
Figure 1
CMR Measurements of ventricular volumes in one of mitral stenosis patients. End diastolic short-axis images from the apex to the base with epicardial (green lines) and endocardial (red lines) contours drawn for the left ventricle and endocardial contours for the right ventricle.
Figure 2
Figure 2
Tagged cardiac magnetic resonance imaging with epicardial and endocardial border tracing in: short axis (A), horizontal long axis (apical four chambers) (B), vertical long axis (apical two chambers) (C), and left ventricular outflow view (three chambers views) (D). The short axis images were used for estimation of circumferential strain while long axis views were used for estimation of longitudinal strain.
Figure 3
Figure 3
(A) Measurement of regional and global circumferential strain (Bull's eye plot) in a patient with mitral stenosis before and 1 year after BMV with comparison to a control individual (B) Graph representation of GCS in a patient with mitral stenosis before and after BMV in comparison to a control individual.
Figure 4
Figure 4
Bar graphs showing Changes in LV GLS after BMV (A) and Changes in LV GCS after BMV (B).
Figure 5
Figure 5
Line chart representing changes in GLS and GCS in individual mitral stenosis patients 1 year after BMV.
Figure 6
Figure 6
Correlation between change in LV deformation parameters and baseline values. (A) Correlation between change in GLS and baseline GLS. (B) Correlation between change in GCS and baseline GCS.

References

    1. Seckeler MD, Hoke TR. The worldwide epidemiology of acute rheumatic fever and rheumatic heart disease. Clin Epidemiol. (2011) 3:67–84. 10.2147/CLEP.S12977
    1. Karthikeyan G, Mayosi BM. Is primary prevention of rheumatic fever the missing link in the control of rheumatic heart disease in Africa? Circulation. (2009) 120:709–13. 10.1161/CIRCULATIONAHA.108.836510
    1. Inoue K, Owaki T, Nakamura T, Kitamura F, Miyamoto N. Clinical application of transvenous mitral commissurotomy by a new balloon catheter. J Thorac Cardiovasc Surg. (1984) 87:394–402. 10.1016/S0022-5223(19)37390-8
    1. Turi Z, Reyes V, Raju B, Raju A, Kumar D, Rajagopal P, et al. . Percutaneous balloon versus surgical closed commissurotomy for mitral stenosis. A prospective, randomized trial. Circulation. (1991) 83:1179–85. 10.1161/01.CIR.83.4.1179
    1. Arora R, Nair M, Kalra GS, Nigam M, Khalilullah M. Immediate and long-term results of balloon and surgical closed mitral valvotomy: a randomized comparative study. Am Heart J. (1993) 125:1091–4. 10.1016/0002-8703(93)90118-S
    1. Gash AK, Carabello BA, Cepin D, Spann JF. Left ventricular ejection performance and systolic muscle function in patients with mitral stenosis. Circulation. (1983) 67:148–54. 10.1161/01.CIR.67.1.148
    1. Ozdemir AO, Kaya CT, Ozcan OU, Ozdol C, Candemir B, Turhan S, et al. . Prediction of subclinical left ventricular dysfunction with longitudinal two-dimensional strain and strain rate imaging in patients with mitral stenosis. Int J Cardiovasc Imaging. (2010) 26:397–404. 10.1007/s10554-009-9550-2
    1. Dogan S, Aydin M, Gursurer M, Dursun A, Onuk T, Madak H. Prediction of subclinical left ventricular dysfunction with strain rate imaging in patients with mild to moderate rheumatic mitral stenosis. J Am Soc Echocardiogr. (2006) 19:243–8. 10.1016/j.echo.2005.09.014
    1. Fawzy ME, Mimish L, Sivanandam V, Lingamanaicker J, Patel A, Khan B, et al. . Immediate and long-term effect of mitral balloon valvotomy on left ventricular volume and systolic function in severe mitral stenosis. Am Heart J. (1996) 131:89–93. 10.1016/S0002-8703(96)90055-1
    1. Mohan JC, Bhargava M, Agrawal R, Arora R. Effects of balloon mitral valvuloplasty function on left ventricular muscle function. Int J Cardiol. (1995) 49:17–24. 10.1016/0167-5273(94)02272-K
    1. Akcakoyun M, Karap H, Esen O, Karg R, Pala S, Em Y, et al. . Effects of mitral balloon valvuloplasty on left ventricular systolic functions : assessment with color tissue doppler. Kosuyolu Hear J. (2010) 13:16–9.
    1. Roushdy AM, Raafat SS, Shams Ka, El-Sayed MH. Immediate and short-term effect of balloon mitral valvuloplasty on global and regional biventricular function: a two-dimensional strain echocardiographic study. Eur Hear J Cardiovasc Imaging. (2015) 17:jev157. 10.1093/ehjci/jev157
    1. Goto S, Handa S, Akaishi M, Abe S, Ogawa S. Left ventricular ejection performance in mitral stenosis, and effects of successful percutaneous transvenous mitral commissurotomy. Am Heart J. (1992) 69:233–7. 10.1016/0002-9149(92)91311-Q
    1. Razzolini R, Ramondo A, Isabella G, Cardaioli P, Campisi F, De Leo A, et al. . Acute changes in left ventricular function after percutaneous transluminal mitral valvuloplasty. Hear Vessel. (1996) 11:86–91. 10.1007/BF01744508
    1. Pamir G, Ertas F, Oral D, Gumus H, Omurlu K, Remzi Karaoguz. Left ventricular filling and ejection fraction after successful percutaneous balloon mitral valvuloplasty. Int J Cardiol. (1997) 59:243–6. 10.1016/S0167-5273(97)02959-8
    1. Sengupta PP, Mohan JC, Mehta V, Kaul UA, Trehan V, Arora R, et al. . Effects of percutaneous mitral commissurotomy on longitudinal left ventricular dynamics in mitral stenosis : quantitative assessment by tissue velocity imaging. J Am Soc Echocardiogr. (2004) 17:824–8. 10.1016/j.echo.2004.04.025
    1. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, et al. . 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. J Am Coll Cardiol. (2014) 63:e57–185. 10.1016/j.jacc.2014.02.536
    1. Tucke PA, Ferguson JJ, Harlan M, Gaos CM, Massumi A. Balloon mitral valvuloplasty. Clinical Experience at the Texas Heart Institute. Tex Hear Inst J. (1992) 19:270–7.
    1. Nobuyoshi M, Arita T, Shirai S -i, Hamasaki N, Yokoi H, Iwabuchi M, et al. . Percutaneous balloon mitral valvuloplasty: a review. Circulation. (2009) 119:e211–9. 10.1161/CIRCULATIONAHA.108.792952
    1. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. . Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American society of echocardiography and the European association of cardiovascular imaging. Eur Heart J Cardiovasc Imaging. (2015) 16:233–71. 10.1093/ehjci/jev014
    1. Alfakih K, Reid S, Jones T, Sivananthan M. Assessment of ventricular function and mass by cardiac magnetic resonance imaging. Eur Radiol. (2004) 14:1813–22. 10.1007/s00330-004-2387-0
    1. Götte MJW, Germans T, Rüssel IK, Zwanenburg JJM, Marcus JT, van AC, et al. . Myocardial strain and torsion quantified by cardiovascular magnetic resonance tissue tagging. Studies in Normal and Impaired Left Ventricular Function. J Am Coll Cardiol. (2006) 48:2002–11. 10.1016/j.jacc.2006.07.048
    1. Shehata ML, Cheng S, Osman NF, Bluemke DA, Lima JA. Myocardial tissue tagging with cardiovascular magnetic resonance. J Cardiovasc Magn Reson. (2009) 11:55. 10.1186/1532-429X-11-55
    1. Tandon R, Sharma M, Chandrashekhar Y, Kotb M, Yacoub MH, Narula J. Revisiting the pathogenesis of rheumatic fever and carditis. Nat Rev Cardiol. (2013) 15 10:171–7. 10.1038/nrcardio.2012.197
    1. Mohan JC, Nair M, Arora R. Left ventricular volumes and function immediately after balloon mitral valvoplasty. Int J Cardiol. (1991) 33:275–80. 10.1016/0167-5273(91)90358-V
    1. Sengupta SP, Amaki M, Bansal M, Fulwani M, Washimkar S, Hofstra L, et al. . Effects of percutaneous balloon mitral valvuloplasty on left ventricular deformation in patients with isolated severe mitral stenosis: a speckle-tracking strain echocardiographic study. J Am Soc Echocardiogr. (2014) 27:639–47. 10.1016/j.echo.2014.01.024
    1. Tischler MD, Sutton MSJ, Bittl JA, Parker JD. Effects of percutaneous mitral valvuloplasty on left ventricular mass and volume. J Am Coll Cardiol. (1993) 22:2059–61.
    1. Bektaş O, Günaydin ZY, Karagöz A, Vural A, Kaya A, Atmaca H, et al. . Evaluation of the effect of percutaneous mitral balloon valvuloplasty on left ventricular systolic function via strain and strain rate in patients with isolated rheumatic mitral stenosis. J Heart Valve Dis. (2015) 24:204–9.
    1. Mohan JC, Khalilullah M, Arora R. Left ventricular intrinsic contractility in pure rheumatic mitral stenosis. Am J Cardiol. (1989) 64:240–2. 10.1016/0002-9149(89)90469-4
    1. Heller SJ, Carleton RA. Abnormal left ventricular contraction in patients with mitral stenosis. Circulation. (1970) 10.1161/01.CIR.42.6.1099
    1. Bolen JL, Lopes MG, Harrison DC, Alderman EL. Analysis of left ventricular function in response to afterload changes in patients with mitral stenosis. Circulation. (1975) 52:894–900. 10.1161/01.CIR.52.5.894
    1. Silverstein DM, Hansen DP, Ojiambo HP, Griswold HE. Left ventricular function in severe pure mitral stenosis as seen at the Kenyatta National Hospital. Am Heart J. (1980) 99:727–33. 10.1016/0002-8703(80)90622-5
    1. Sengupta PP, Burke R, Khandheria BK, Belohlavek M. Following the flow in chambers. Heart Fail Clin. (2008) 4:325–32. 10.1016/j.hfc.2008.02.005
    1. Sengupta PP, Pedrizzetti G, Kilner PJ, Kheradvar A, Ebbers T, Tonti G, et al. . Emerging trends in CV flow visualization. JACC Cardiovasc Imaging. (2012) 5:305–16. 10.1016/j.jcmg.2012.01.003
    1. Fleming HA, Wood P. The myocardial factor in mitral valve disease. Br Heart J. (1959) 21:117–22. 10.1136/hrt.21.1.117
    1. Lee YS, Lee CP. Ultrastructural pathological study of left ventricular myocardium in patients with isolated rheumatic mitral stenosis with normal or abnormal left ventricular function. Jpn Heart J. (1990) 31:435–48. 10.1536/ihj.31.435
    1. Kent R, Uboh C, Thompson E, Gordon S, Marino T, Hoober J, et al. . Biochemical and structural correlates in unloaded and reloaded cat myocardium*. J Mol Cell Cardiol. (1985) 17:153–65. 10.1016/S0022-2828(85)80018-3
    1. Thompson EW, Marino TA, Uboh CE, Kent RL, Cooper G. Atrophy reversal and cardiocyte redifferentiation in reloaded cat myocardium. Circ Res. (1984) 54:367–77. 10.1161/01.RES.54.4.367

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