(99)
ROLE OF TISSUE DOPPLER IMAGING "IN
ASSESSMENT OF PATIENTS WITH AORTIC
STENOSIS AND MITRAL STENOSIS
Protocol of Thesis
Submitted In Partial fulfillment For
The M. Sc. Degree In (CARDIOLOGY)
By
Hesham Mohammad El-Said Hasan
M.B.B. Ch.
Under Supervision Of
Prof. Dr.
Mohammad Lotfy Shahwan
Prof. Of Cardiology
Faculty of Medicine
Zagazig University
Dr.
Mohammad Mohammad El-Gawady
Professor of Cardiology
Faculty of Medicine
Zagazig University
Dr.
Islam Abd Elmoneam El-Sherbeny
Lectures of Cardiology
Faculty of Medicine
Zagazig University
Faculty of Medicine
Zigazig Universit
2005
Summary and conclusion
The coaptation point of the mitral valve leaflets in systole
practically reaches the level of the mitral annulus. This point is displaced
apically in abnormal conditions. Such as morphological abnormalities of
the leaflets or dilatation of the left ventricle. As a result the distance
between the coaptation point of the leaflets and the level of mitral annulus
is increased. This finding is described as incomplete mitral leaflet closure
and may be the result of failure of one or both leaflets to reach the level
of atrio-ventricular ring at the point of its peak systolic movement.lt has
been attributed to papillary muscle dysfunction, raised left ventricular
filling pressure and left ventricular dysfunction. One of the theories that
have been proposed to explain the mechanism of incomplete mitral
closure in patients without intrinsic valvular abnormalities (regional
theory).According to this theory it is proposed that in ischemic heart
disease therefore geometrical changes in the mitral leaflet attachment
region or at the base of papillary muscles producing traction of dyskinetic
areas that prevents the mitral leaflets from coapting fully.
All patients were subjected to the following;
1. Complete history taking.
2. Thorough clinical examination.
3. Standard l2-lead ECG.
4. Complete echocardiographic examination (LVEDD,
LVESD,EF,FS,EPSS, mitral annular diameter and CPMA at baseline)
5. Dynamic echocardiography using a low dose dobutamine protocol to
assess myocardial viability and all the baseline measurements were
detected including CPMA at each stage of dobutamine stress
echocardiography. Patients were classified using low dose
dobutamine echocardiography into group I with viable myocardium
and group II with non viable myocardium. Then we complete
dynamic echo, using high dose dobutamine.
6. Coronary angiography:
Using Judkin's technique (left catheter for left coronary system &
right catheter for right coronary catheter).A coronary stenosis was
considered significant when the vessel diameter was narrowed by >50%
for the left main coronary artery and by>70% for other
coronary vessels.
The cinefilm or CD of coronary angiography was evaluated
visually by more than two observers .
The population characteristics were comparable in the studied
groups and show that they were not contributing in viability.
We also found that during rest L.V systolic & diastolic functions
are more better in viable group than in non viable group which was
explained by better coronary blood flow in viable group and coronary
reserve.
We found that CPMA significantly changed during low dose
dobutamine in viable group with improvement of left ventricular
contractility than in non viable group.
We also found that CPMA was correlated well with contractility
indices (EF,FS) inversely when CPMA is increased EF, FS were
decreased and vice versa. While CPMA correlated positively with WMSI
&it correlated negatively with VI in non viable group.
We also found that CPMA greater than 8mm during low dose
dobutamine indicates non viable myocardium &CPMA <8mm was in
agreement with biphasic response when we proceed to high dose
dobutamine.
We also found that CPMA<8mm had 65.6% sensitivity ,100%
specificity and 78% accuracy in detecting viability.
Conclusion:
In patients with ischemic heart failure and viable myocardium the
distance between mitral valve coaptation point and the mitral annular
plane (CPMA) was decreased during low dose dobutamine in viable
myocardium, while it was worse or at least did not change during low
dose dobutamine in non viable group.
There was a significant correlation between CPMA and
echocardiographic indices of systolic function (ES,FS,...).Overall, there
was an inverse correlation between CPMA and indices of systolic
performance of the left ventricle .
There was no correlation between CPMA and diastolic indices
concluding that it depends mainly on systolic function. There was
significant correlation of CPMA with WMSI &V1 which are
echocardiographic indices of viability.
Low dose CPMA <8mm was our cut off point which yields the
highest sensitivity and specificity for detection of viability and it was
also in association with biphasic response when we proceeded to high
dose of dobutamine adding a value to that cut off point in confirming
the patient's benefit of revascularization.
Low dose CPMA<8mm had 65.6% sensitivity ,100% specificity and
78% accuracy in detection of viability.
Incomplete mitral valve closure and hence CPMA is determined
mainly by contractile function of L.V as reflected by EF and FS .
CPMA at low dose DSE seems to be simple, reproducible more than
WMSI which has been criticized due to poor endocardial delineation
in many cases and interobserver variation.
Recommendation:
We recommended to study CPMA in a large number of patients
and to correlate CPMA with Doppler tissue or radionuclide stress
imaging. Follow up of CPMA study after revascularization is also
recommended to show recovery of viable myocardium and hence the
benefit.