Predictive factors of left atrial spontaneous echo contrast in patients with rheumatic mitral valve stenosis: a retrospective study of 159 patients

Abstract

BackgroundMitral valve stenosis is a common manifestation of chronic rheumatic heart disease. The presence of spontaneous echo contrast in the left atrium and left atrial appendage has been reported to be an independent predictor of thrombo-embolic risk in patients with mitral stenosis. The objective of this study was to retrospectively investigate various clinical and echocardiographic variables to predict the spontaneous echo contrast in these patients.MethodologyThis is a bicentric retrospective study which includes 159 cases of symptomatic mitral stenosis from January 2011 to June 2012. All of the patients had transthoracic and transesophageal echocardiography. Patients who had significant mitral regurgitation (> Grade I), significant aortic valve disease, previous mitral valvulotomy and anticoagulation or antiplatelet therapy were excluded from the study. Our study population was divided into two groups based on the presence (Group I) or absence (Group II) of spontaneous echo contrast.ResultLeft atrial spontaneous contrast was present in 34.6% of cases. Patients in this group have more frequent atrial fibrillation (P = 0.001), larger left atrial area (P = 0.027) and diameter (P=0.023), smaller mitral valve area (P = 0.025), and higher mean transmitral diastolic gradient (p = 0.003) as compared to patients without spontaneous echo contrast. There were no significant differences in the mean age (p = 0.38), duration of symptoms (p = 0.4) and left ventricular ejection fraction (p = 0.7) between patients with and without spontaneous echo contrast. On multivariate analysis, only mitral valve area and transmitral diastolic gradient (OR: 18.753, 1.21, CI [1,838-191,332], [1,064-1,376], p: 0.013, 0.004, respectively) were found to be independently associated to the presence of spontaneous echo contrast.ConclusionPatients with severe rheumatic mitral stenosis in atrial fibrillation or sinus rhythm have a higher risk of developing spontaneous echo contrast. These patients might benefit from prophylactic anticoagulation. The long-term outcomes can be ascertained in a study over a longer period and with periodic follow-up.

Predictor of Left Atrial Spontaneous Echocardiographic Contrast in Rheumatic Mitral Stenosis Patients

“…Sedang pada penelitian yang dilakukan oleh Sanaa dkk, fibrilasi atrium juga lebih banyak pada kelompok dengan SEC (60% lawan 31,7%, nilai p< 0,001) tapi pada analisis multivariat regresi, parameter fibrilasi atrium memiliki hubungan tidak bermakna (OR = 0,6, nilai p= 0,294). 17 Dijelaskan dalam literatur sebelumnya bahwa laju dan irama atrial yang tidak normal berkontribusi terhadap trombogenesis dengan cara: 1) laju atrial cepat dikaitkan dengan peningkatan aktivasi platelet dan generasi trombin; 2) fibrilasi atrium, meskipun juga menunjukkan perubahan aktivasi platelet dan generasi trombin, selain itu menyebabkan disfungsi endotelial dan aktivasi kaskade inflamasi, dan 3) yang menarik, faktor-faktor ini terjadi jauh lebih besar pada atrium kiri dibandingkan dengan sirkulasi perifer. 12 Dari parameter laboratorium didapatkan beberapa parameter yang bisa menjadi prediktor bebas terhadap SEC di atrium kiri seperti hemoglobin, hematokrit, RDW, plateletcrit dan rasio neutrofil/limfosit.…”

“…Beberapa penelitian telah menunjukkan bahwa prevalensi SEC meningkat seiring dengan penurunan area katup mitral. 15,17 Penelitian Beppu dkk, mereka membagi klasifikasi kasus menjadi tiga kategori berdasarkan rata-rata area katup mitral dan SEC yaitu bila MVA 0,7 cm 2 berhubungan dengan SEC berat, MVA 1,1 cm 2 berhubungan dengan SEC ringan, dan MVA 1,5 cm 2 tidak berkaitan dengan SEC. Sedangkan dalam penelitian ini, ukuran area katup mitral yang beresiko tinggi untuk kejadian SEC pada pasien stenosis mitral rematik adalah ≤ 0,9 cm 2 .…”