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Cardiac catheterization for patients with pure mitral stenosis—I
LElTERS TO THE EDITOR
CARDIAC CATHETERIZATION FOR PATIENTS WITH PURE MITRAL STENOSIS-I
REPLY
Motro and Neufeldl argue that cardiac catheterization can be replaced by noninvasive methods in assessing patients with mitral stenosis. Although I sympathize with their desire to decrease risk as well as hospital costs, I believe that noninvasive methods do not adequately assess the question of concomitant valve or coronary disease. Although two dimensional echocardiography is probably superior to cardiac catheterization in detecting left atria1 thrombi and in assessing mobility of the mitral cusps, and fluoroscopy is most useful in detecting valve calcification, the extent of mitral regurgitation can best be assessed with ventriculography. Many patients with mitral stenosis have a systolic murmur, and knowledge of the severity of mitral regurgitation is necessary when deciding if a commissurotomy, with its lower operative risk, can be performed. Mitral stenosis will often mask the signs of significant aortic stenosis.2 Unfortunately, two dimensional echocardiography has not proved reliable in assessing aortic stenosis.3 Also, many patients with mitral stenosis have concomitant aortic regurgitation, which is best assessed with hemodynamic and ventriculographic variables. I disagree that significant coronary artery disease may be ruled out by exercise radionuclide techniques. The usefulness of exercise gated equilibrium angiography in detecting coronary artery disease in patients with valve disease and left ventricular dysfunction is uncertain, and patients with mitral stenosis have a significantly lower ejection fraction than normal.4 Additionally, many patients with mitral stenosis have atria1 fibrillation, which can interfere with computer analysis of radionuclide angiography.5 Finally, thallium-201 stress testing is more reliable when used in conjunction with electrocardiographic S-T segment information than when used alone.6 However, many patients with mitral stenosis are receiving digitalis preparations, which make electrocardiographic changes difficult to interpret. With careful attention to detail the risk of cardiac catheterization is indeed low. The information obtained at catheterization regarding the presence or severity, or both, of mitral regurgitation, aortic valve disease, and coronary artery disease justifies the use of cardiac catheterization in most patients with mitral stenosis. Marc J. Schweiger, MD, FACC Cardiac Catheterization Laboratory Baystate Medical Center Springfield, Massachusetts References 1. Mofro M. NWfsM HN. Should patients with pure mitral stenosis undergo cardiac c&heterizaticn. Am J Cardiol 1960;46:515-6. 2. Zllnlk RS, Plamms TE, Massor RJ, Read DP, Hayner FW, Dealer L. The masking of acrtlc stenosis by mitral stenosis. Am Heart J 1965;69:22-30. 3. Kotler MN, Mlnlz OS, Ssgal BL, Parry WR. Clinical uses of two dimensional echocardiography. Am J Cardiol 1980;45:1061-62. 4. Helfer SJ, Carla&m RA. Abncrmal left ventricular contraction in patients with m#ral stenosis. Circulation 1970;42:1099-110. 5. Elmer MM, Banks VS. Helfanf RH. Nuclear cardiology. I. Radionuclids angie SapMc assBssmem of left ventricul;v ccntracticn: uses. limitations and fuhra clrections. Am J Cardiol 1960;45:661-71. 6. Epstefa SE. Implications of probability analysis on the strategy used for noninvasive detection of cwcnaly artery disease. Am J Cardiol 1960;46:491-9.
We did not refer to assessment of the degree of mitral regurgitation, because we addressed ourselves exclusively to pure mitral stenosis. Patients with a mitral systolic murmur are not considered to have pure mitral stenosis and should therefore undergo cardiac catheterization to assess the degree of mitral insufficiency. We agree that echocardiographic assessment of the severity of aortic stenosis is still crude, but there is no argument today that the presence or absence of aortic stenosis can be reliably detected or excluded with echocardiography.1-3 With regard to the concomitant presence of aortic insufficiency with pure mitral stenosis, we believe that in patients with a normal-sized left ventricle and aortic insufficiency that can be neither perceived on physical examination nor detected with echocardiography, the significance of such a lesion plays a minor role after mitral commissurotomy or replacement. Patients with pure mitral stenosis may fall within the age group prone to coronary artery disease, and yet may be free of angina and have no other suspicious indexes. In sucha case exercise thallium perfusion scans are performed. When scan results are negative, we see no reason for coronary angiography. However, if any of the preceding factors are present or even suspected, coronary angiography is indicated. Within these guidelines most patients with pure mitral stenosis will not require coronary angiography. Michael Motro, MD Henry N. Neufeld, MD Heart Institute Chaim Sheba Medical Center Tel Hashomer, Israel 1. DaYarIa AN, Bommer W. Joye J, Las G, Boateller J, Mason DT. Value and limitation of the acrtic valve in the diaanosis and auantification of valvular acrtic stenosis. Circulation; 1960;62:304. 2. Weyman AE, Felgeabaum H, Dlllon JC, Chan9 S. Cross-sectional echocardiography in assessing the severity of valvular acftlc stenosis. Circulation; 1975;52:626. 3. Weyman AF, FMgsnbaum H, Hurwlfz RA, Glrad DA, Dlllon JC. Cross-sectional echocqdiographic assessment of the severity of acrtfc stenosis in children. Circulation 1977;55:773.
CARDIAC CATHETERIZATION FOR PATIENTS WITH PURE MITRAL STENOSIS-II
The recommendations of Motro and Neufeld to utilize gated equilibrium radionuclide angiography and thallium-201 myocardial perfusion scintigraphy for the assessment of coronary artery disease in patients with pure mitral stenosis deserve some comments. Although both techniques have become widely accepted diagnostic aids in the detection of coronary artery disease, their usefulness in patients with pure mitral stenosis has never been established. None of the eight studies quoted by the authors to elucidate the value of exercise thallium perfusion scintigraphy and radionuclide cineangiography included patients with pure mitral stenosis. Mitral stenosis has a significant left ventricular preload-reducing effect, decreasing left ventricular volume and therefore decreasing wall tension, a major determinant of myocardial oxygen demand. This may help to maintain a positive balance
January 1992
The American Journal of CARDIOLOGY
Volume 49
257
CARDIAC CATHETERIZATION FOR PATIENTS WITH PURE MITRAL STENOSIS-I
REPLY
Motro and Neufeldl argue that cardiac catheterization can be replaced by noninvasive methods in assessing patients with mitral stenosis. Although I sympathize with their desire to decrease risk as well as hospital costs, I believe that noninvasive methods do not adequately assess the question of concomitant valve or coronary disease. Although two dimensional echocardiography is probably superior to cardiac catheterization in detecting left atria1 thrombi and in assessing mobility of the mitral cusps, and fluoroscopy is most useful in detecting valve calcification, the extent of mitral regurgitation can best be assessed with ventriculography. Many patients with mitral stenosis have a systolic murmur, and knowledge of the severity of mitral regurgitation is necessary when deciding if a commissurotomy, with its lower operative risk, can be performed. Mitral stenosis will often mask the signs of significant aortic stenosis.2 Unfortunately, two dimensional echocardiography has not proved reliable in assessing aortic stenosis.3 Also, many patients with mitral stenosis have concomitant aortic regurgitation, which is best assessed with hemodynamic and ventriculographic variables. I disagree that significant coronary artery disease may be ruled out by exercise radionuclide techniques. The usefulness of exercise gated equilibrium angiography in detecting coronary artery disease in patients with valve disease and left ventricular dysfunction is uncertain, and patients with mitral stenosis have a significantly lower ejection fraction than normal.4 Additionally, many patients with mitral stenosis have atria1 fibrillation, which can interfere with computer analysis of radionuclide angiography.5 Finally, thallium-201 stress testing is more reliable when used in conjunction with electrocardiographic S-T segment information than when used alone.6 However, many patients with mitral stenosis are receiving digitalis preparations, which make electrocardiographic changes difficult to interpret. With careful attention to detail the risk of cardiac catheterization is indeed low. The information obtained at catheterization regarding the presence or severity, or both, of mitral regurgitation, aortic valve disease, and coronary artery disease justifies the use of cardiac catheterization in most patients with mitral stenosis. Marc J. Schweiger, MD, FACC Cardiac Catheterization Laboratory Baystate Medical Center Springfield, Massachusetts References 1. Mofro M. NWfsM HN. Should patients with pure mitral stenosis undergo cardiac c&heterizaticn. Am J Cardiol 1960;46:515-6. 2. Zllnlk RS, Plamms TE, Massor RJ, Read DP, Hayner FW, Dealer L. The masking of acrtlc stenosis by mitral stenosis. Am Heart J 1965;69:22-30. 3. Kotler MN, Mlnlz OS, Ssgal BL, Parry WR. Clinical uses of two dimensional echocardiography. Am J Cardiol 1980;45:1061-62. 4. Helfer SJ, Carla&m RA. Abncrmal left ventricular contraction in patients with m#ral stenosis. Circulation 1970;42:1099-110. 5. Elmer MM, Banks VS. Helfanf RH. Nuclear cardiology. I. Radionuclids angie SapMc assBssmem of left ventricul;v ccntracticn: uses. limitations and fuhra clrections. Am J Cardiol 1960;45:661-71. 6. Epstefa SE. Implications of probability analysis on the strategy used for noninvasive detection of cwcnaly artery disease. Am J Cardiol 1960;46:491-9.
We did not refer to assessment of the degree of mitral regurgitation, because we addressed ourselves exclusively to pure mitral stenosis. Patients with a mitral systolic murmur are not considered to have pure mitral stenosis and should therefore undergo cardiac catheterization to assess the degree of mitral insufficiency. We agree that echocardiographic assessment of the severity of aortic stenosis is still crude, but there is no argument today that the presence or absence of aortic stenosis can be reliably detected or excluded with echocardiography.1-3 With regard to the concomitant presence of aortic insufficiency with pure mitral stenosis, we believe that in patients with a normal-sized left ventricle and aortic insufficiency that can be neither perceived on physical examination nor detected with echocardiography, the significance of such a lesion plays a minor role after mitral commissurotomy or replacement. Patients with pure mitral stenosis may fall within the age group prone to coronary artery disease, and yet may be free of angina and have no other suspicious indexes. In sucha case exercise thallium perfusion scans are performed. When scan results are negative, we see no reason for coronary angiography. However, if any of the preceding factors are present or even suspected, coronary angiography is indicated. Within these guidelines most patients with pure mitral stenosis will not require coronary angiography. Michael Motro, MD Henry N. Neufeld, MD Heart Institute Chaim Sheba Medical Center Tel Hashomer, Israel 1. DaYarIa AN, Bommer W. Joye J, Las G, Boateller J, Mason DT. Value and limitation of the acrtic valve in the diaanosis and auantification of valvular acrtic stenosis. Circulation; 1960;62:304. 2. Weyman AE, Felgeabaum H, Dlllon JC, Chan9 S. Cross-sectional echocardiography in assessing the severity of valvular acftlc stenosis. Circulation; 1975;52:626. 3. Weyman AF, FMgsnbaum H, Hurwlfz RA, Glrad DA, Dlllon JC. Cross-sectional echocqdiographic assessment of the severity of acrtfc stenosis in children. Circulation 1977;55:773.
CARDIAC CATHETERIZATION FOR PATIENTS WITH PURE MITRAL STENOSIS-II
The recommendations of Motro and Neufeld to utilize gated equilibrium radionuclide angiography and thallium-201 myocardial perfusion scintigraphy for the assessment of coronary artery disease in patients with pure mitral stenosis deserve some comments. Although both techniques have become widely accepted diagnostic aids in the detection of coronary artery disease, their usefulness in patients with pure mitral stenosis has never been established. None of the eight studies quoted by the authors to elucidate the value of exercise thallium perfusion scintigraphy and radionuclide cineangiography included patients with pure mitral stenosis. Mitral stenosis has a significant left ventricular preload-reducing effect, decreasing left ventricular volume and therefore decreasing wall tension, a major determinant of myocardial oxygen demand. This may help to maintain a positive balance
January 1992
The American Journal of CARDIOLOGY
Volume 49
257