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
Introduction
The incidence of thromboembolic complications is higher in patients with rheumatic mitral stenosis and is a major cause of morbidity and mortality [1], [2], [3]. The left atrium and left atrial appendage are well recognised sites of clot formation in these patients. Patients with a clot in the left atrium and left atrial appendage had a higher incidence of systemic embolization [4], [5], [6]. Various factors determine the individual risk for the development of left atrial clot and thromboembolization in patients with rheumatic mitral valve disease which include atrial fibrillation [4], left atrial size [7], duration of symptoms [8], older age [6], [8] and severity of mitral stenosis [9], [10]. However the presence of moderate to severe mitral regurgitation has a negative predictive value for the development of clot in the left atrium [4], [11]. The presence of left atrial spontaneous echo contrast which is frequently observed by transesophageal echocardiography in patients with mitral valve disease has been associated with increased risk of clot formation in the left atrium and systemic thromboembolization [4], [5], [7], [9], [12], [13]. However, previous studies evaluating patients with mitral stenosis were either small [10], [13], [14], [15], [16] or included a heterogeneous group of mitral valve disease patients consisting of the whole spectrum of severity of mitral stenosis [9], [11], [14], [15] and associated mitral regurgitation [4], [11], [16]. It has been shown that transesophageal echocardiography is highly sensitive for the detection of left atrial clot, especially in the left atrial appendage [8], [17]. The purpose of this study was to prospectively evaluate a large group of patients with severe rheumatic mitral stenosis, who were not receiving anticoagulation or antiplatelet therapy at the time of study, to determine if clinical and echocardiographic variables can predict the presence of clot in the left atrium or left atrial appendage and left atrial spontaneous echo contrast seen by transesophageal echocardiography.
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Patients
Two hundred consecutive patients with severe mitral stenosis (mitral valve area ≤1 cm2) being evaluated for percutaneous transvenous mitral commissurotomy, were studied in a tertiary-care referral centre in north India. All clinical and echocardiographic data were collected prospectively. Patients with more than mild mitral regurgitation, significant aortic valve disease on transthoracic echocardiography, previous closed mitral valvulotomy and on anticoagulation or antiplatelet therapy were
Results
The mean age of the patients was 29.6±9.6 years (range 13–64 years). There were 112 males and 88 females. Mean duration of symptoms was 32.0±27.4 months (range, 1–180 months). Sixty percent of the patients were in New York Heart Association functional class II and the remaining were in functional classes III (37%) and IV (3%). Twenty-seven patients had mild or less than mild mitral regurgitation and the remaining had no mitral regurgitation. A total of 69.5% of the patients were in normal sinus
Discussion
In this prospective study of patients with rheumatic severe mitral stenosis we evaluated several clinical and echocardiographic variables which correlated with the presence of left atrial and left atrial appendage clot and spontaneous echo contrast. Left atrial clot formation is a major complication in patients with rheumatic mitral valve disease [1], [2], [3] and these patients with clot had higher chance of systemic embolization [4], [5], [6]. Besides the presence of clot in the left atrium,
Conclusion
We concluded that in patients with severe mitral stenosis, atrial fibrillation and left atrial size were found to be independent predictors of clot and spontaneous echo contrast formation in left atrium and left atrial appendage. In a subgroup of the patients with normal sinus rhythm, patients with larger left atrium (>40 cm2) and spontaneous echo contrast have a higher risk of clot formation in the left atrium and left atrial appendage. We postulated that in patients with severe mitral
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