%8
No ,5
Two-Dimensional and Doppler Echocardiographic Determinants of the
Natural History of Mitral Valve Narrowing ; in Patients With
Rheumatic Mitral Stenosis : Implications for Follow-Up
STEFHEN P. F . GORDON, MB,BS, PAMELA S . DOUGLAS, MD, FACC,
PATRICIA C . COME, MD, FACC, WARREN J . MANNING, MD, FACC
Hosrun, Massachusetts
Fifty patients with rheumatic mitral stenosis were studied with
serial twmdimeisitital and Doppler echocardiography to deter .
mice the normal history of changes in mural valve area and its
retalton to iransndtra gradients and mil-al valve morphology .
Over the 39-month observatlan period (range 7 m 74 months) the
decline in valve area was 0.09 x 0.21 cmdfyear. In addition, there
were aignilcaat inereasss in total echoeardiagraphie scare (p =
0 .0001), severity of mitral anulas calcification (p to 0,05) and
severity of ultra) regurgitation (p = 0 .11007). Patients with an
eeborardiographic score wit had a more progressive course .
In addition, patients with a more progressive course (decline in
valve area ?0 .1 cmrhear) had a significantly greater initial mean
gradient (p = 0 .01), peak gradient (p =.007)
0 and total emoar.
diagraphic score 4p = O .000d). Initial valve area did not correlate
The ratural history of rheumatic mitral stenosis has been the
subject of several extensive studies (I-3). These studies
have documented a generally slow, but often variable clini-
cal course, with some patients showing little or no clinical
progression nor lung periods and others manifesting a more
rapid course . In contrast to these clinical studies, little
information is known regarding the temporal changes in
mitral valve gradient or valve area . Such information would
he important because symptomatic deterioration may not
reflect progression in valvuiar stenosis but may be the result
of a coincident event such as the development of atnlal
fibrillation, myocardial failure, pulmonary hypertension or
increasing valvular regurgitation, In addition, the hemody-
namic, morphologic and mechanical factors that influence or
predict the rate of stenosis progression have not been
From the Charles A . Dana Research Institute and she Harvard-Thomdlke
laboratory of she Beth Israel Hospital, Department of Medicine, Cardiovas .
cular Division, Hem srael Hospital and Harvard Medical School, Boston .
Massadmsetes. Dr. Gordon is supported by a W. A . end M . G . Saw Medical
Research Fellowship from the University of Western Australia . Penh, West.
trot Aosiralia. Australian Dr. Manning is supported in pan by Physician .
Solent Award P.GCntvs from the National Institute of Aging, Belheea,
Maramd .
Manuscript received July 22 . 1991 : revised manuscripl received October
4,1991, -pre osleber 18. 1991.
Address for rrednh
; : Warren l . Manning. MD. Cardiovascular Division .
Bent Note Hasplml, 330 Braakkne Avenue, Boston . Massaclmseus 02215.
C19112by tie Anseican College of Cardiology
1ACC so1 .19.
Apd11YROss-73
with the rate of stenmis progression. Of 22 patients with an
echocardiographic score <0 and a peak mitral gradient
c10 mm Hg, only I patient (5%) had a more progressive course,
compared with 50% of those with a toted eclrocardiographic score
A and a gradient alO mm Hg.
The rate of mitral valve narrowing in individual patients with
rheumatic mural stenosis is variable. Patients whose valve disease
progresses rapidly are those with a greater mitral valve eehnrar-
diographie scorn and hither poak and moan lraasniltralgradlautn .
These findings emphasize the importance at nanlnvaslve evalun.
tion of valvular morphology and hemadynamics and have hop1F
cation for the frequency of follow-up mad prognosis in patients
with mural stenosis .
(J Am Cuff Cannot 2992;19:968-73)
identified. Such information is of clinical importance for
determining both the optimal frequency of follow-up in such
patients and the urgency of surgery or percutaneous balloon
valvuloplasty.
The ability to image the valve and subvalvular apparatus
with two-dimensional echocardiography allows for the non-
invasive evaluation of mechanical or structural factors, or
both, that might influence the rate of orifice narrowing. This
ability, along with Doppler echocardiography, which permits
repeated noninvasive estimation of hemodynamic factors
including mitral valve area (4) and transmittal pressure
gradient (5), has made possible a more extensive evaluation
of the natural history of mitral stenosis .
The purposes of this study were to determine the nateral
history of changes in mitral valve area and transmittal
gradient in patients with rheumatic mitral sfenessis and to
evaluate structural, mechanical and hemodynamic factors
that might be related to the rate of stenosis progression,
Methods
Study patients. Adult echocardiographic records (u =
6,650), representing all studies performed at our institution
between July 1, 1983 and December 31, 1985, were re-
viewed. From these, 140 consecutive patients with a rtseu.
matically deformed mural valve and measutrat trarmaritoal
0r715.1097nsess.m


JACC VaL 19, No. 5 0AROON as AL. %9

Aprl 991-963-73 ECNrrCARDr0RARNV ANa VALVE AREA IN MITRAL STENOSIS

gradient were selected for further study . Of these, 90 pa- Characteristics of 50 Study patients at Entry and at
Table 1 .

tients were excluded because they had no subsequent study Follow-Up

performed before August 31, 1990 or no study performed at Fallow-Up
least 6 months after the entry study (n = g0) • had an Emry (39-) p Value
intervention (surgical or percutaneous balloon va)vulo- Neat rate tbeatt'minl 67 -- 13 66 2 14 NS
piasty) ether previously (n = 1) or before subsequent Mean ramminat gradient (mm ng) 4.9 14 s .d S 3 .2 NS
echocardiographic study (n = 7) or had technically inade . Peat 95 toAmol grd&em I mm Ngl 103 ! 6 .2 11 .5 ± 5 .8 NS
quate studies (n = 2), yielding a study group of 50 patients Mitral vane once Cur'i 1 .7 S 0.7 1 .S x 0.7 OAOIS
Total Ed0 seers (0-161 5 .4 ! 2 .0 9.4 x 2.1 O.OWI
including 10 torn and 40 women. Their mean age was 56
Mina]-ake .vehitip(0--' ; 1 .6 -
1 0% 2.1 ±0.9 0-0ml
years (range 23 to 87) . The average interval between entry
Subvotvulanhidae4e t0-4t 0.9- 1 .0 3.0 ± In 0.0101
and most recent follow-up echocardiographic study was 39 Mitml valve thickening (0-41 2.2 = 0.9 18. o 0.8
1 afoot
months (range 7 to 74). Mital valve cakiteation (0-41 1.2 _ 1 .1 2 .5 L0 OA901
Echoeardiographic studies, Two-dimensional imaging Maul anulus ealcdkalion (0-31 0 .5 a 0.9 0.6 x 0.9 LOS
and guided transmittal pulsed Doppler echocardiographic Miael .cVmmion (0-el 1 .4 -1 .3 2 0 =- 1 .5 a0am

studies were performed with use of on HP 77030A or Len 51051 d -11i. (cal 5 .0 a 09 5.2 x 1 .1 0.03

71020AC (Hewlett-Packard) combined imaging/Doppler W- are mean values ± SD . Echo= asaawngnphu .

echocardiograph equipped with 2 .5-MHz phased array trans-
ducers or an ATL MK 690 (Advanced Technology Labora-
tories) combined imaging/Doppler echocardiograph
equipped with a 3-MHz mechanical transducer . Images were
stored on standard VHS videotape.
Two-dimensional tchocardiographic analysis . Mitral
valve morphology was evaluated with a semiquentitative
scoring method described by Wilkins et al, (6) . This method
assigns a severity grade of 0 to 4 for each of the following
characteristics of the mitral valve! mobility, subvalvular
thickening . leaflet thickening and calcification . A score of 0
represents normality and higher values represent increasing
degrees of severity. A total echocardiographic score (0 to 16)
is derived by summing :ire individual scores . Mitral anulus
calcification was graded as 6 (none), I (mild) . 2 (mo( erate) or
3 (severe). Left atria) dimension was measured in the
parasterrul long-axis view by standard techniques (7). The
echocardiographic studies of all patients were reviewed in
random order by an observer who had no knowledge of
patient data.
Doppler analysis. Doppler recordings of transmittal in-
flow velocities were recorded from the apical four-chamber
view as previously described (0), Recording= were printed at
a paper speed of 100 mmls and analyzed with an off-line
computer analysis system (Cardiology Workstation, GTl
Freeland Medical Division). Doppler spectra were traced on
a digitizing graphics tablet and analyzed to determine peak
and mean transmittal pressure gradients . Mitral Valve area
was determined by the pressure-half time method (4,9) . A
minimum of five consecutive beats was analyzed in each
patient and the results were averaged . Extent of mitral
regurgitation was assessed by pulsed Doppler recordings and
graded o (none) to 4 (several (10) . Ali Doppler analyses were
performed by a single observer who had no knowledge of
patient outcome and echoeardiographic data.
To assess intro-and iarerohserver vmi0biliry in the Dopp-
let spectra, 20 patients were randomly selected for repeal
analysis . Interobserver variability was estimated by compar-
ing the values for mean gradient, peak gr_dient and mitral
valve area obtained by two independent observers (S .P .F .G.
and .Q.C Intraobserver variability far the same variables
P
.
was detcruened by comparison of estimations performed by
the same observer an initial evaluation mall >2 months later .
lalerventio es. Computerized hospital records were re-
viewed to determine those patients who had died or had
undergone mliral valve surgery or percutaneous balloon
mural valvuloplasty between the time of the ir initial study
and the end of August 1990 . Patients who had no docu-
mented Initial valve procedures were contacted by tele-
phone to determine if they had undergo" such a procedure
at another institution. If an intervention was performed, the
echocardiographic study immediately before the interven-
tion was used as the follow-up study for analysis . No patient
was lost to follow-up
.
Statistical, methods All results are expressed as mean
values a SD. Comparison of entry data with those at
follow-up was by paired Student t test (two-tailed) . Individ-
ual patients were stratified into two groups defined by the
rate of valve area decrease, In the progression group, this
increase was ?0.1 cm°lyear and in the nonprogression group
it was <0 .1 cm=lyear. The unpaired Student t test (two-
tailed) was used to compare the progression and the nonpro-
gression groups. Multiple group comparisons were by one-
way analysis of variance and post hoe testing by the
Newman-Keels method . Least squares linear regression
analysis was used to determine the relation between rate of
progression and the total eclocardiographic score (and its
components) . Significance was defined as a p value s 0 .05.
Results
Group characteristics at entry and fallow-up (Table I).
Over the 39 mouths of follow-up, there was a significant
decrOast is inital valve area (p = 0 .0015), and there were
s:gnineant increases in turai cchnrardiagraphic morphology
score (p = 0 .0001), each of the components 0 the echocar-
diographic score (all p = 0.9007), severity of miual snubs
calcification Ip= 0 .05), severity ofmitral regurgitation /p~


970 GOtRON ET AL, 7.ACC Vol . 19 . No . 5

ECHOCARUIOGRA!'HY AND VALVE AREA IN MITRAL STENUSIS April 1992:908-77

1.0- I

0 .g'

~ 0b'
u^ GA-
M
02-
01
00
U
-02

DA o
0 10 20 30 40 6o
0-3 47 0-12
(n-It) In-31) (n.al Ranked Patient Order
Total Echo Score Figure 2. Individual (patient rank order) rates of moral valve
narrowing for all 3D study patients . Patients were stratified in the
Figure 1 . Comparison of total echocardiographic (Echo) score and ptnoression (triangles, n ' 16)or the nonprogression (circles, a =34)
rate of initial valve narrowing in 50 patients . 'p < 0,05 versus group the basis of valve narrowing a0 .1 cm'lyear or
echocardiogmphic scores 0 to 3 and 4 to 7 ; n r mtmber of patients <0 .1 em'tycar, respectively.
in each group.

0.0007) and left a'rial dimension (p = 0.03). There were no ties associated with more rapid progression, study patients
significant differences in mean Iransmitrat gradient, peak were stratified into two groups defined by the rate of valve
transmittal gradient or heart rate at rest, area decrease for each patient being greater (progression) or
Change in mitral valve area. The mean rate of decline in less (nonprogression) than 01 cm 2lyear, The progression
mitral valve area was 0.09 ± 0.21 cm'lyear (p = 0 .0015). group comprised 16 patients (32% of the study group), and
Analysis of variables that might be associated with the rate the nonprogressive group included 34 patients . The mean
of stenosis demonstrated a significant difference in the rate rate of valve area decrease in the progression group was 0 .3
0.2 cm 2lyear ; in the nonprogression group, valve area did
of progression between patients with a total entry echocar-
diographic score <8 (0,0 *_ 0 .1 em 2 lyear) and patients with a not change (0 ± 0.l cm2)year) .
score >_8 (0 .3 ± 0 .3 c0 year) (p < 0 .05) (Fig . I). There was The chamcterisries at study entry were compared be-
no significant difference in the rate of valve area decrease tween the progressive and nonprogressive groups (table 2).
between men and women, patients with sinus rhythm (n = The progression group had a greater mean transmittal gra-
32) and atria[ fibrillation (n = 18), patients with increased
(>4 cm) and normal left atria) dimension or among patients
Wit, 2. Entry Characteristics of Caoups With Progression
with mild (valve area >2 cm'), moderate (valve area .4 1 to
and Nonprogression
2 cm') or moderately severe (valve area . <1 .4 cm') mitral
stettosis at study entry . Proerssion Nonprogression
(n = 16) (n = 34) p Value
The interobserver variabilities were minimal with a cor-
relation coefficient of r = 0 .96 and SEE = .19 mm Hg for Hale ofvalvenanowtm(cm"N) 0.7±0.2 010.1
comparison of peak gradient (range of peak gradients : 4 to Oar lyn 58 ! 18 94 17 NS
%Women Et 79 NS
29 mm Hg); r = 0.96 and SEE = 0.7 mm Hg for mean
Hein rate (ficaw'mim 72 ± 10 65 *- 14 Y5
gradient (range of mean gradients 1 .8 to 9 mm Hg), and r =
Wall salve area (am e) 1 .7 1-0.6 .8
16T0 NS
0.93 and SEE = 0 .2 cm' for mitral valve area (range of valve Mean Itatumival gndknt 6.7 ! 4 .0 4.1 ± 2 .7 0.01
areas 0.6 to 3.1 cm2), Intraobserver variabilities were also term till
small with a correlation coefficient of r = 0-98 and SEE _ Peak transtdiral geadient 13.7 a 7 .7 R.7 ± 4 .7 0,007
.4 mm Hg for peak gradient (range 4 to 28 .7 mm Hg), r =
1 lair Hg)
0.95 and SEE = 0 .7 mm Hg for mean gradient (range 1 .5 to Total Echo scare (9-I61 7 .8 2 2 .9 5.0 ± 2 .3 0 .4998
Milm I valve mabillw (0-4) 1 .9 m 0.8 1.4 n 0.7 0 .02
15 .2 mm Hg) and r = 296 and SEE = 0 .2 cm'- for valve area Suh'oivdecehkkening(0-4) 1 .2 a: 1 .1 0.8 s 1 .0 N5
(range 0 .8 to 3 .1 cm'). Mibm1 valve thickening (0-4) 2 .6 0 0A 2.0 ! 0 .8 003
Progressive and nvaprogressse groups . Examination of Mural valve cakificetian (6-4) 20 a 1 .2 0.8 *- 0.9 0.0004
the individual data (Fig . 2) demonstrated two subgroups of MItmI anuius ealeincalion (0-3) 04 a 0.9 .1 ! 0.9
0 NS
patients, are with relatively rapid progression of declire in Mam1 regurgitation (0-4) 1,4 ^- : 1.4 0 1 .3 NS
valve area and a second with little or no change in valve area Left trAil dimension Jr .) 4,7 D.8 5.1 a 0.9 NS

over the follow-up period . To better define the characteris- Values are mean values a SD . Abbreviations as in Table I.

MACC Vol . 19 . No. 5
AP11 1992:968-13 LCHUrARDIaORAPHY AND VALVE AREA IN MITRAL STI :RVS15
12
la
e-
q m mo o patients with mitral stenusis who had two or more cardiac
D Da D O 0
0 0
2
n
a to 20 30
Peak Gradiew. (mm He)
Flip me 3, lndioidual entry study echeearutagraphic (Echo) score
and peak tree,milml 8radieat rot all 50 study patients . Only I (5%)
of 22 patients with an eehncardiogaphic score c8 and a peak
transmittal gradient .10
v mm Hg was in the progression group
(Wangls) wmpared with 6 180%1 of the IO patients wilh an
echocardiographic scare >8 and a peak gradient >t9 mm He.
Circles = patients in the nonprogression group .
dient (p = 0.01) . peak transmittal valve gradient (p = 0 .007).
and total eehocardiographic score (p - 0.0008). The groups
did not differ in age, gender, heart rate at rest. I hyihm, initial
mitral valve area, severity of mitral anuius calcification,
severity of mitral regurgitation or left atrial size . Mean
follow-up time was longer in the nonprogression than in the
progression group (44 vs . 31 months, p = 0.03) .
Each of the significant variables was examined to deter-
mine if a threshold existed that might be clinically useful in
identifying patients at increased risk for having a progressive
course. Of 36 patients with an echocardiographic morphol-
ogy score <8, only 5 (14%) were in the progression group
compared with 11(79%) of 14 patients with a score all (Fig .
3) . Of 28 patients with a peak gradient <10 mm Hg, only 4
(14%) had a progressive course. Only t (5%) of 22 patients
with a total eehocardiographic score <8 and a peak gradient
<10 mm Hg, only I had a progressive course (Fig . 3).
Discussion
Previous shift
. The classic natural history studies of
Rowe et al . (0, Oleson (2) and Grant (3) have shown that
while the overall rate of clinical progression in patients with
rheumatic mitral stenosis is slow, the rate of progression
varies widely among patients. In the study of Rowe et al . (1)
of 250 patients with mitral stenosis, at 10-year follow-up 40%
had not changed symptom status, 40% had died and 20% had
shown progression, Of the patients who were initially
asymptomatic, 59% remained without symptoms at 10 years
compared with only 24% at 20 years . Similarly, Cram (3), in
a study of 238 British servicemen with mitral stenosis, noted
that at 10-year follow-up . 33% had died. 33% had no change
GORDON ET AL. 971
in symptoms and 33% had shown progression . Unfortu-
. these carly studies lacked the hemodynamie data that
nately
would ncrmit determination of whether rapid symptomatic
deterioration reflects a faster rate of valvular stenosis or is
the result of another cumptication such as atrial fibrillation,
myocardial failure, pu'monary hypertension or valvular in-
competence.
Orbits et al . (11) studied serial hemodynamic data from 42
catheterizatiens over a period of up to 10 years. Sixty-seven
percent of the patients showed evidence of progression, with
a mean rate of valve area loss in this group of 032 cmzlyear
over a mean follow-up period of 2 .6 years, whereas 33%
showed no change in valve area over a mean follow-up
period of 3 .7 years. Patients who showed progression of
valve area decline were more likely to show symptomatic
deterioration during the follow-up period . This study was
limited by the face that an observationallretrospectivc study
of patients having a second catheterization will be biased
toward patients with more progressive disease . Thus, the
true prevalence of patients with progressive disease may
have been overestimated in this study.
Leurcrtegger et al . (12) studied 13 patients with mitral
stenosis in New York Heart Association llmetional class I or
I1 with M-mode echocardiograms separated by a mean of 37
months. Examining EF slope and mitral valve closure index,
they identified a subgroup comprising 23% of the study
group who manifested greater progression . The substantial
limitations of the EF slope and other M-mode measurements
in quantifying severity of mitral stenosis have since been
defined 111), although their use in monitoring changes in a
single patient may still be valid (14).
Present Tidings By utilizing noninvasive cardiac imag-
ing and Doppler estimates of mitral valve area and iransmi-
tml gradients, our study avoids many of the limitations of
these previous studies and adds important additional data
regarding mitral valve morphology and valvular regurgita-
tion. The ability to describe mitral valve morphology with
two-dimcnsioaal echocardiography has allowed for a mere
thorough investigation of the possible determinants of more
rapidly progressive stenosis. We confirm the previously
described variability in the rate of stenosis progression.
More than 67% ofthe patients in our series showed minima)
or no change in valve area over several years, whereas
almost 33% showed a more malignant course . The rate of
change in mitral valve area observed in Our progression
group is very similar to that observed in the comparable
group of Dubin et al . (11), who utilized catheterization-
derived valve areas.
An important finding in our study was that the initial
mitral valve area at study entry did not help identify patients
who exhibited more rapid progression in valve area decline .
Our analysis, however, does identify several other important
echocardiographic characteristics at the entry study that are
associated with an increased rate of mitral valve stenosis .
Patients with higher peak and mean transmital gradients and
972 GORDON FT A1 . .
ECNOCARDIOORAPtIY AND VALVE AREA IN MITAAL STr:NU5IS
those with higher echocardiographic scores for mitral valve
mobility, thickening, calcification and total morphology
were more likely to exhibit a more progressive course than
were patients with low gradients and low echocardiographic
scores . A total echocardiographic score <8 mm Hg or a peak
Iransmitral gradient <i0 mm Hg, ur boo,, represent levels
that identify patients with a very low incidence of progres-
sive stenosis . Conversely, patients with a score a8 are much
more likely to exhibit progression and they represent a group
in whom closer follow-up should be considered,
Pathogenesis of progression. Although there is still debate
about whether the progressive changes observed in mitral
stenosis might result from a continuous lowgrade subclinical
rheumatic process, most authorities now view the progres-
sive anatomic changes in the mitral valve to be the response
of valvular tissue to the stress of chronic turbulent flow
through a deformed valve (15) . Variations in the degree of
initial valvular deformity may be a result of differences in the
severity of the initial infection, streptococcal virulence or
the number of attacks of rheumatic fever. The greater the
morphologic deformity, the greater the turbulence, leading
to greater tirrue stresses, which result in further thickening,
calcification and cotnmissural fusion . This is also consistent
with the concept of hemodynnmie forces acting to influence
the rate of stenosis, with greater gradients causing greater
tissue stresses and thus a greater proliferative and calcific
reaction. Such a hypothesis is in keeping with our data
demonstrating that valves exhibiting greater morphologic
deformity, and thus a higher echocardiographic score, she-
a greater tendency to more rapid stenosis .
Comparison with postvalvotwtiy studies. If mitral valve
morphology and gradient influence the rate at which stenosis
progresses in the absence of an intervention, then the same
factors may influence the incidence and timing of restenosis
after surgical valvotomy or percutaneous balloon valvulo-
plmty. The reported incidence of restenosis after open or
closed surgical valvotomy has varied considerably among
diderent studies, with estimates varying between 2% and
60% (16) . Several of these studies have documented in-
creased valvular calcification as a risk factor for late deteri-
oration (17,18). Initial success of the valvatomy and the
subsequent course do not correlate closely, suggesting that
factors other than the absolute valve area determine the rate
at which symptoms return (17). In an extensive review and
follow-up of 339 patients after open or closed commissur-
otomy, Hickey et al . (18) documented a need for mitral valve
replacement at 10 years in 22% of patients and a need for
valve replacement at 20 years in 53% . Risk factors for
subsequent valve replacement were the severity of stenosis
before commissurotomy, the degree of mitral leaflet coleifl-
cation and immobility and the degree of mitral regurgitation
after commissurotomy-
Few studies, however, have been able to determine
whether true restenosis or an inadequate primary result has
been the cause of late symptomatic deterioration as surgical
results arc rarely assessed hemodyuamically . However.
JACC Vol . 19, en, 5
April 1992 :955-73
fliggs et al . (19), by comparing a routine early postoperative
cardiac catheterization with subsequent data, documented
true restenosis in 5 of 45 patients who returned with recur-
rent symptoms over a meali follow-up period of 6.5 years . In
another study, Heger et a! . (201 followed up 18 patients who
had en early postoperative catheterization after successful
commissurotomy with either echocardiography or repeat
cardiac catheterization at a mean of 12 .2 years. Significant
restenosis was found in five patients (28%). As in our study,
neither age nor gender nor initial valve area was predictive of
later restenosis.
Factors influencing restenosis following pereutaneom hal-
loan mitral vnlvuloplwty . These factors have been the sub-
ject ofmore intense scrutiny. Uncles et al . (21) reportedthe
outcome of 100 patients followed up an average of 13 mouths
after percutaneous balloon valvuloplasty . Mural valve mor-
phology was assessed by the same echocardiographically
based scoring method utilized in our study . Patients with a
low total echocardiographic score (tell) had only a 4%
incidence of restenosis documented, whereas those with a
score >8 had a 7040 incidence . The individual components of
this score were not examined for their relation to later
restenosis. Although patients with a higher score were less
likely to have a good immediate hemadynamic result, mul-
tiple stepwise regression analysis identified the echocardio-
graphic score as the single most importune factor predictive
of restenosis, whereas the mitral valve area immediately
after valvuloplasty was not predictive of restenosis by either
univariate or stepwise multiple regression analysis . These
results are consistent with those of the present study and
suggest that the same pathogenic mechanisms may be oper-
ating. Patients who achieve a good long-term result after
balloon mitral valvuloplasty may do so as a result of already
belonging to a slow progression subgroup determined, al
least in part, by their valve morphology . Such observations
held significant implications for the selection of patients
most likely to benefit from mitral valvuloplasry and the
timing or valvuloplasty and follow-up study .
Limitations . Several potential biases are inherent in the
present study . Retrospective studies of untreated natural
history tend to select patients with less severe disease, as the
more severely affected patients are more likely to have had
an intervention before follow-up study . Many of our patients
did have mild mitral stenosis, but the number of patients
with a small valve area at entry in both the progression and
nonprogression groups suggests a reasonably equal distribu-
tion of patients with moderately severe stenosis in both
groups. Patients with a more progressive clinical course
might be expected to have more frequent echocardiographic .
follow-up studies and thug. be overrepresented . This does not
appear to be the situation far oo' -idy because the majority
of patients were in the nonprogression group . We also
assumed a linear progression between entry and final echo-
cardiographic studies . Tins seems reasonable given the
similar progression rates in patients with mild and more
severe mitral stenosis .

JArr Vol . 19.N ..5
Ap.. 1992 WM-71 RCHVCARD7o4R,1Pev AND V.mL1'E AREA IN MITRAL STh91151S
Some patients showed an apparent increase in valve area
over the follow-up period . The magnitude of this apparent
increase, however. was small in all but one patient and
within the range of variation in the IBeasuTement technique
as determined from our inrraohserver error analysis . The
milral valve echocardiographic score 111etnod used in this
study is a subjective grading and is semiquantitative in
nature (22) . However, it has been successfully applied to
studies of outcome after percutaneous balloon vaivulo-
plasty. The method has also been validated against postmor-
tem specimens of rheumatic milral valves (23) .
Clinical ii ig4icatious . In addition to furthering our under-
standing of the natural history of rheumatic mural slenosis,
the results of this study are of importance in the clinical
management of such patients and in understanding the
mechanism of resienosis after surgical or balloon valvulu-
plasly. The rate of progression of milral stenosis in individ-
ual patients is quite variable . Health care resourceswould be
best utilized by individualizing patient follow-up based on
the likelihood of progression of stenosis- Our data suggest
that patients with a low echocardiographic score and a law
transmitral gradient have a low rate of valve area narrowing
and may need less frequent echocardiugraphic follow-up-
Most important, this study stresses the relation between
valvular morphology as assessed by echocardiography and
the clinical course ofpatients with mitral stenosis . The value
of morphologic assessment in predicting the outcome after
surgical valvotomy or balloon valvuloplasty has already
been demonstrated. Our study extends the utility of this
index to that of the natural history of progression of valve
Cterteale .
We art Fateful fo, Ike leehniool as,puoece of Manlyn S . Rile. . RDCS and
Lisa V, Cad, RDCB.
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