CLINICAL AND HAeMODYNAMIC OBSERVATIONS ON COMBINED MITRAL AND AORTIC STENOSIS

Abstract

The association of significant aortic stenosis with mitral stenosis in rheumatic heart disease is not very common. It is, however, important to recognize the presence of the accompanying aortic stenosis and to be able to assess its severity, since this lesion also can be relieved surgically. The clinical and hmmodynamic features of 35 patients, seen at Guy's Hospital between 1952 and 1959, with this combination of lesions have been studied in order to learn more about the ways in which each lesion modifies the effects of the other: these observations have been applied to the problems of diagnosis and assessment of severity. MATERIAL AND METHODSThis series includes those patients (32) in whom an estimate of the mitral valve area has been made by the surgeon, and in whom aortic stenosis was suspected clinically and confirmed by the demonstration of a systolic gradient across the aortic valve, at operation for mitral or combined mitral and aortic valvotomy. Seventeen of these had a pre-operative right heart catheterization, together with a left ventricular puncture in three and a left atrial puncture in three. Two unoperated patients have had full heamodynamic assessment by left atrial puncture; one of these died while awaiting operation and one was thought not to require surgical relief of either stenosis. In one operated patient, a small aortic valve gradient was demonstrated at left atrial puncture but not measured at operation.None of the 35 patients had dominant regurgitation at either valve. In 23, an early diastolic murmur thought to be due to slight aortic regurgitation was recorded, but in only two was this possibly of haemodynamic significance. In 12 of the 33 operated patients, slight mitral regurgitation was detected, but in none was this sufficient to contraindicate valvotomy; in the 2 unoperated patients, the clinical features suggested dominant mitral stenosis, though both had apical systolic murmurs. Three (Cases 8, 11, and 19) had organic tricuspid stenosis.The presence or absence of those symptoms commonly occurring in lone mitral or aortic stenosis and the degree of disability (criteria of Baker et al., 1952) were noted. The findings on examination were not analysed since this was a retrospective study and only a few of the patients were personally examined before operation. The cardiogram was inspected for evidence of right or left or bi-ventricular hypertrophy; left ventricular hypertrophy (L.V.H.) was regarded as slight when the sum of the amplitudes of the deepest S wave in a right ventricular lead and the tallest R in a left ventricular lead was 35 to 45 mm., and moderate when 46 to 60 mm.; changes in the S-T segment and T wave were of little value since most of the patients were receiving digitalis. The cardiac rhythm was also noted. The chest radiograph was examined for dilatation of the first part of the aorta and pulmonary venous congestion, and the screening report for observations on the presence of left ventricular hypertrophy and mitral or aortic valvar calcification and the aortic a...

Assessment of Aortic Stenosis From the External Carotid Pulse Wave

“…At operation in many of these patients the aortic valve gradient increased after mitral valvotomy before aortic valvotomy. Similar observations were noted by Brock (1957) and Honey (1961). The increase in aortic valve gradient reflects an increased flow across the valve.…”

“…The cardiac output is diminished in severe mitral stenosis (Gorlin and Gorlin, 1951), and this also applies when the mitral stenosis is combined with aortic stenosis. Uricchio et al (1959), Katznelson et al (1960, and Honey (1961) found subnormal cardiac outputs in their series of patients with combined aortic and mitral stenosis.…”

The clinical challenge of concomitant aortic and mitral valve stenosis

“…However, several pitfalls should be kept in mind. As described in the early sixties, the reduction of cardiac output is usually more dramatic than it is in isolated valvular stenosis 3 . The occurrence of a low flow situation can account for smaller pressure gradients in the case of severe stenosis.…”

Combined mitral and aortic stenosis of rheumatic origin with double-valve replacement in an octogenarian

“…Of the 267 patients reported in the previously mentioned 8 studies [2][3][4][5][6][7][8][9], 171 (64%) were women. .…”

“…Several studies have examined cardiac hemodynamics in patients with combined MS and AS [2][3][4][5][6][7][8][9]. Although there are exceptions, the degree of AS when combined with MS is not as great (transvalvular peak systolic gradient) as in patients with isolated AS.…”