Early assessment by transesophageal echocardiography of left atrial appendage function after percutaneous mitral commissurotomy

Early p&ketit by l’runsesophageal Echaetirdkgraphy tif Left Atrial Appendage Function Aft&r Percutaneous Mitral Commissurotomy Jean Marc Porte, MD, Bertrand Cormier, MD, Bernard lung, MD, Eric Dadez, MD, Charles Starkman, MD, Olivier Nallet, MD, Pierre Louis Michel, MD, Jean Acar, MD, and Alec Vahanian, MD Thirty-seven consecutive admitted patients with severe mitral stenosis un !I erwent percutaneous mitral commissurotomy with a transthoracic and biplane or multiplane transesophageal echocardiogmphic examination before and between 24 and 48 hours after percutaneous mitral commissurotomy. Thirty patients (8 1%) were in sinus rhythm and 7 were in atrial fibrillation. left atrial appendage (MA) function was evaluated in both the transverse and the Ion itudinal planes by pkmimetry and pulsed Doppler ec\ ocardiogmphic interrogation at the LAA outlet. Percutaneous mitral commissurotomy resulted in a twofold increase in mitral valve area, and no severe mitral u itation occurred. with use of the pkmimetry m’ , there was 73 no significant improvement in IAA election fraction, except in the transverse plane for patients in sinus rhythm (p = 0.03). with use of Doppler method, 3 distinct flow patterns were observed before the procedure:

a “sinus pattern” in patients in sinus rhythm, and a “fibrillatory pattern” (n = 3) or a “no-flow pattern” (n = 4) in tients in atrial fibrillation. After commissurotr ere was a marked increase in LAA peak fqf, Doppler veloci (+62%) and in tAA veloci time integral (+31%). d the 4 patients in atrial fibri7 lation with a no-flow pattern, 2 had recovery of a typical effective fibrillatory flow pattern after the procedure. The increase in peak Dop ler velocity after commissurotomy was related to the 8 ecrease or regression in left atrial spontaneous echo contrast, and correlated with the increase in mitral valve area, the decrease in transmittal pressure gradient, and the increase in cardiac index; improvement in valve function after successful percutaneous mitral commissurotomy is associated with early improvement in LAA function. (Am J Cardiol 1596;77z72-76)

eripheral embolism is a major complication in paP tients with mitral stenosis’,* and most frequently results from the migration of thrombi developing in the

+ SD 44 f 17 years]) were enrolled in the study. All had mitral stenosis with valve area cl.5 cm*, but there was no case of mitral regurgitation >2/4 according to criteria of Sellers et al.‘” Exclusion criteria for the series were LAA resection because of previous surgical treatment and the presence of a left atria1 thrombus, which contraindicated percutaneous mitral commissurotomy. One patient was in New York Heart Association class II, 34 (92%) were in class III, and 2 were in class IV Thirty patients (81%) were in sinus rhythm and 7 were in atrial fibrillation. Echocardiogmphy: All patients underwent transthoracic and transesophageal examination, including a study of LAA function, before and within 24 to 48 hours of percutaneous mitral commissurotomy using the same protocol. Examinations were performed with a Sonos 1000 ultrasound system (Hewlett-Packard Co., Andover, Massachusetts) using a 2.5 MHz transthoracic probe and a 1.9 MHz Pedoff transducer for mean transmitral gradient measurements by continuous-wave Doppler. Mitral valve area was calculated from planimetry in the left parasternal short axis and from the pressure half-time according to the method of Hatle et al.t7 The left atrium diameter was measured in the parastemal longitudinal axis. Transesophageal examinations were performed with the same echocardiogram using a 5 MHz biplane (n = 24) or multiplane (n = 13) probe. Spontaneous echo contrast was assessed by the transesophageal approach using appropriate gain settings to differentiate real spon-

left atria1 appendage (LAA).‘s~*~ Several studies have suggested a relation between a decrease in LAA function and more frequent thromboembolic events of cardiac origin.s-lo Since 1984, percutaneous mitral commissurotomy has been demonstrated to be a safe and efficient procedure for severe mitral stenoses.“-‘4 It results in the disappearance of spontaneous echo contrast or a decrease in its intensity, suggesting a beneficial effect on left atria1 blood stasis.” However, the results of percutaneous mitral commissurotomy on LAA function have not, to date, been assessed. The present study assesses LAA function before and after percutaneous mitral commissurotomy using transesophageal echocardiography, and determines factors related to improvement in LAA function. METHODS Patients: Thirty-seven

consecutively admitted patients (8 men and 29 women, aged 22 to 77 years [mean From the Cardiac Unit, Tenon Hospital, Paris, France. Manuscript received June 14, 1995; revised manuscript received and accepk ed September 18, 1995. Address for reprints: Jean Marc Porte, MD, Service de Cardiologie, Hbpital Tenon, 4 rue de la Chine, 75970 Paris Cedex 20, France.

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taneous echo contrast from backTABLE I ljemodynamic and Echocardiographic Data before (TO) and After (ll) Percutaground noise. Spontaneous echo conneous Mitral Commissurotomy trast was graded as previously deVariable TO Tl p Value scribed: t5 grade 0 = no contrast; grade I = slight contrast localized in parts of Hemodynamic data 16i7
Appendage

Planimetry

Before

(TO) and

After

Transverse Variable

TO

(Tl)

P ercutaneous

Mitral

Commissurotomy

Plane Tl

Longitudinal p Value

TO

Plane Tl

p Value

Global LAA LAA LAA

population (n = 37) maximal area (cm2) minimal area (cm2) ejection fraction (%)

6.5 zt 1.9 4.8 * 1.6 26zt 10

5.9 4.1 31

* 2 f 1.8 f 15

0.02 0.002 0.08

4.7 * 1.5 3.4 f 1.3 27* 15

4.6 3.4 27i

e 1.2 * 1.1 13

0.40 0.20 0.57

Sinus LAA LAA LAA

rhythm (n = 30) maximal area (cm*) minimal area (cm2) ejection fraction (%)

6.4 f 4.7 f 27*

1.7 1.4 10

5.8 k 1.8 3.9 * 1.6 34* 14

0.02 0.004 0.03

4.7 f 1.5 3.3 * 1.2 30* 15

4.7 3.3 29

f 1.1 k 0.8 f 11

0.25 0.34 0.75

Atrial LAA IAA LAA

fibrillation maximal minimal ejection

6.9 5.4 2oi

i 2.9 f 2.3 12

6.3 sz 2.9 5.2 ct 2.5 17*a

0.91 0.75 0.60

4.6

4.4 f 1.5 3.8 * 1.7 17 f 14

0.06 0.39 0.61

(n = 7) are0 (cm*) area (cm*) fraction (%)

i 1.8 4* 1.6 15 f a

Values ate expressed os meon * SD. LAA = left atria1 appendage.

VALVULAR

HEART

DISEASE/L&A

FUNCTION

AFTER

MITRAL

COMIv%SUROTOMY

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TABLE III left Atrial Mitral

Appendage

Doppler

Flow

Before

(TO) and

After

Percutaneous

TO

Tl

(cm/s) (cm]

272 17 2.3 * 1.4

44 2 26 3.1 i 1.6


velocity integral

(cm/s) (cm)

292 17 2.5 * 1.3

48 tt 26 3.5 f 1.5

<0.0001 0.0002

velocity integral

(cm/s) (cm)

0.9 zt 0.6

Varioble Global population Peak Doppler velocity Velocity time integral Sinus rhythm Peak Doppler Velocity time Atrial fibrillation Peak Doppler Velocity time Valuer

ore expressed

as mean

14*

11

26* 16 1.4 f 0.8

* SD.

Statistical analysis was performed on a Compaq PC computer with the CSS Statistica program (Statsoft Inc., Tulsa, Oklahoma). RESULTS

Global results of percukmeous mitral commissurotomy (Table I): Percutaneous mitral commissurotomy resulted in a twofold increase in mitral valve area and no severe

FIGURE 1. Example of a left news mitral cammissuratam dure (TO: PDV = 19.4 cm/s;

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mitral regurgitation occurred. Thirtysix patients had good results after dilatation, as defined by a final mitral valve area >1.5 cm* without angiographic mitral regurgitation >2/4. One patient with a calcified mitral valve had a suboptimal result with a final valve area of 1.4 cm*. left atrial spontaneous

OF CARDIOLOGY@

left atrial appendage planimetry and ejection fraction (Table II): Before dilatation there was no significant dif-

ference between LAA areas as a function of atrial fibrillation or sinus rhythm; LAA ejection fraction was lower in patients in atrial fibrillation than in patients in sinus rhythm (p = 0.01). After dilatation there was no signifi-

pe~utaneous mitral ccunmissurotamy in a patient cl0 cm/s. After the procedure 01) a characteristic

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echo con-

trast: Before dilatation, 30 patients (81%) had a left atrial spontaneous 0.07 echo contrast graded slight in 16 0.28 patients (43%) and heavy in 14 (38%). After dilatation, spontaneous echo contrast intensity did not change in 20 patients (54%), decreased in 5 (14%), and disappeared in 12 (32%).

in a patient in sinus rhythm before (TO) and after t in peak Doppler vekxity (PDV) outflow wave &r

FIGURE 2. Example of a n&w pattern befare cedure (TO) there is a minor flow with v&cities

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in atrial fittrilkrfian. fibrillatary pattern

(Tl) percutathe prace-

Befare the is rt?ca&r

gradient (r = 0.56; p = 0.001) and the increase in cardiac index (r = 0.41; p = 0.04). In multivariate analysis, only the decrease in transmitral pressure gradient was linked to the increase in LAA peak Doppler velocity (p = 0.01). Left atrial appendage Doppler flow patterns, (Table 111): The increase in LAA peak Doppler velocity after dilataThree distinct Doppler flow patterns were observed tion was also related to the decrease or regression in left before dilatation, as previously described by Pollick and atria1 spontaneous echo contrast: +23 + 17 cm/s in Taylors and Garcia-Femandez et a1.6In patients in sinus patients with decrease or regression of spontaneous echo contrast versus +12 + 12 cm/s in patients without modrhythm, a single Doppler flow pattern (“sinus pattern”) was observed, characterized by a biphasic wave (Figure ification of spontaneous echo contrast (p = 0.05). The 1) with an alternating positive wave, occurring after the increase in the velocity time integral of the LAA outstart of the electrocardiographic P wave and corre- flow wave after dilatation correlated only with the sponding to active emptying of the LAA, and a negative decrease in transmitral pressure gradient (r = 0.54; p = wave corresponding to passive filling of the LAA. In 0.001). patients in atrial fibrillation, 2 kinds of Doppler flow pattern were observed: (1) a “no-flow pattern” (n = 4) when DISCUSSION no effective ejection flow was visualized (i.e., absoluteOur series studies for the lirst time the early changes ly no flow recorded despite minimal velocity scale and in LAA function after percutaneous mitral commissurominimal wall filter, or a minor prolonged flow with veloc- tomy, and the factors related to improvement in LAA ities cl0 cm/s [Figure 2, left]); (2) a “fibrillatory pattern” function. (n = 3) with rapidly alternating emptying and filling Pkmimetry evaluation of left atrial appendage function: waves, corresponding to active fibrillatory contractions LAA planimetry shows no significant improvement in (Figure 3). There was no significant difference in Dop- LAA ejection fraction, except in the transverse plane (but pler velocities by the different planes. not in the longitudinal plane), in patients in sinus rhythm. LAA peak Doppler velocity and velocity time inte- This discrepancy in the improvement in LAA ejection gral were greater in patients in sinus rhythm than in fraction may be due to technical difficulties with the patients in atrial fibrillation (p = 0.006 and p = 0.04, planimetry method in assessing LAA function, such as respectively). After dilatation, there was a significant in- the definition of the base of the LAA and its apex truncrease in these variables, and changes were especially cation, because of rotational movements of the heart marked for patients in sinus rhythm (Table III). Of the along its great axis. For these reasons, it is our view that 3 patients in atrial fibrillation with a fibrillatory flow pat- the planimetry method is less appropriate than the Doptern before dilatation, LAA Doppler flow pattern did not pler method for assessing LAA function. change after the procedure (Figure 3). Of the other 4 DopplerfknvpattemevaluationoFleftatrialappenpatients in atrial fibrillation with a no-flow pattern, 2 dage: Pollick and TaylorS first demonstrated the mechanrecovered a typical effective fibrillatory flow pattern after ical activity of the LAA using transesophageal pulsed percutaneous mitral commissurotomy, indicating re- Doppler echocardiography. Their data have since been sumption of LAA activity (Figure 2). confirmed by Garcia-Femandez et aL6 who described 3 different kinds of Doppler flow patterns in 39 cases of Factors related to left atrial appendage Doppler flow mitral stenosis; our data support these findings. improvement after percutaneous mitral commissurotomyz The increase in LAA peak Doppler velocity after dilataRelation between left atrial appendage function and tion correlated with the increase in mitral valve area (r homboembolii risk: The relation between LAA Doppler = 0.42; p = 0.02), the decrease in transmitral pressure flow patterns and the presence of an atrial thrombus was cant improvement in LAA ejection fraction. In patients in sinus rhythm, LAA ejection fraction improvement was significant in the transverse plane (p = 0.03), but not in the longitudinal plane.

FIGURE patient

3. Exam le of a characteristic fibrillatory in atrial Pkillation. Note the improvement

pattern before (TO) and after (Tl) percutaneous in left atria1 appendage Doppler outflow after

VAlVUlAR

HEART DISEASE/LA4

FUNCTION

mitral commissurotomy the procedure.

AFTER MITRAL COMMISSUROTOMY

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demonstrated by the 2 above-mentioned studies.5Jj They both concurred in the connection between a no-flow pattern in patients in atria1 fibrillation and the presence of atria1 thrombi. More recently, Mtigge et al7 showed, in patients with nonvalvular atria1 fibrillation, a connection between an LAA low-flow profile (velocity ~25 cm/s) and both the presence of thrombi in the LAA and events suggestive of cardiogenic embolism. Improvement in left atrial appendage function after percutaneous mitral commissurotomyz Our study demon-

strates an early improvement after

PerCu~neOuS

mitral

in LAA Doppler outflow

COmmISSurOtOmy.

Changes

=e

especially marked in patients in sinus rhythm. For patients in atria1 fibrillation, there is a tendency toward improvement in LAA Doppler outflow, but this is not statistically significant (p = 0.07), probably because of the few patients in this group. Moreover, our results suggest that for some patients in atrial fibrillation, LAA Doppler flow pattern may change from a no-flow pattern, which was previously related to a high risk of thrombosis, to a fibrillatory pattern, previously related to a lower thromboembolic risk.6 The mechanisms underlying

the

improvement

in

LAA

Doppler

Outflow

after

percutaneous mitral commissurotomy are uncertain. Nevertheless, 2 explanations are possible: (1) an improvement in the intrinsic LAA function, resulting in an improvement in active LAA contraction; and (2) acute reduction in atrial afterload induced by percutaneous mitral commissurotomy which may passively improve LAA Doppler outflow. Indeed, Hoit and alI9 previously showed that loading conditions can influence LAA flow velocities. Factors related to improvement in left atrial appendage function: Improvement in LAA function after percuta-

neous mitral commissurotomy is related to improvement in valve function (i.e., increase in mitral valve area). In addition, improvement in LAA function is linked to a decrease or regression in left atria1 spontaneous echo contrast, which has been related to blood stasisT20and which is widely accepted as a marker of thromboembolic events.2’,22 Clinical implications: The effect of percutaneous mitral commissurotomy on LAA function, and on the evolution of spontaneous echo contrast in the left atrium,15 suggests a beneficial effect of the procedure on left atrial blood stasis, from which a lower risk of thromboembolism may be expected. Shady limitations: Our subgroup of patients in atria1 fibrillation is small. A larger group of patients with LAA Doppler analysis may provide a more accurate percent-

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age of recovery of the mechanical activity of the LAA after percutaneous mitral commissurotomy. 1. Jordan RA. Scheifley CH, Edwards JE. Mural thrombosis and arterial embolism in mitral stenosis. Circulation 1954;3:363-367. 2. Seizer A, Cohn KE. Natural history of mitral stenosis: a review. Circulation ‘972;45:878-890. 3. Acar I, Cormier B, Grimberg D. Kawthekar G, lung B, Scheuer B. Farah E. Diagnosis of left atria’ thrombi in mitral stenosis: usefulness of ultrasound tcchniques compared with other methods. Eur Heurr J 199 I (suppl B); I2:7&76. 4. Kmnzon I, Tunick PA, Glassman E. Slater J. Schwinger M, Freedberg RS. Transesophageal echocardiography to detect atria’ clots in candidates for percutaneous transseptal mitral balloon valvuloplasty. J Am Co// Cardiol 1990; 16: 132% 1322. 5. Pollick C, Taylor D. Assessment of left atrial appendage function by transesophageal echocardiography. Implications for the development of thrombus. Circulation 1991;84:223-23 I. 6. Garcia-Femandez MA, Torrecilla EG, San Roman D, Azevedo I, Buena H, Moreno MM, Delcan JL. Left atria’ appendage Doppler flow patterns: implications on thmmbus formation. 4m Hrort J 1992; 124~955-96 I. 7. Miigge A, Kiihn H, Nikutta P, Grate J, Lopez AC. Daniel WG. Assessment of left atrial appendage function by biplane transesophageal echocardiography in patients with nonrheumatic atrial fibrillation: identification of a subgroup of patients at increased embolic risk. .I Am CON Cardiol 1994;23:599607. 8. PozLoli M, Febo 0, Torbicki A. Tramarin R, Calsamiglia G, Cohclli F, Specchia G, Roelandt JR. Left atrial appendage dysfunction: a cause of thrombosis‘? Evidence by transesophageal echocardiography Doppler studies. J Am .Yoc Echocurdiogr199’;4:435-441. 9. Suetsugu M, Matsuzaki M, Toma Y, Anno Y, .Maeda T, Okada K, Lonishi M, 1310 s, Tanaka N, Hiro I. Detection of mural thrombi and analysis of blood flow velocities in the left atrial appendage using transesophageal two-dimensional echocardiography and pulsed Doppler flowmetry. J Cardiol 1988;18:385-394. IO. Fatkin D, Kelly RP, Feneley MP. Relations between left atria’ appendage blood flow velocity, spontaneous echocardiogrdphic contrast and thromhcembolic risk in viva. JAm Co/l Cardiol 1994;23:961-969. 11. Inoue K, Owaki T, Nakamura T, Kitamura F, biiydmoto N. Clinical application of transvenous mitral commissumtomy by a new balloon catheter. J Thuraf Cardiovasc Surg 1984;87:3WO2. 12. Vahanian A, Michel PL, Cormier B, Vitoux B, Michel X, Slama M. Enriquez Sarano L. Trabelsi B, Ben lsmail M. Acar J. Results of percutaneous mitral commissurotomy in 200 patients. Am J Curdiol 1989;63:847-852. 13. Hung JS, Chem MS, Wu JJ. Fu M, Yeh KH. Wu YC, Chemg WI, Chua S, Lee CB. Short- and long-term results of catheler balloon percutaneous transvenous mitral commissurotomy. Am J Cardiol 1991;67:854-862. 14. The National Heart, Lung, and Blood Institute Balloon Valvuloplacty Regisny Participants. Multicenter experience with balloon mitral commissurotomy. NHLBI balloon valvuloplasty registry report on immediate and 3(1-day follow-up results. Cir,-ujation‘992;85:448-46’, 15. Cormier B, Vabanian A, Iung B, Pane JM, Dadez E. Lazarus A, Starkman C, Acar J. Influence of percutaneous mitral commissurotomy on left atrial spontaneous contrast of mitral stenosis. Am J Cardiol 1993;71:842-M7. 16. Sellers RD. Levy MJ, Amplatz K, Lilehei CW. Left retrograde cardioangiography in acquired cardiac disease. Am J Cardiol 1964; 14:437+7. 17. Hatle L, Angelsen B, Tromsdal A. Noninvasive assessment of atrioventricular pressure half-time by Doppler ultrasound. Circulation 1979;60: 1%’ 104. 18. Gorlin R, Gorlin G. Hydraulic formula for calculation of area of stenodc mitral valve, other valves and central cimulatory shunts. Am Heart J 195 I ;4 I ; I- IO. 19. Hoit BD. Shao Y, Gabel M. Influence of acutely altered loading conditions on left atrial appendage flow velocities. JAm Coil Cardiol 1994;24: I I 17-l 123. 20. Sigel B, Coelho JCU, Spigos DG, Flanigan DP, Schuler JJ. Kasprisin DO, Nyhus LM, Capek V. Ultrasonography of blood during stasis and coagulation. Invest Radio1 198’;16:71-76. 21. Daniel WG, Nellesen U, Schrdder E, Nonndst-Daniel B, Bednarski P, Nikutta P, Lichtlen PR. Left atria1 spontaneous contrast in mitral valve disease: an indicator for an increased thrombcembolic risk. J Am Cull Cardiol 1988; I 1:1204-l 2 I I. 22. Black I, Hopkins A, Lee L, Walsh WF. Left atrial spontaneous contrast: a clinical and echocardiographic analysis. J Am CON Cardiol 1991; 18:398~04.

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