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Does patent foramen ovale presence procure favourable outcomes in patients with severe rheumatic mitral stenosis?

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Abstract

Mitral stenosis (MS) is tolerated for an extended period in patients with atrial septal defect (ASD) known as Lutembacher syndrome due to depressurizing effect. In a similar way, patients with patent foramen ovale (PFO) may have clinical benefits in severe MS. We aim to evaluate the clinical effects of PFO in rheumatic MS. Transthoracic and transesophageal echocardiography records of the patients with symptomatic severe MS were screened for the period between 2008 and 2019 in a single center. 320 symptomatic patients with severe MS were included and presence of PFO recorded. Left atrial appendix (LAA) thrombotic status was defined as clear, spontaneous echo contrast, and thrombus. Two different statistical models were used to determine the predictors of either smallest (mitral valve area) MVA at symptomatic presentation or more thrombogenic LAA. 34 patients had PFO. Multivariable ordinary least square model demonstrated that increase in systolic pulmonary arterial pressure, ejection fraction and presence of PFO were associated with smaller MVA on presentation. Multivariable proportional odds logistic regression model demonstrated that advanced age, increased left atrial diameter, absence of PFO were associated with more thrombotic status whereas larger MVA was associated with decreased thrombotic status in LAA. Presence of PFO in severe MS results in two clinical benefits as (i) being asymptomatic with smaller MVA and (ii) having less LAA thrombosis probably caused by depressurizing effect on the left atrial pressure. Our study could serve as an example for patient groups with expected symptomatic benefits from left atrium pressure offloading interventions.

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References

  1. Hugenholtz PG, Ryan TJ, Stein SW, Abelmann WH (1962) The spectrum of pure mitral stenosis. Hemodynamic studies in relation to clinical disability. Am J Cardiol 10:773–84

    Article  CAS  PubMed  Google Scholar 

  2. Mittnacht AJ, Fanshawe M, Konstadt S (2008) Anesthetic considerations in the patient with valvular heart disease undergoing noncardiac surgery. Semin Cardiothorac Vasc Anesth 12:33–59

    Article  PubMed  Google Scholar 

  3. Lutembacher R (1916) De la stenose mitrale avec communication interauriculaire. Arch Mal Coeur 9:237–260

    Google Scholar 

  4. Guler N, Demirbag R, Ozkara C, Eryonucu B, Güneş A, Tuncer M et al (2004) Clinical and echocardiographic predictors of left atrial appendage dysfunction in patients with rheumatic mitral stenosis in sinus rhythm. J Am Soc Echocardiogr 17(8):819–23

    Article  PubMed  Google Scholar 

  5. Agmon Y, Khandheria BK, Gentile F, Seward JB (1999) Echocardiographic assessment of the left atrial appendage. J Am Coll Cardiol 34:1867–77

    Article  CAS  PubMed  Google Scholar 

  6. Gölbaşi Z, Ciçek D, Canbay A, Uçar O, Bayol H, Aydogdu S (2002) Left atrial appendage function in patients with mitral stenosis in sinus rhythm. Eur J Echocardiogr 3(1):39–43

    Article  PubMed  Google Scholar 

  7. Lin JM, Hsu KL, Hwang JJ, Li YH, Tseng YZ (1995) Effects of percutaneous mitral valvuloplasty on left atrial appendage flow velocity. Am J Cardiol 76:609–611

    Article  CAS  PubMed  Google Scholar 

  8. Hagen PT, Scholz DG, Edwards WD (1984) Incidence and size of patent foramen ovale during the first 10 decades of life: an autopsy study of 965 normal hearts. Mayo Clin Proc 59:17

    Article  CAS  PubMed  Google Scholar 

  9. Chau-Chung Wu, Chen W-J, Chen M-F, Liau C-S, Chu S-H, Lee Y-T (1993) Left-to-right shunt through patent foramen ovale in adult patients with left-sided cardiac lesions: a transesophageal echocardiographic study. Am Heart J 125:1369

    Article  Google Scholar 

  10. Kaye D, Shah SJ, Borlaug BA, Gustafsson F, Komtebedde J, Kubo S et al (2014) Effects of an interatrial shunt on rest and exercise hemodynamics:results of a computer simulation in heart failure. J Card Fail 20:212–221

    Article  PubMed  Google Scholar 

  11. The Helsinki Declaration of the World Medical Association (WMA) (2014) Ethical principles of medical research involving human subjects. Pol Merkur Lekarski 36(215):298–301

    Google Scholar 

  12. Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP et al (2009) Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr 10(1):125

    Article  Google Scholar 

  13. Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA et al (2013) Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European association of cardiovascular imaging. Eur Heart J 14:611–644

    Google Scholar 

  14. Silvestry FE, Cohen MS, Armsby LB, Burkule NJ, Fleishman CE, Hijazi ZM et al (2015) Guidelines for the echocardiographic assessment of atrial septal defect and patent foramen ovale. J Am Soc Echocardiogr 28:910–58

    Article  PubMed  Google Scholar 

  15. Kerut EK, Norfleet WT, Plotnick GD, Giles TD (2001) Patent foramen ovale: a review of associated conditions and the impact of physiological size. J Am Coll Cardiol 38:613

    Article  CAS  PubMed  Google Scholar 

  16. Kurzyna M, Dabrowski M, Bielecki D, Fijalkowska A, Pruszczyk P, Opolski G et al (2007) Atrial septostomy in treatment of end-stage right heart failure in patients with pulmonary hypertension. Chest 131:977–983

    Article  PubMed  Google Scholar 

  17. Lehner A, Schulze-Neick I, Fischer M, Fernandez-Rodriguez S, Ulrich S, Haas NA et al (2019) The creation of an interatrial right-to-left shunt in patients with severe, irreversible pulmonary hypertension: rationale, devices, outcomes. Curr Cardiol Rep 21(5):31

    Article  PubMed  Google Scholar 

  18. Steinbrunn W, Cohn KE, Selzer A (1970) Atrial septal defect associated with mitral stenosis. The lutembacher syndrome revisited. Am J Med 48:295–302

    Article  CAS  PubMed  Google Scholar 

  19. Crawford MH (1990) Iatrogenic Lutembacher’s syndrome revisited. Circulation 81:1422–1424

    Article  CAS  PubMed  Google Scholar 

  20. Cequier A, Bonan R, Serra A, Dyrda I, Crepeau J, Dethy M, Waters D (1990) Left-to-right atrial shunting after percutaneous mitral valvuloplasty: incidence and long-term hemodynamic follow-up. Circulation 81:1190–1197

    Article  CAS  PubMed  Google Scholar 

  21. Reddy YNV, Olson TP, Obokata M, Melenovsky V, Borlaug BA (2018) Hemodynamic correlates and diagnostic role of cardiopulmonary exercise testing in heart failure with preserved ejection fraction. JACC Heart Fail 6:665–675

    Article  PubMed  PubMed Central  Google Scholar 

  22. Dorfs S, Zeh W, Hochholzer W, Jander N, Kienzle R-P, Pieske B et al (2014) Pulmonary capillary wedge pressure during exercise and longterm mortality in patients with suspected heart failure with preserved ejection fraction. Eur Heart J 35:3103–12

    Article  CAS  PubMed  Google Scholar 

  23. Hasenfuβ G, Hayward C, Burkhoff D, Silvestry FE, McKenzie S, Gustafsson F et al (2016) A transcatheter intracardiac shunt device for heart failure with preserved ejection fraction (REDUCE LAP-HF): a multicentre, open-label, single-arm, phase 1 trial. Lancet 387:1298–304

    Article  Google Scholar 

  24. Obokata M, Reddy YNV, Shah SJ, Kaye DM, Gustafsson F, Hasenfuβ G et al (2019) Effects of interatrial shunt on pulmonary vascular function in heart failure with preserved ejection fraction. J Am Coll Cardiol 74(21):2539–2550

    Article  PubMed  Google Scholar 

  25. Tabata T, Oki T, Fukuda N, Luchi A, Manabe K, Kageji Y et al (1996) Influence of left atrial pressure on left atrial appendage flow velocity patterns in patients in sinus rhythm. J Am Soc Echocardiogr 9:857–64

    Article  CAS  PubMed  Google Scholar 

  26. Goldsmith I, Kumar P, Carter P, Blann AD, Patel RL, Lip GYH (2000) Atrial endocardial changes in mitral valve disease: a scanning electron microscopy study. Am Heart J 140(5):777–784

    Article  CAS  PubMed  Google Scholar 

  27. Porte JM, Cormier B, Iung B, Dadez E, Starkman C, Nallet O et al (1996) Early assessment by transesophageal echocardiography of left atrial appendage function after percutaneous mitral commissurotomy. Am J Cardiol 77:72–6

    Article  CAS  PubMed  Google Scholar 

  28. Ito T, Suwa M, Kobashi A, Yagi H, Hirota Y, Kawamura K (1998) Influence of altered loading conditions on left atrial appendage function in vivo. Am J Cardiol 81:1056–1059

    Article  CAS  PubMed  Google Scholar 

  29. Goswami KC, Narang R, Bahl VK, Talwar KK, Manchanda SC (1997) Comparative evaluation of transthoracic and transesophageal echocardiography in the detection of left atrial clot before percutaneous transvenous mitral commissurotomy: do all patients need transesophageal examination? Int J Cardiol 62:237–249

    Article  CAS  PubMed  Google Scholar 

  30. Goswami KC, Yadav R, Rao MB, Bahl VK, Talwar KK, Manchanda SC (2000) Clinical and echocardiographic predictors of left atrial clot and spontaneous echo contrast in patients with severe rheumatic mitral stenosis: a prospective study in 200 patients by transesophageal echocardiography. Int J Cardiol 73:273–279

    Article  CAS  PubMed  Google Scholar 

  31. Kronzon I, Tunick PA, Glassman E, Slater J, Schwinger M, Freedberg RS (1990) Transesophageal echocardiography to detect atrial the presence of left atrial spontaneous echo contrast clot in candidates for percutaneous transseptal mitral balloon valvuloplasty. J Am Coll Cardiol 16:1320–1322

    Article  CAS  PubMed  Google Scholar 

  32. Fatkin D, Kelly RP, Feneley MP (1994) Relations between left atrial appendage blood flow velocity, spontaneous echocardiographic contrast and thromboembolic risk in vivo. J Am Coll Cardiol 23(4):961–969

    Article  CAS  PubMed  Google Scholar 

  33. Ozkan M, Kaymaz C, Kirma C, Civelek A, Cenal AR, Yakut C et al (1998) Predictors of left atrial thrombus and spontaneous echo contrast in rheumatic valve disease before and after mitral valve replacement. Am J Cardiol 82:1066–1070

    Article  CAS  PubMed  Google Scholar 

  34. Kaymaz C, Ozdemir N, Erentug V, Sismanoglu M, Yakut C, Ozkan M (2003) Location, size, and morphologic characteristics of left atrial thrombi as assessed by transesophageal echocardiography in relation to systemic embolism in patients with rheumatic mitral valve disease. Am J Cardiol 91(6):765–9

    Article  PubMed  Google Scholar 

  35. Sadanandan S, Sherrid MV (2000) Clinical and echocardiographic characteristics of left atrial spontaneous echo contrast in sinus rhythm. J Am Coll Cardiol 35:1932–1938

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We would like to extend our sincere thanks to Prof. Dr. Halil Ibrahim Tanboga. He provided us invaluable insight into statistical analyses and patience throughout the duration of this project. We’d also like to extend our gratitude to Dr. Suzan Hatipoglu Akpinar for constructive criticism and helpful contributions.

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The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Authors and Affiliations

  1. Cardiology Department, Mehmet Akif Ersoy Thoracic And Cardiovascular Surgery Training and Research Hospital, University Of Health Sciences Istanbul, Turgut Ozal Bulvarı no:11, 34303, Istanbul, Küçükçekmece, Turkey

    Gamze Babur Guler, Arda Can Dogan, Ali Kemal Kalkan, Ali Rıza Demir, Begum Uygur, Ali Birant, Hicaz Zencirkiran Agus, Kadriye Memiç, Fatih Uzun & Mehmet Erturk

  2. Department of Medical Biotecnologies, Division of Cardiology, University of Siena, Siena, Italy

    Maria Concetta Pastore & Matteo Cameli

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  1. Gamze Babur Guler
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  2. Arda Can Dogan
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  3. Ali Kemal Kalkan
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All of the authors contributed planning, conduct, and reporting of the work. All authors had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Correspondence to Gamze Babur Guler.

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Babur Guler, G., Dogan, A.C., Kalkan, A.K. et al. Does patent foramen ovale presence procure favourable outcomes in patients with severe rheumatic mitral stenosis?. Int J Cardiovasc Imaging 37, 2871–2879 (2021). https://doi.org/10.1007/s10554-021-02257-5

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  • DOI: https://doi.org/10.1007/s10554-021-02257-5

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