Atrial Fibrillation May Affect the Success of Mitral Balloon Valvuloplasty

We read the original investigation “Effects of Percutaneous Balloon Mitral Valvuloplasty on Left Ventricular Deformation in Patients with Isolated Severe Mitral Stenosis: A Speckle-Tracking Strain Echocardiographic Study” by Sengupta et al ., published in the June 2014 issue of JASE , with great interest. We would like to touch on some points regarding this article.

Sengupta et al . investigated 57 patients with isolated severe rheumatic mitral stenosis (MS) undergoing balloon mitral valvuloplasty and 19 age-matched and sex-matched healthy volunteers from the community who served as controls. Seven patients with MS were in atrial fibrillation (AF) at the time of baseline echocardiographic evaluation, whereas the remaining 50 were in normal sinus rhythm. The average heart rate of patients with MS was significantly higher than that of controls (81.3 ± 18.7 vs 71.2 ± 10.7 beats/min, P = .03), even after excluding those with AF (79.7 ± 18.1 beats/min, P = .065). In their study, Sengupta et al . evaluated patients with AF and patients in sinus rhythm in the same category, on the basis of achievement of ventricular rate control. However, we think that this patient group should have been excluded, because atrial contraction is required for left ventricular (LV) filling in patients with isolated MS. Left atrial volume, LV end-diastolic volume, LV end-systolic volume, LV stroke volume, and LV ejection fraction are affected negatively in patients with MS because of a lack of atrial contraction resulting from atrial fibrosis. In short, patients without atrial contraction should not be placed in the same category as those in sinus rhythm. We suggest that patients with MS with AF will benefit less from the hemodynamic improvement after percutaneous balloon mitral valvuloplasty compared with patients in sinus rhythm. The patients with AF should have been excluded from the control group, or the control group should have included an equivalent percentage of patients with AF. We suggest that AF is a much more complex disease than estimated, and therefore patients with AF cannot be evaluated in the same category as those in sinus rhythm, even if control of ventricular rate has been achieved.

A study conducted by Shikano et al . supports our argument. They investigated 33 patients (five men, 28 women) with isolated MS aged 56 ± 9 years. Left atrial dimension, LV diastolic and systolic dimensions, mitral valve area, and mean transmitral pressure gradient were measured by echocardiography. LV ejection fraction was measured by Simpson’s method. Patients were divided into two groups according to ejection fraction (<50% and ≥50%). Seven patients (21%) had impaired LV contraction, and 26 (79%) had normal contraction. The incidence of AF in the patients with low ejection fractions was significantly higher than in those with normal ejection fractions (86% vs 31%, P < .01).

Second, coronary artery disease, if present, affects LV function in patients with MS. Sengupta et al . did not mention what percentage of patients >40 years of age with isolated MS had undergone coronary angiography and were found to have noncritical coronary artery disease.

We hope the authors are willing to comment about these two issues.

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Apr 21, 2018 | Posted by in CARDIOLOGY | Comments Off on Atrial Fibrillation May Affect the Success of Mitral Balloon Valvuloplasty

Full access? Get Clinical Tree

Get Clinical Tree app for offline access