Impact of Mitral Valve Replacement on the Right Ventricle Function in Mitral Stenosis

Abstract

Background
In patients with mitral stenosis (MS), right ventricular (RV) function may be altered due to an increase in the left atrial pressure and/or changes in pulmonary arteriolar vasculature or may be affected by rheumatic process directly.

Aims
In this study we have evaluated the recovery of RV function upto 3 months in patients undergoing mitral valve replacement (MVR) using two dimensional and tissue Doppler echocardiographic indices (TDI).

Materials and Methods
A total of 30 patients who were advised MVR were enrolled prospectively. All patients underwent MVR successfully. RV function was assessed using conventional and TDI pre-operatively, 1 week, and 3 months after surgery.

Results
New York Heart Association (NYHA) functional class improved significantly at the end of one week. Mean transmitral gradient reduced postoperatively. Tricuspid regurgitation severity reduced significantly. Significant RV reverse remodelling was noted at the end of 3 months. Global RV function parameters fractional area change and RV Tei index improved significantly at the end of 3 months. In patients with mild to moderate pulmonary hypertension (PH), global RV function improved significantly, RV remodelling was seen. In patients with severe PH, both global and longitudinal functions did not improve at the end of 3 months follow up, though RV remodelling was noticed.

Conclusion
In patients with severe rheumatic MS whenever per-cutaneous trans-mitral commissurotomy is not feasible, MVR promotes RV remodelling and improvement in RV function along with significant improvement in NYHA functional status. But this improvement in RV function was noted only in patients with mild to moderate PH rather than in patients with severe PH.

Full text

© 2020 Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging | Published by Wolters Kluwer - Medknow
232
Original Research
intrOductiOn
Rheumatic heart disease (RHD) is an important health
problem in developing countries. Mitral stenosis (MS) is the
most common presentation of RHD in developing countries.
From available data from RHD studies, the estimated
average prevalence is 0.5/1000 children in the age group of
5–15 years. There are expected to be more than 3.6 million
patients of RHD estimated from 2011 census.[1] Almost
44,000 patients are added every year, and expected mortality
is 1.5%–3.3% per year.[2] The timing of intervention in valvular
heart disease is decided by the clinical, morphological, and
functional characteristics. Although percutaneous transluminal
mitral commissurotomy (PTMC) has become an effective
and safe treatment for MS patients, surgical mitral valve
replacement (MVR) has its role in patients in whom PTMC
is not possible due to the morphology of the valve. The
right ventricular (RV) function is an important factor which
determines the recovery of the patient postoperatively and
the long-term improvement in functional status.[3] In patients
with MS, RV function may be altered by increased left atrial
pressure, changes in pulmonary vasculature, or by rheumatic
process itself. Many studies have evaluated the changes in
RV function postcardiac surgery and its impact in overall
outcome.[4,5]
Aim
The purpose of this study was to analyze the recovery
of RV function after MVR in isolated MS patients in
immediate and short term (3 months) follow-up using
Impact of Mitral Valve Replacement on the Right Ventricle
Function in Mitral Stenosis
N. Swaminathan, Venkatesan S. Sangareddi, G. Ravishankar, Justin Paul, L. Alen Binny
Institute of Cardiology, Rajiv Gandhi Government General Hospital, Chennai, Tamil Nadu, India
Background: In patients with mitral stenosis (MS), right ventricular (RV) function may be altered due to an increase in the left atrial pressure
and/or changes in pulmonary arteriolar vasculature or may be affected by rheumatic process directly. Aims: In this study we have evaluated
the recovery of RV function upto 3 months in patients undergoing mitral valve replacement (MVR) using two dimensional and tissue Doppler
echocardiographic indices (TDI). Materials and Methods: A total of 30 patients who were advised MVR were enrolled prospectively. All
patients underwent MVR successfully. RV function was assessed using conventional and TDI pre-operatively, 1 week, and 3 months after
surgery. Results: New York Heart Association (NYHA) functional class improved signicantly at the end of one week. Mean transmitral
gradient reduced postoperatively. Tricuspid regurgitation severity reduced signicantly. Signicant RV reverse remodelling was noted at the
end of 3 months. Global RV function parameters fractional area change and RV Tei index improved signicantly at the end of 3 months. In
patients with mild to moderate pulmonary hypertension (PH), global RV function improved signicantly, RV remodelling was seen. In patients
with severe PH, both global and longitudinal functions did not improve at the end of 3 months follow up, though RV remodelling was noticed.
Conclusion: In patients with severe rheumatic MS whenever per-cutaneous trans-mitral commissurotomy is not feasible, MVR promotes RV
remodelling and improvement in RV function along with signicant improvement in NYHA functional status. But this improvement in RV
function was noted only in patients with mild to moderate PH rather than in patients with severe PH.
Keywords: Mitral stenosis, mitral valve replacement, pulmonary hypertension, right ventricle function
Address for correspondence: Dr. L. Alen Binny,
Institute of Cardiology, Rajiv Gandhi Government General Hospital,
Chennai, Tamil Nadu, India.
E‑mail: alenbinny@gmail.com
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DOI:
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How to cite this article: Swaminathan N, Sangareddi VS, Ravishankar G,
Paul J, Binny LA. Impact of mitral valve replacement on the right ventricle
function in mitral stenosis. J Indian Acad Echocardiogr Cardiovasc Imaging
2020;4:232-6.
Abstract
Submitted: 10-Mar-2020 Revised: 29-Mar-2020
Accepted: 07-Apr-2020 Published: 18-Dec-2020
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Swaminathan, et al.: Impact of mitral valve replacement on RV function in mitral stenosis
Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging ¦ Volume 4 ¦ Issue 3 ¦ September-December 2020 233
two-dimensional echocardiographic and tissue Doppler
indices.
materials and methOds
The study was done in a Rajiv Gandhi Government General
Hospital Chennai from June 2018 to June 2019. A total of thirty
patients in all age groups with isolated MS in whom PTMC
was not feasible and were advised surgical MVR were enrolled
in the study. RV function was assessed using conventional
two-dimensional and Tissue Doppler imaging (TDI) before
surgery, 1 week and 3 months after surgery. New York Heart
Association (NYHA) Functional class, tricuspid annular
plane systolic excursion (TAPSE), RV systolic velocity
(RVSm), RV myocardial performance (RIMP), fractional area
change (FAC), pulmonary artery systolic pressure (PASP), RV
basal diameter (systole and diastole). All studies were obtained
using Aloka ultrasonographic machine equipped with 3.5 MHz
transducer.
Inclusion criteria
• All age group
• Both male and female
• Severe MS (those were not suitable for PTMC)
• Normal left ventricular (LV) function.
Exclusion criteria
• More than mild mitral regurgitation
• Other causes of pulmonary hypertension (PH)
• Associated aortic valve lesion
• LV dysfunction.
Echocardiographic measurements
The mitral valve area was measured by planimetry. Transmitral
gradients were measured using Bernoulli’s principle from
continuous‑wave Doppler recordings through mitral inow.
Suitability for PTMC was assessed using Wilkins score
and commissural calcium score. Systolic pulmonary artery
pressures (PASP) were derived from tricuspid regurgitant jet
velocity. The right atrial pressure was calculated by estimating
the inferior vena caval size and its variation with respiration.
Parameters for RV function were measured according to
the American Society of Echocardiography guidelines.[6]
TAPSE was measured by displacement of the lateral tricuspid
annulus during systole using M mode. RV end-diastolic and
end-systolic areas were measured from the RV focused apical
four-chamber view to calculate RV FAC. RIMP was calculated
as the time between tricuspid valve closure to tricuspid valve
opening, divided by the RV ejection time, determined by TDI.
Statistical analysis
Statistical analysis was performed with Statistical Package
for the Social Sciences IBM company, NY, USA. Data
were presented as mean ± standard deviation for continuous
variables. Comparisons of data before and after MVR were
performed using Student’s t-test. A P < 0.05 was considered
to indicate statistical signicance.
results
MVR was done through the left atrial approach on pump.
St. Jude bileaet mechanical valve was used in most of the
patients (25 patients), and TTK Chitra single leaet valve was
used in the remaining (% patients). The selection of the valve
was based on surgeons’ preference. The postoperative period was
uneventful in all the patients. The postoperative mitral inow
gradients were peak 8.9 ± 2.7 mm Hg, mean 3.5 ± 1.5 mmHg.
Descriptive statistics
A total of 30 patients with severe MS were included
prospectively in this study. Twelve patients were <40 years,
11 patients were 40–50 years age, and 7 patients were >50 years
17 patients were female [Figure 1].
Eleven patients had RV dysfunction. Twelve patients had
severe PH [Figure 2].
Functional class
Most of the patients were in NYHA Functional Class III
preoperatively and improved to functional Class I at the end
of 1-week post-MVR PASP reduced from 56.4 ± 22.4 to
27.2 ± 6.5 at the end of 3 months [Figure 3]. TAPSE reduced
from a preoperative value of 16.0 ± 5.3 to 8.85 ± 2.5 at the
end of 1-week post-MVR and improved to 15.1 ± 2.3 at the
end of 3 months with no signicant change from preoperative
value. RVSm also reduced from its preoperative value
10.8 ± 3.39 to 7.55 ± 1.53 at the end of 1 week and improved to
10.15 ± 1.50 at the end of 3 months with no signicant change
from preoperative value. FAC reduced from 42.1 ± 11.8 to
35.2 ± 7.71 at the end of 1 week but increased signicantly to
49.2 ± 7.66 comparing preoperative value. RIMP improved
from 0.549 ± 0.152 to 0.44 ± 0.082 at the end of 3 months.
Pulmonary acceleration time increased from 73.4 ± 17.9 to
102.3 ± 15.49 at the end of 3 months. RV basal diameter
in systole and diastole reduced signicantly at the end of
3 months.
In patients with severe PH (tricuspid regurgitation peak
gradient [TR PG] >60 mmHg), though PASP reduced
signicantly, among TAPSE, RVSm, FAC, RIMP, none of
them showed improvement at the end of 3 months’ follow-up.
RV basal diameter in systole and diastole reduced signicantly
from preoperative values.
In patients with mild-to-moderate PH (TR PG <60 mmHg),
TAPSE and RVSm did not improve at the end of 3 months,
while FAC (from 42.7 ± 11.5 to 50.83 ± 7.84) and RIMP (from
0.55 ± 0.17 to 0.42 ± 0.05) improved signicantly at the end of
3 months’ follow-up [Figure 4]. RV basal diameters in systole
and diastole also reduced signicantly.
In patients with preoperative RV dysfunction also, RV function
improved at the end of 3 months postsurgery, noticed by
improvement in TAPSE from 10.2 ± 3.4 to 13.1 ± 1.60, FAC
from 31.7 ± 12.3 to 48.8 ± 9.45, RVSm from 7.4 ± 2.06 to
9 ± 0.89, RIMP from 0.63 ± 0.12 to 0.45 ± 0.10. RV basal
diameter in systole and diastole also reduced signicantly.
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Swaminathan, et al.: Impact of mitral valve replacement on RV function in mitral stenosis
Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging ¦ Volume 4 ¦ Issue 3 ¦ September-December 2020
234
discussiOn
In patients with severe MS, RV function is inherently
related to functional capacity, perioperative mortality, and
postoperative outcome.[3] Due to asymmetrical shape and
narrow acoustic window, the evaluation of RV function is
difcult by transthoracic echocardiography. Although a wide
variety of techniques have been proposed, none of the echo
parameters are considered gold standard at present. In this
study, we used various two dimensional and TDI indices to
assess RV function in severe MS pre- and post-surgery and a
3 months’ follow-up.
NYHA functional class improved at the end of 1 week.
PASP reduced signicantly, and pulmonary acceleration
time improved at the end of 3 months. Signicant RV
reverse remodeling was noted at the end of 3 months in
all the groups. Longitudinal function assessed by TAPSE
decreased at the end of 1-week postsurgery but improved
to preoperative values with no signicant change at the
end of 3 months’ follow-up. RVSm also reduced from
its preoperative value at the end of 1 week and improved
at the end of 3 months with no signicant change from
preoperative value [Table 1]. Several hypotheses have
been proposed to explain the fall in longitudinal function
in the RV in the immediate postoperative period. Some
of them are intraoperative ischemia, right atrial injury
due to cannulation,[7] poor myocardial protection,[8]
pericardial disruption, postoperative adherence of the
right ventricle to thoracic wall[9] and due to geometrical
changes in RV chamber in association with paradoxical
septal motion.[10] Drighil et al. found that RVSm did not
change immediately after PTMC.[11] Global RV function
parameters FAC and RIMP improved signicantly at the
end of 3 months [Table 1]. The improvement is probably
due to fall in RV afterload and improvement in contractility.
Drighil et al. noticed a signicant improvement in RIMP
from 0.5 ± 0.2 to 0.3 ± 0.2 (P < 0.0001) and Bensaid et al.
observed a nonsignificant improvement in RIMP after
PTMC from 0.33 ± 0.1 to 0.36 ± 0.12 (P = 0.2).[11]
In subgroup analysis, in patients with mild-to-moderate
PH [Table 2], global RV function improved signicantly, RV
remodeling was seen, while longitudinal function stayed at
preoperative values. In patients with severe PH [Table 3],
both global and longitudinal functions did not improve at
the end of 3 months’ follow-up, though RV remodeling was
noticed in this group. Even in patients with preoperative RV
dysfunction [Table 4], global and longitudinal RV function
improved significantly along with fall in PASP and RV
remodeling.
Table 2: Comparision of pre‑and post‑mitral valve replacement echo parameters in patients with mild to moderate
pulmonary hypertension
Group B (n=18; 60%) mild to moderate pulmonary hypertension
Pre‑MVR (A) 1 week post‑MVR (B) 3 months post‑MVR (C) Significance (A/B) Significance (A/C)
PASP (mmHg) 41.4±8.1 36.5±16.2 27.83±5.63 0.068913 0.000036
TAPSE (mm) 16.4±4.9 9.0±2.1 15.41±2.46 0.000643 0.46293
RV Sm (cm/s) 11.75±3.5 7.9±1.72 10.41±1.56 0.006342 0.24905
FAC (%) 42.7±11.5 36.5±7.4 50.83±7.84 0.162995 0.01769
RV MPI 0.55±0.17 0.71±0.19 0.42±0.05 0.038576 0.01066
Pulmonary acceleration time
(ms)
78.4±19.04 78.4±20.69 101.83±14.40 0.48319 0.00131
RV basal diameter-D (mm) 40.5±6.3 40.3±5.3 35±5.0 0.214811 0.00316
RV basal diameter-S (mm) 31.7±5.6 32.1±5.02 29.16±4.64 0.377252 0.04271
MVR: Mitral valve replacement, PASP: Pulmonary artery systolic pressure, TAPSE: Tricuspid annular plane systolic excursion, RV: Right ventricular,
FAC: Fractional area change, MPI: Myocardial performance index, RV Sm: Right ventricle myocardial systolic velocity
Table 1: Comparision of transthoracic echocardiographic parameters before and after mitral valve replacement
Whole study group (n=30) Pre‑MVR (A) 1 week post‑MVR (B) 3 months’ post‑MVR (C) Significance (A/B) Significance (A/C)
PASP (mmHg) 56.4±22.4 36.6±12.1 27.2±6.5 0.001 0.00001
TAPSE (mm) 16.0±5.3 8.85±2.5 15.1±2.3 0.000 0.253
RV Sm (cm/s) 10.8±3.39 7.55±1.53 10.15±1.50 0.000 0.22
FAC (%) 42.1±11.8 35.2±7.71 49.2±7.665 0.057 0.009
RV MPI 0.549±0.152 0.691±0.162 0.44±0.082 0.000 0.006
Pulmonary acceleration time
(ms)
73.4±17.9 81.2±21.3 102.3±15.49 0.092 0.00001
RV basal diameter-D (mm) 45.7±9.031 42.7±7.02 36.57±5.26 0.083 0.00023
RV basal diameter-S (mm) 36.3±7.39 34.8±6.59 29.15±5.069 0.200 0.00057
MVR: Mitral valve replacement, PASP: Pulmonary artery systolic pressure, TAPSE: Tricuspid annular plane systolic excursion, RV: Right ventricular,
FAC: Fractional area change, MPI: Myocardial performance index, RV Sm: Right ventricle myocardial systolic velocity
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Swaminathan, et al.: Impact of mitral valve replacement on RV function in mitral stenosis
Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging ¦ Volume 4 ¦ Issue 3 ¦ September-December 2020 235
0
23 23
8
5
7
20
20
200
0
5
10
15
20
25
PRE MVR 1 WEEK POST MVR 3 MONTHS POST MVR
NYHA FC 1NYHA FC 2NYHA FC3NYHA FC 4
Figure 3: NYHA functional class improvement. NYHA FC: New York Heart
Association functional classification, MVR: Mitral valve replacement
MILD, 14
MODERA
TE, 15
SEVERE,
1
TRICUSPID REGURGITATION
25
5
0
POST OP TR - 1 WEEK
MILD MODERATE SEVERE
25
5
0
POST OP TR - 3 MONTHS
MILD MODERATE SEVERE
Figure 4: Tricuspid regurgitation (TR) severity
Figure 1: Age and sex distribution
11
19
0
5
10
15
20
RV
DYSFUNCTION
YES NO
18
12
PHT
SEVERE MILD
Figure 2: Preoperative right ventricular (RV) dysfunction and pulmonary
hypertension (PHT) severity
A study by Kumar et al.[12] showed that immediately after
PTMC both longitudinal and global functions of the RV
improved significantly. However, in our study group,
immediately following the surgery (MVR), RV functions
actually reduced but improved signicantly at the end of
3 month's follow-up.
cOnclusiOn
In patients with severe rheumatic MS whenever PTMC is not
feasible, MVR promotes RV remodeling and improvement
in RV function along with significant improvement in
NYHA functional status. However, this improvement in RV
function was noted only in patients with mild-to-moderate
Table 3: Comparision of pre‑and post‑mitral valve replacement echo parameters in patients with severe pulmonary
hypertension
Group A (n=12) severe pulmonary hypertension
Pre‑MVR (A) 1 week post‑MVR (B) 3 months post‑MVR (C) Significance (A/B) Significance (A/C)
PASP (mmHg) 80±16 36.7±6.2 26.28±8.19 0.000039 0.001
TAPSE (mm) 15.3±6.2 8.6±3.2 14.57±2.22 0.00094 0.1703
RV Sm (cm/s) 9.3±2.8 7.0±1.0 9.71±1.38 0.003498 0.3595
FAC (%) 41.2±13.03 33.3±8.2 46.57±7.06 0.012798 0.3068
RV MPI 0.54±0.11 0.65±0.11 0.47±0.10 0.012192 0.1784
Pulmonary acceleration time
(ms)
65.8±13.9 85.3±22.9 103.14±18.39 0.035714 0.00026
RV basal diameter-D 53.6±6.8 46.2±8.0 39.28±4.85 0.152217 0.0064
RV basal diameter-S 43.2±2.7 38.7±6.9 29.14±6.12 0.19384 0.0053
MVR: Mitral valve replacement, PASP: Pulmonary artery systolic pressure, TAPSE: Tricuspid annular plane systolic excursion, RV: Right ventricular,
FAC: Fractional area change, MPI: Myocardial performance index, RV Sm: Right ventricle myocardial systolic velocity
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Swaminathan, et al.: Impact of mitral valve replacement on RV function in mitral stenosis
Journal of the Indian Academy of Echocardiography & Cardiovascular Imaging ¦ Volume 4 ¦ Issue 3 ¦ September-December 2020
236
PH rather than in patients with severe PH. Hence, MS should
be intervened at an earlier stage before the development of
severe PH.
Limitation
The recovery of RV function was not analyzed in correlation
to the indexed mitral valve orice area. Patients with atrial
fibrillation were included. Hence, the impact of atrial
brillation per se on RV function has its own implications
apart from the severity of MS. A longer follow-up of 6 months
would have claried whether the longer duration is required
for RV function to recover in case of severe PH.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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Table 4: Comparision of pre‑and post‑mitral valve replacement echo parameters in patients with right ventricular
dysfunction
(n=11; 37%) pre‑MVR RV dysfunction
Pre‑MVR (A) 1 week (B) 3 months (C) Significance (A/B) Significance (A/C)
PASP (mmHg) 60.5±16.5 43.14±13.2 30.5± 6.05 0.03171 0.00138
TAPSE (mm) 10.2±3.4 7.85±2.91 13.1±1.60 0.09813 0.03931
FAC (%) 31.7±12.3 33.83±8.51 48.8±9.45 0.36889 0.0073
RV Sm (cm/s) 7.4±2.06 7±1 9±0.89 0.32521 0.05046
RV MPI 0.63±0.12 0.73±0.24 0.45±0.10 0.17831 0.00546
Pulmonary acceleration time (ms) 67.4±9.24 70.2±19.81 98.66±23.6 0.3696 0.00236
RV basal diameter-D (mm) 47.8±5.48 43.5±5.94 39.5±5.85 0.10079 0.01355
RV basal diameter-S (mm) 40±5.09 36.4±6.62 31.8±4.62 0.14723 0.00769
MVR: Mitral valve replacement, PASP: Pulmonary artery systolic pressure, TAPSE: Tricuspid annular plane systolic excursion, RV: Right ventricular,
FAC: Fractional area change, MPI: Myocardial performance index, RVSm: Right ventricle myocardial systolic velocity
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