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Oup Accepted Manuscript 2020
doi:10.1093/eurheartj/ehaa828
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This editorial refers to ‘Prognostic importance of the trans- .. (confidence interval 1.049–1.080). Increasing severity of concomitant
mitral pressure gradient in mitral annular calcification with .. mitral regurgitation was associated with incremental increases in
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associated mitral valve dysfunction’, by P. B. Bertrand et al., .. mortality only in the low gradient group. Mean transmitral gradient is
doi: 10.1093/eurheartj/ehaa819.
.. thus a continuous rather than a categorical variable with respect to
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.. outcomes. More alarming is the increase in mortality compared with
Although mitral stenosis (MS) is most commonly caused by rheumat-
.. a control group, for even the low gradient cohort, with their spline
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ic heart disease, there is an increasing prevalence of non-rheumatic, .. analysis suggesting an increased hazard for death starting at a mean
senile calcific disease or degenerative MS.1,2 Mitral annular calcifica-
.. gradient of 2.5 mmHg. Thus although the study adds significantly to
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tion (MAC) originates in the annulus and extends to a variable extent .. the literature about outcomes associated with degenerative MS, it
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onto the leaflets or myocardium, resulting in a reduced annular area .. raises more questions about the relationship of mean gradient to
and leaflet restriction.3 Degenerative MS has received renewed at- .. valve area and the utility of mean gradient for patient management.
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tention on the coattails of structural heart interventions in the form .. The relationship between gradient and valve area is dependent
of valve-in-MAC procedures.4 Whereas the severity of rheumatic MS .. upon assumptions about anatomic orifice area and the effective ori-
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can be accurately assessed by echocardiographic mean transmitral .. fice area. The difference between these two measurements is
gradient, planimetry (by 2D or 3D methods), continuity equation, .. affected by the coefficient of orifice contraction (Cc = effective/ana-
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proximal isovelocity surface area, and pressure half-time,5 these .. tomic area) which reflects the principle that flow, directed to con-
methods have been questioned for quantifying degenerative MS.5–7 .. verge toward a narrow orifice, will continue to converge beyond the
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Echocardiographic Doppler-derived mean gradient in rheumatic MS .. orifice.9 For flow approaching an orifice with a flat surface, the prox-
has a direct relationship to mitral valve area and is more reproducible
.. imal convergence has greater distal contraction (Cc 0.6) and, for
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and accurate than direct invasive measurements, with cut-offs of <5 .. flow approaching a prolonged tube, the collimated flow has no distal
mmHg for mild, 5–10 mmHg for moderate, and >10 mmHg for se-
.. contraction (Cc approaches 1.0).11 These variations could result in a
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vere disease.5 The haemodynamic severity of degenerative MS has .. 40% higher pressure gradient in the flat surface orifice (i.e. rheumatic
also relied upon measurements of transvalvular gradients;5 however,
.. MS) for the same anatomic area and flow rate as a more tubular or
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the association with gradients and outcomes in this disease has been .. tapered orifice (i.e. degenerative MS). In addition, mean gradients are
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poorly studied. .. dependent on the pressure difference between the left atrium and
In this setting, Bertrand et al. performed a retrospective study, pub- .. left ventricle, and reduced left ventricular (LV) compliance frequently
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lished in this issue of the European Heart Journal, using a vast single- .. seen in the elderly could also result in lower mean gradients and
institution echocardiographic database to determine the natural his- .. increased mortality. In fact, compared with high gradient degenera-
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tory of significant MAC and prognosis of mean gradient in this popu- .. tive MS patients, the low gradient subgroup in Bertrand et al.8 were
lation.8 A total of 5754 patients were stratified by mean gradient: low .. older with higher prevalence of hypertension, coronary artery dis-
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(3–5 mmHg, n = 3927), mid (5–10 mmHg, n = 1476), and high (>_10 .. ease, and prior myocardial infarction, and with lower ejection frac-
mmHg, n = 351). After adjusting for age-, sex-, and MAC-related risk .. tion. Thus it is highly likely that although prognostic, mean gradients
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factors (hypertension, diabetes, coronary artery disease, and chronic .. underestimate the haemodynamic severity of degenerative MS and
kidney disease), mean gradient was independently associated with
.. the same cut-offs of stenosis ‘severity’ may not be relevant in this dis-
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mortality with an adjusted hazard ratio of 1.064 per 1 mmHg increase . ease. By the time calcific disease has caused the mean gradient to
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
* Corresponding author: Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, New York, NY 10032, USA. Tel: þ1 212 305
7060, Fax: þ1 212 342 3660, Email: rth2@columbia.edu
Published on behalf of the European Society of Cardiology. All rights reserved. VC The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.
2 Editorial
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ME, Dinshaw H, Qamruddin S. Echocardiographic assessment of degenerative
.. geometry on the coefficient of orifice contraction, pressure loss, and the Gorlin
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