Mitral stenosis cardiac catheterization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Overview

While echocardiography remains the diagnostic imaging modality of choice, cardiac catheterization is useful to evaluate mitral stenosis when the results of the non-invasive testing are insufficient. Simultaneous left and right heart catheterization demonstrate a pressure gradient such that the pulmonary capillary wedge pressure (a surrogate of the left atrial pressure) exceeds the left ventricular end diastolic pressure.

Cardiac Catheterization

A definitive method of assessing the severity of mitral stenosis is the simultaneous left heart catheterization and right heart catheterization. The right heart catheterization gives the physician the mean pulmonary capillary wedge pressure, which is a reflection of the left atrial pressure. The left heart catheterization, on the other hand, gives the pressure in the left ventricle. By simultaneously taking these pressures, it is possible to determine the gradient between the left atrium and right atrium during ventricular diastole, which is a marker for the severity of mitral stenosis. This method of evaluating mitral stenosis tends to over-estimate the degree of mitral stenosis, however, because of the time lag in the pressure tracings seen on the right heart catheterization and the slow Y descent seen on the wedge tracings. If a trans-septal puncture is made during right heart catheterization, however, the pressure gradient can accurately quantify the severity of mitral stenosis.

Shown below is an image depicting intracardiac pressure measurements in an individual with severe mitral stenosis. Pressure tracings in the left atrium (LA) and the left ventricle (LV) in an individual with severe mitral stenosis. Blue areas represent the diastolic pressure gradient due to the stenotic valve.

Intracardiac pressure measurements in an individual with severe mitral stenosis. Pressure tracings in the left atrium (LA) and the left ventricle (LV) in an individual with severe mitral stenosis. Blue areas represent the diastolic pressure gradient due to the stenotic valve.

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)[1]

Invasive Hemodynamic Evaluation Indications (DO NOT EDIT)[1]

Class I
"1. Cardiac catheterization for hemodynamic evaluation should be performed for assessment of severity of mitral stenosis when noninvasive tests are inconclusive or when there is discrepancy between noninvasive tests and clinical findings regarding severity of mitral stenosis.(Level of Evidence: C) "
"2. Cardiac catheterization for hemodynamic evaluation including left ventriculography (to evaluate severity of mitral regurgitation) for patients with mitral stenosis is indicated when there is a discrepancy between the Doppler-derived mean gradient and valve area.(Level of Evidence: C) "
Class III
"1. Diagnostic cardiac catheterization is not recommended to assess the mitral valve hemodynamics when 2D and Doppler echocardiographic data are concordant with clinical findings.(Level of Evidence: C) "
Class IIa
"1. Cardiac catheterization is reasonable to assess the hemodynamic response of pulmonary artery and left atrial pressures to exercise when clinical symptoms and resting hemodynamics are discordant.(Level of Evidence: C) "
"2. Cardiac catheterization is reasonable in patients with mitral stenosis to assess the cause of severe pulmonary arterial hypertension when out of proportion to severity of mitral stenosis as determined by noninvasive testing.(Level of Evidence: C) "

References

  1. 1.0 1.1 Bonow RO, Carabello BA, Chatterjee K; et al. (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)

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