Effects of Percutaneous Balloon Mitral Valvotomy on Pulmonary Venous Flow in Severe Mitral Stenosis Deepak Natarajan, MD, DM, Ved P. Sharma, MD, Subhash Chandra, MD, Sanjay K. Dhar, MD, Mahendra Gaba, MD, and Birjis Caroli, MD

ulsed Doppler Echocardiography has revealedthat P normal pulmonary venous flow consistsof systolic and diastolic phases,which are equal in sizeand velocity. Systolic flow occurs when the mitral valve is closed,the left atrium is relaxed and the mitral annulus is descending toward the apex. The secondcomponent occurs in diastole when the mitral leafletsopenand allow blood to enter the left ventricle.* The biphasic flow may be disturbed in certain pathologic states.For instance,in dilated cardiomyopathy, mitral annulus motion subjectto the degreeof systolic dysfunction, may be markedly reduced.There is, consequently,a reduction or absenceof the systolic phase of pulmonary venousflow. 1,2Mitral stenosisdue to rheumatic heart diseasealsoresultsin marked reduction in the mobility of the mitral valve apparatusand leaflets.Moreover, there is considerable fusion of the commissures3 Percutaneous balloon mitral valvotomy (PBMV) has rapidly emergedasan alternative to surgical valvotomy in patients with mitral stenosis.“SuccessfulPBMV results in rapid reduction of left atria1 pressureand transmitral gradient, with significant increase in mitral valve area. There have been no reports demonstrating alteration in pulmonary venousflow with acute reduction in left atria1 pressureafter PBMV in mitral stenosis.5This study was designedto investigate alterations in pulmonary venous flow, using transesophagealechocardiography(TEE) after PBMV in patients with severemitral stenosis. From the Department of Cardiology, Dr. Ram Manohar Lohia Hospital, New Delhi 110 001, India. Manuscript received July 17, 1991; revisedmanuscript receivedand acceptedNovember 15,199l.

Fifteen patients (6 men and 9 womenagerange 16 to 32 years, average 24) with severemitral stenosis were studied. All patients were in New York Heart Association functional class IZZand had sinus rhythm. No patient with left atria1 thrombus, demonstrated by 2-dimensionaland TEE, underwentPBMV. Allpatients had an echoscore of 18 and none had any degreeof mitral regurgitation. All patients underwent right- and left-sided cardiac catheterization before and after PBMV, which wasperformed with the Inoue balloon catheter after obtaining informed consent.6 Patients had fasted for 4 hours before examination and had given informed consent.TEE wasperformed 24 hours beforePBMVand within 48 hours after the intervention. Dysphagic diseasewas excluded. No sedation was administered beforeexamination. In all patients 2% lidocaine hydrochloride solution was usedfor local anesthesia. The patients were asked to gargle with the lidocaine solution until theyfelt numbnessof the tongue. No routine antibiotic prophylaxis was given. Patients wereplaced in the supine position, with the headjlexed in midline. We useda 5 MHz phased-array ultrasound transducer (model 21362A of Hewlett Packard) for the TEE. Thepatient was asked to swallow the probe after it was placed on the posterior aspectof the tongue. Theprobe wasadvancedabout 30 to 35 cmfrom the incisors, where it wasplaced behind the left atrium, and standard short-axis andoblique viewsobtained. The model 2199A TEE adaptor connectedthe TEE imaging transducer to a SONOS 1000 Hewlett Packard ultra-

TABLE I Clinical, Hemodynamic and Pulmonary Venous Flow Data Before and After Percutaneous Balloon Mitral Valvotomy in 12 Patients MPG (mm Hg)

MVAkm*)

Age (yr) & Sex

Pre

Post

Pre

Post

Pre

Post

0.6 0.7 0.7 0.8 0.7 0.8 0.9 0.7 0.6 0.6 0.8 0.7

1.9 1.8

13

4 2 4 2 3 0

0 0 0 0 0

1 0 0 0 0

0 0

1 1

11 12

25F 23F 17M 32F 18M 25F 28F 22M 28F 25F 21F 23M

0 0 0 0 0

1 0 0 0 0

Mean r SD

24-t4

0.7 ~0.1

Pts.

1 2 3 4 5 6 7 8 9

10

2.0 2.2 2.1

16 26 12 15 11

1.9

10

1.8 1.7 2.3 2.3 2.2

9 18 24 16 22

1.9

2 +0.2*

1626

0 1 3 4 2 3 23-t

Heart Rate (beats/min)

MR Grade

l*

SPVF

DPVF

km/s)

km/s)

Pre

Post

Pre

Post

Pre

Post

78

76 86 80 111 74 86 86 86 84 96 98 78

15 21 18 23 27 24 16 20 16 25 23 15

54 48 64 49 48 68 72 60 64 46 52 52

18 24 22 38 38 34 28 30 24 38 38 25

50 46 63 45 42 66 70 58 42 42 46 38

2024

56+9*

3Ozt 7

51 f lO*

100 74 72 116

90 78 74 88 90 94 88 872

13

86e

11

lp

Effects of percutaneous balloon mitral valvotomy on pulmonary venous flow in severe mitral stenosis.

Effects of Percutaneous Balloon Mitral Valvotomy on Pulmonary Venous Flow in Severe Mitral Stenosis Deepak Natarajan, MD, DM, Ved P. Sharma, MD, Subha...
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